Guidelines fall short on bariatric surgery

To the Editor: I am writing in relation to the concerns raised by Dixon in his critique of the Clinical practice guidelines for the management of overweight and obesity from the National Health and Medical Research Council (NHMRC).1

When developing guidelines, the NHMRC always includes a consultation phase and Dixon did not raise his concerns during this phase. When his concerns were subsequently brought to NHMRC’s attention — just as the guidelines were in the process of being published — the guideline committee agreed to remove examples of nutritional complications as they were open to misinterpretation.

The revised guidelines were issued in October 2013 and Dixon was informed of the amendment. Hence the version of the guidelines cited in Dixon’s article does not contain the text with which he took issue in the Journal.

Further, the guidelines are not intended for bariatric surgeons and their teams, as Dixon suggests. The guidelines are specifically targeted at primary care management of overweight and obesity. As such they note that “Individual monitoring and follow-up protocols should be determined by the appropriate specialist team or surgeon, in consultation with the primary care health professionals involved”.

The evidence base for the guidelines is documented in the accompanying 656-page systematic review, available on the NHMRC website.2

The NHMRC develops guidelines against a rigorous set of standards that include governance by an expert multidisciplinary committee, a documented evidence review process, strict conflict of interest management, and independent expert and methodological review.

An integral element is a transparent public consultation process, and the NHMRC urges all clinicians to review guidelines at this stage and respond as appropriate.

Changes in the sodium content of leading Australian fast-food products between 2009 and 2012

The burden of ill health attributable to obesity, type 2 diabetes and other diet-related health risks is increasing in both developed and developing countries.1 Fast foods, which are convenient, quick and cheap, are generally nutrient-poor and eaten in large portions that can contribute significantly to energy, fat, sugar and sodium intake.2 Links between fast-food consumption and a range of chronic diseases have been made,3 with excess dietary sodium causing high blood pressure4 and a range of vascular diseases.5,6 Although there is no current definitive estimate of population dietary salt intake in Australia, it is widely accepted that average consumption is well above the government’s suggested dietary target of 4 g/day.7 About three-quarters of salt in the diet comes from processed and restaurant foods,4 with fast foods known to be a significant contributor in Western populations.8

In Australia, expenditure on fast foods has risen substantially over recent years9 and there is evidence that children who are exposed to unhealthy dietary patterns carry these behaviours into adulthood.3 The Australian Government’s 2009 National Preventative Health Strategy – the roadmap for action10 identified the need to improve the healthiness of fast foods in Australia, and the Food and Health Dialogue has commenced a food reformulation program.11 Neither, however, has set targets for fast foods, although some companies and non-government organisations have been working to lower salt levels in these products.12,13 These efforts have been informed by data that systematically describe the salt levels in Australian fast foods1 and how they compare with those in other countries.14 The primary objective of this study was to determine whether there have been any changes in the sodium content of leading Australian fast-food products in the 4 years from 2009 to 2012.

Methods

Nutrient content data were obtained from surveys of the information available on company websites for fast-food menu items available from six leading fast-food companies in Australia. Identical surveys were done in March each year in 2009, 2010, 2011 and 2012.

Variables collected

For each food item, the brand and product name, serving size (grams), and sodium content (mg/100 g) were the minimum data recorded. Sodium per serve was also documented where provided or else was calculated using the serving size and sodium per 100 g. Likewise, if sodium per 100 g was not available, it was calculated on the basis of the serving size and the sodium per serve.

Definitions and selection of fast-food categories

Definitions of food types are those used in previous reports,1,15 and were derived from categorisations commonly used by the fast-food industry. In this study, items were grouped into seven broad categories: breakfast products, burgers, chicken products, pizzas, salads, sandwiches and side menu items. Other categories, such as beverages and desserts, were excluded since they generally have low levels of sodium.

Fast-food companies included

Nutrient data for 2009, 2010, 2011 and 2012 were available for fast-food menu items served by six leading fast-food companies in Australia: Domino’s, Hungry Jack’s, Kentucky Fried Chicken (KFC), McDonald’s, Subway and Pizza Hut. We focused on these fast-food companies since they are six of the largest fast-food companies globally.16

Statistical analysis

We first assessed the distributions of the sodium variables and confirmed no major deviations from normality for measures per 100 g or per serve by reviewing the graphed data for all years, for all products, for separate categories of products and for products sold by each company. We used independent samples t tests to estimate differences in sodium content across the whole range of products, and by each category and company, between 2009 and 2012. In addition, we fitted mixed models to estimate average annual changes in sodium per 100 g and sodium per serve over the same period. These models used the data from all 4 years in a two-level model with a random coefficient and intercept for the year variable. Two-tailed 95% CIs were estimated for both the t tests and the mixed models. We made no correction for multiple testing, since we drew our main conclusions from the two overall analyses shown in Box 1 and treated the other analyses as exploratory only. Stata version 12.1 (StataCorp) was used for all calculations.

Results

Overall, sodium data were available for 1410 products: 302 in 2009, 348 in 2010, 381 in 2011, and 379 in 2012 (Box 1). Pizzas comprised the greatest number of products, accounting for between one-half and one-third of items each year, while salads made up the least (Box 2 and Appendix 1). Likewise, Domino’s accounted for two to three times more products each year than other companies (Box 3 and Appendix 2). Mean sodium levels varied between food categories and between companies each year, and there was variation in sodium levels between products, which was particularly wide for side menu items because of the different types of products included in this category (Box 2).

The overall mean sodium content across all items offered by major chains fell by 43 mg/100 g (95% CI, − 66 to − 20 mg/100 g) between 2009 and 2012, from 514 mg/100 g to 471 mg/100 g (Box 1). The corresponding mixed model provided a directly comparable estimate of the annual fall in sodium of 14 mg/100 g/year (95% CI, − 16 to − 11 mg/100 g). The sodium content per serve across all products was 654 mg in 2009 and 605 mg in 2012 (difference, − 49 mg/serve; 95% CI, − 108 to + 10 mg/serve), with the average annual fall estimated to be 21 mg/year (95% CI, − 25 to − 16 mg/year) (Box 1). Most product categories had lower mean sodium levels per 100 g and per serve in 2012 compared with 2009, and the mixed models suggested corresponding falls in sodium over the 4 years in all categories except breakfast products and sides (Box 2 and Appendix 1). Side menu items were the only category for which there was a rise in sodium content over the 4-year study period. This appears to reflect the introduction in 2012 by Pizza Hut of side menu items that had a high sodium content and large serving sizes. Pizza Hut was the only company with an indication of a possible increase in the sodium content of their products. For all other companies, it appeared sodium levels decreased over the 4 years (Box 3 and Appendix 2). A peak in the sodium content of sandwiches and Domino’s products in 2011 resulted from 26 sandwich items that were present in 2011 but absent in other years. For sodium per serve of chicken products, there is an apparent discrepancy between a decrease observed in the annualised data derived from the mixed model and a rise when just 2009 and 2012 data are compared. This was found to be a consequence of a small number of chicken products introduced in 2011 that had high levels of sodium per serving.

Discussion

There has been a small reduction in the overall mean sodium content of fast foods between 2009 and 2012. Our finding of a statistically significant reduction of 2%–3% in sodium levels each year in Australian fast-food products is encouraging, although sodium levels in many fast-food products are still high. In many cases, there is wide variability in the sodium content of very similar products, suggesting that there is no technical reason preventing further sodium reduction in many. The wide variation in sodium content per serving highlights the need for standardisation of portion sizes. Further, trends towards increased fast-food portion sizes globally17 could easily undo the benefits achieved by reducing levels of sodium per 100 g of product. While the direction of the change in sodium levels in Australian fast foods is promising, there is an urgent need for a sector-wide strategy that will deliver further falls in the short term.

Australian efforts to reduce dietary sodium parallel work to lower the sodium levels of restaurant foods in the United Kingdom, Canada and United States.18,19 While data to objectively describe changes in salt levels of fast foods are not available for these countries, there are reports showing that salt levels in UK fast-food products are generally lower than those of other countries,14 reflecting the intensive work done by the UK Food Standards Agency over the past decade.20 Following the success of the UK program, and with strong government backing, both the US and Canada have based their sodium reduction strategies on the UK model.21,22 The US National Salt Reduction Initiative identified that different patterns of consumption between packaged foods and restaurant foods required different sodium reduction targets and have tailored their program accordingly.21 Likewise, the Sodium Reduction Strategy for Canada specifically targeted fast foods,22 and while disbanded in early 2011, most territorial and provincial governments of Canada are calling on their federal government to persist with efforts to reduce the sodium intake of the Canadian population. Australia does not currently have the same kind of coherent approach, and the adoption of a strategy similar to the UK would seem a sensible way of enhancing Australia’s current salt reduction efforts, particularly in relation to the fast-food sector. The establishment of the government’s Food and Health Dialogue is a welcome start, although fast food has yet to be targeted.

The success of the UK program has been attributed to the strength of government engagement in the process. It is becoming increasingly clear that changes to the food supply will only be achieved by regulation, or the threat of regulation by a government committed to addressing diet-related disease burden. As for other industrial diseases, the commercial imperative of the food industry to deliver shareholder value appears likely to override health concerns until regulatory checks are put in place.23 While individual companies may deliver moderate improvements to their products, there is little evidence that significant sector-wide improvements can be achieved in a non-regulated setting.

The primary strength of this study is that data on the sodium content of fast foods were collected in a standardised way, over a number of years, and therefore provide an objective measure of sodium levels in Australian fast foods on an ongoing basis. While only six chains were included, these six companies are sector leaders in Australia and globally.16 Nutrition information provided on company websites was used, and although there is no guarantee that the information was accurate, most large chains report that they base their nutrient data on analysis done by external parties. Unpublished data comparing reported sodium values to analytical values for a sample of 115 popular fast-food items has shown good correlation of results in Australia. A further limitation of our analysis is that estimates were crude means. Sales-weighted estimates that captured market share for each product would have been a better way of estimating the likely public health impact of observed changes in salt content. However, the broad comparability of the changes across subcategories of products suggests sales weighting would not have changed the primary conclusions.

Although KFC and Pizza Hut are both owned by Yum! Brands, sodium in KFC products decreased over the study period, yet increased for Pizza Hut. A similar observation has been made for salt levels in breads, where a leading manufacturer in Australasia decreased sodium in products in one country but increased them in the other.24 This is symptomatic of the lack of a coordinated effort to improve the healthiness of foods in many large corporations and the absence of government leadership. The success of the UK program shows that this problem can be rectified but it will require stronger federal government engagement and a comprehensive and transparent target-setting process. The regular reporting of objective metrics, as exemplified by the Food Safety Authority of Ireland, could also advance sodium reduction activities in Australia.25 Salt reduction remains one of the most cost-effective options for improving public health in Australia and many other countries. The key question continues to be how to persuade industry and government to take the actions required to reap the benefits of reducing the salt intake of the population.

1 Sodium content of fast foods in Australia from 2009 to 2012*

* Each circle represents one product, and the line connects the median values in each year. The differences (95% CI) are reported for 2012 v 2009, and as an annualised average change over the 4-year study period.

2 Sodium content of fast foods in Australia from 2009 to 2012 for major food subcategories*

3 Sodium content of fast foods in Australia from 2009 to 2012 for each company included*

Vitamin D and tuberculosis

To the Editor: Any role that vitamin D deficiency plays in increasing the risk of tuberculosis1,2 should not detract from the fact
that infection with the causative organism is the necessary risk factor for disease, and decreasing the risk of infection initially will prevent disease even while factors that increase the risk of progression
to active disease3 are present.

A letter in the Journal in
20132 suggested that vitamin D supplementation may decrease
the incidence of tuberculosis. This was based on the distribution of tuberculosis notifications and vitamin D levels in Australia, and an earlier analysis by the authors of
the effect of latitude on seasonality of tuberculosis in Australia.4

The cross-sectional studies on which the letter was based used grouped national data without adjusting for confounding from other factors associated with the variability of rates of tuberculosis infection across Australia. These include variability in relative proportions of migrants and Indigenous and non-Indigenous Australians and the differing age-related incidence of tuberculosis in these groups; the role of migrant screening programs in different jurisdictions and how this impacts on the stage of disease at diagnosis; and the timing of screening in relation to annual intakes of overseas students. These factors
can variably confound associations with seasons, latitude and age.

There is no denying the need for a holistic approach that incorporates recognising and treating conditions that increase the risk of latent tuberculosis becoming active, and
it is certainly important to tackle vitamin D deficiency in its own
right. However, the major focus
for decreasing the burden of tuberculosis remains the need to be aware of those populations with a disproportionately greater risk of primary tuberculosis infection and
to ensure early diagnosis and management of the disease to prevent transmission initially.

Food giants accused of selling out their customers

AMA President Dr Steve Hambleton has launched a broadside at the food industry following revelations it has been actively campaigning to scuttle the breakthrough Food Health Star Rating system.

Dr Hambleton said he was “very concerned” by revelations peak food industry body the Australian Food and Grocery Council (AFGC) had been lobbying against the system just hours before Assistant Health Minister Fiona Nash ordered its new website to be taken down.

“The system’s website was to be a major part of the public education campaign to make people aware of the new system, and how it works,” the AMA President said.

The Brisbane GP said it was extremely disappointing that the food industry, which had been closely involved in the two-year development of the scheme, was now undermining it.

“Even though they worked closely with the public sector on the development of the new system, the AFGC has lobbied against the consumer-friendly labels since they were agreed by the Federal and State governments last year,” he said.

Political furore erupted after Assistant Health Minister Fiona Nash ordered the Federal Health Department to take down the www.healthstarrating.com.au website just hours after it was launched.

It has since been revealed that the decision was taken soon after a major food industry group contacted the Minister’s office to express concern about the website.

Food and Grocery Council Chief Executive Officer Gary Dawson told the ABC he called Senator Nash’s office the day the website went live to raise his objections.

“On the day, yes, we expressed a view that we thought it was premature,” Mr Dawson said, though he denied asking for it to be taken down.

Senator Nash told the Senate she had ordered the Department to take down the website because “the health star rating is not yet in place. It would have been extremely confusing for consumers had that website been allowed to remain in place”.

The decision cost the Minster’s Chief of Staff, Alastair Furnival, his job after it was admitted that at the time he retained shares in a lobbying firm, Australian Public Affairs (APA), that had had major food companies among its clients.

Dr Hambleton said it was extremely concerning that the food industry appeared to be trying to scuttle the Food Star Rating system, which had been developed to enable consumers to make healthy food choices.

Under the system, which has been agreed upon by the Council of Australian Governments, all packaged food would be given a rating from half a star to five stars to indicate its nutritional value, as well as a panel detailing how much saturated fat, sugar, sodium and one other ingredient (to be determined by the manufacturer) it contains.

An analysis of several foods conducted by consumer organisation Choice found that several products manufactured by food giant Mondelez, which had been a clients of APA, scored poorly in the rating system by comparison with competitors.

Last week, 66 public health experts sought to outflank the Federal Government, writing to State and Territory food ministers urging them to “take whatever action is within their power” to get the food rating system implemented as soon as possible.

One of the signatories to the letter, leading cancer expert Emeritus Professor Bruce Armstrong of the University of Sydney, told the Sydney Morning Herald he supported the move because giving consumers better information about food was crucial.

“Obesity is shaping up as being one of the major drivers of cancer rates into the future,” Professor Armstrong said. “As a consumer myself, I see how extracting from the label the information you want to find out … is really quite difficult.”

At its meeting in December, the peak body for Australian and New Zealand food ministers, the Legislative and Governance Forum on Food Regulation, endorsed the food star rating system.

But at the meeting, Senator Nash announced the Federal Health Department would conduct a cost-benefit analysis of the scheme, even though it is due to be introduced from the middle of the year.

Dr Hambleton called on the food industry to drop its delaying tactics and instead honour its original undertakings to back the scheme, in the interests of better informing their customers.

“It is time that the food industry and its peak Council did the right thing and put their full support behind a bold initiative that will help people make healthier food choices and take some pressure off the health Budget,” he said.

Adrian Rollins

Abbott tries to brazen out conflict of interest quagmire

Prime Minister Tony Abbott has thrown his unequivocal support behind embattled Assistant Health Minister Fiona Nash despite confusing and contradictory statements regarding the handling of an apparent conflict of interest involving departed senior staffer Alastair Furnival.

Mr Abbott repeatedly told Parliament last week that Senator Nash was doing “a fine job…and I back her to the hilt”.

But revelations that Senator Nash was aware for months that Mr Furnival held a stake in a lobbying firm with links to a major food manufacturer, and yet declared to the Senate on 11 February that he had “no connection whatsoever” with Australian Public Affairs (only to return to the chamber hours later and admit he was a shareholder in the company), have fuelled attacks on the Minister and intensified scrutiny of potential links between the Government and the food and alcohol industries.

The Opposition has mounted a concerted attack on the Government and Senator Nash after Mr Furnival was forced to resign amid accusations of a conflict of interest over the decision to direct the Health Department to take down the Food Health Star Rating website.

At the time, Mr Furnival was a shareholder and director of a lobbying firm that had had a major food manufacturer, Mondelez, among its clients.

It has subsequently been revealed that Senator Nash directed the website be taken down after a major food industry group had contacted her office earlier in the day to voice its concerns about the initiative.

During a Senate Estimates hearing last week, Senator Nash said she had known Mr Furnival for a decade, and had been aware of his involvement with Australian Public Affairs and the food industry.

She told the hearing Mr Furnival had agreed to divest himself of his APA shareholding and resign as a director when he joined her staff, but was still in the process of divestiture five months later.

The Senator told the hearing she was “completely aware” that Mr Furnival was still a shareholder and director of APA when she told the Senate he had no connection with the firm.

Appearing to implicate the Prime Minister’s Office in the saga, the Minister told the Senate on 13 February that “all information around my chief of staff was given to the Prime Minister’s Office, in accordance with appropriate timing”.

At the time of Mr Furnival’s resignation, Mr Abbott gave as the reason that he had been “dilatory” in divesting himself of APA shares, but last week shifted his ground, telling Parliament that Mr Furnival had resigned to avoid any perception of a conflict of interest.

“In order to prevent any perception of potential conflict of interest, the staffer in question resigned,” he said.

Meanwhile, Senator Nash has given no clear reason for her chief of staff’s departure.

In Parliament last week, the Prime Minister attempted to play down the saga, seeking to dismiss it as “not so much a storm in a tea cup; it is not even a zephyr in a thimble; it is nothing, because the conflict-of-interest rules have been observed”.

He added that Senator Nash was “doing a fine job. Every single decision that has been made by her in that portfolio is eminently defensible and I back her to the hilt”.

But Mr Abbott risks being drawn more directly into the affair, with questions being raised about the circumstances surrounding his pledge last August to give chocolate maker Cadbury $16 million to develop visitor facilities at its Hobart factory.

Earlier in the year, Mr Furnival had been lobbying the Tasmanian Government on behalf of Cadbury, and sat near Mr Abbott when the Liberal leader visited the factory last year to announce his pledge.

Adrian Rollins

School loses sugar coating

The ACT Government has become the first in the nation to ban the sale of soft drink and fruit juices in public schools, drawing warm praise from the AMA and other health groups.

In a measure it hopes will help curb rising rates of overweight and obesity among ACT schoolchildren, the Government has announced that the sale of fruit juices and soft drinks from vending machines will be prohibited at all public schools in the Territory from the end of Term One this year, with a complete ban to be in place by the end of the 2014 school year.

AMA President Dr Steve Hambleton said the ban sent a clear message that soft drinks and fruit juices should not be part of an everyday diet, and called on other governments and schools to take similar action.

“Soft drinks and fruit juices can be enjoyed occasionally as a treat, but there is no doubt that consuming these products daily is inconsistent with a healthy diet,” Dr Hambleton said. “Positioning these in schools so that they are available every day sends the wrong message.”

The ACT Government had originally planned to phase out sugary drinks at public schools over a five-year period by offering incentives for schools that agreed to stop selling them.

But late last year the Government toughened its stance following the release of data showing 63 per cent of ACT residents were overweight or obese, including more than 25 per cent of children.

Announcing the ban on 20 February, ACT Chief Minister Katy Gallagher said her Government had “a clear plan to reduce the amount of people who are overweight or obese, and a key way to achieve that is to reduce the availability of sugary drinks to children”.

“The evidence for us is very clear,” Ms Gallagher told the Canberra Times. “We’ve got to make this decision.”

The ACT Chief Minister flagged the possibility the ban would be extended to other Government-controlled facilities, such as hospitals and ACT Government departments.

Dr Hambleton said obesity was a major public health issue, and it was important to educate young people about healthy diets and exercise.

“The ACT Government has done a great job to show leadership in reducing the alarming rates of overweight and obesity in our young people,” the AMA President said, and called on non-government schools and other State and Territory governments to take similar steps.

“Further, initiatives such as the sugary drink ban need to be followed up with action from all governments to reduce the targeted marketing of unhealthy foods and beverages to children, simplify food labelling, and increase opportunities for physical activity among all children and adults,” he said.

The Public Health Association of Australia said the ACT Government should be given “full marks” for the sugary drinks ban in public schools.

President Professor Heather Yeatman said that, as an Associate Professor in Public Health Nutrition at the University of Wollongong, and as a mother of two children, “I know that sugary drinks are not necessary in anyone’s diet – on an occasional basis they may add variety or novelty, but they certainly are not an everyday choice”.

The measure has been criticised by the industry group Fruit Juice Australia.

The group’s Chief Executive Geoff Parker told the Canberra Times it was a “simplistic” approach that did not address the central issue of ensuring a balance between a child’s level of activity and their diet.

Adrian Rollins

Guidelines fall short on bariatric surgery

Appropriate guidance is lacking in long-term nutritional monitoring and support

The National Health and Medical Research Council (NHMRC) Clinical practice guidelines for the management of overweight and obesity were released in early June 2013, replacing the 2003 version, intended for use by specialists and general practitioners.1 A multidisciplinary committee oversaw the guideline development process, aiming to systematically identify and evaluate evidence. In my view, this process has failed with regard to the section dealing with bariatric surgery, thereby failing severely obese Australians and those caring for them.

My greatest concern is the section about nutrition and supplementation after bariatric surgery. Nutritional issues are a critical downside to bariatric surgery and should be front of mind whenever doctors, nurses, dietitians or any other health professionals interact with a patient after surgery. High-quality guidance is required in the care of the thousands of patients who have had bariatric surgery. After bariatric surgery, energy intake is markedly reduced, food choices and diet quality often change, absorption of micronutrients such as iron, calcium, vitamin D and vitamin B12 can be impaired with some procedures and, more rarely, protein malnutrition and more complex deficiencies occur. All bariatric procedures require excellent nutritional support, monitoring and supplementation.

The guidelines’ suggestion that nutritional issues should be assessed through clinically manifest disease, including neuropathy, weakness and muscle wasting, bone pain and oral lesions, is dangerous, reflecting an “after the horse has bolted” mentality. Progressive nerve damage related to nutritional deficiency can be catastrophic and only partially reversible;2 metabolic bone disease related to nutritional deficiency is symptomatic only when it is generally too late to take any effective preventive action; and it is definitely too late when a pregnant woman’s baby is diagnosed with a neural tube defect. Anaemia, metabolic bone disease, and neuropathy are reported at much higher levels after bariatric surgery than in the community. Nutritional issues are predictable, and also preventable with appropriate monitoring.

These nutritional guidelines contrast starkly with the broader literature and the recently released United States guidelines for pre- and post-bariatric surgical care developed conjointly by the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery.3 Their detailed literature review comes to very different conclusions. However, the recent NHMRC document1 does not detail any critical appraisal of the literature about nutritional support, monitoring or supplementation after bariatric surgery. What was the evidence base for the guidance provided, given its inconsistency with known nutritional deficiencies and the available literature on prevention? As soon as I became aware of the guidelines, I alerted the NHMRC and colleagues who were members of the relevant committees to the specific issues that worried me.

The greatest concern is the process that led to this unsatisfactory section of the guidelines. The review process is described as rigorous and transparent, yet the result, in my view, is not evidence-based, and is potentially dangerous. Rigour and transparency were used when looking at the weight loss extent and duration, the changes in obesity-related comorbid conditions and the overall mortality advantage after bariatric surgery. However, the guidelines are intended to provide practical assistance to health professionals managing chronic disease in patients with severe complex obesity who have undergone bariatric surgery. Surgery does not cure obesity or obesity-related comorbid conditions. Lifelong follow-up and support are required.

I recommended that the NHMRC consider revising the section on nutrition and nutritional supplementation after bariatric surgery. In addition, the NHMRC should review its aims and processes before conducting evidence-based reviews to ensure that guidelines provide the most relevant practical information for the target audience rather than a detailed formal review with limited practical relevance to patient selection and care. The NHMRC has recently confirmed that the section of concern will be revised. Meanwhile, I urge bariatric surgeons and their multidisciplinary teams to follow high-quality guidelines,3 provide individualised advice to patients and their key health care providers. Additional support for practitioners is available in two recent reviews detailing the nutritional aspects of bariatric surgery.4,5

Nutrition in schools — outdated guidelines need updating

To the Editor: The National Healthy School Canteens (NHSC) project commenced in 2008 to help provide guidelines for healthier food and drink choices in Australian schools. At their core, the guidelines seek to restrict the availability of poor food choices by encouraging the preferential availability of healthy options. These guidelines should ensure the translation of health research and national health curriculum into practice. However,
the current NHSC guidelines are inadequate and fall short of their aims as they rate foods only on energy, fat and sodium, and disregard the sugar content of commercially available foods.

The initial decision to disregard sugar as a criterion for rating foods available in school canteens was intentional. The New South Wales government website states that sugar content was not included “To keep the criteria as simple as possible and to ensure that foods containing naturally occurring sugars . . . were not disadvantaged”.1 Surprisingly, sugar content is not even a criterion for assessing “sugar-sweetened drinks”.2

Excess sugar consumption is associated with type 2 diabetes and obesity. This has been reported in both human and non-human studies and is evidenced by outcomes including fatty liver, impaired glucose tolerance and increased site-specific adiposity. It is of little surprise then, that the most recent update to the Australian dietary guidelines in February of this year included a revision of the recommendation about foods and drinks containing added sugars (Guideline 3).3

Before February 2013, national dietary advice was to consume only moderate amounts of food and drinks with added sugar. This has since
been revised to advise their intake be limited. This shifts foods and drinks containing added sugar into the same category as foods high in fat, salt or alcohol. There is now an immediate need to review policies borne from the outdated national guidelines (such as the NHSC) to include “added sugar” as criteria for assessing the suitability of foods, just as fat and sodium currently are. Until then, the healthy development of our children and hence future health of our nation is at risk.

The impact of obesity treatment and dietary guidelines on eating disorders

To the Editor: We wish to highlight how the recently released National Health and Medical Research Council (NHMRC) Clinical practice guidelines for the management
of overweight and obesity1 and the Australian dietary guidelines2 may affect clinical and public health practice. Children, adolescents and adults with obesity are at increased risk of eating disorders (EDs) compared with others in the community.3–5

The dietary guidelines provide sound nutritional advice to improve the health of the Australian population. Importantly, the document states, “When promoting healthy weight . . . it is essential to avoid inadvertently encouraging disturbed body image and disordered eating or exercise behaviour”.2 This
is essential to changing the way government health campaigns on obesity are delivered, as previous campaigns may have increased obesity stigma and body image distress, both known contributors
to EDs.

Restrictive eating in the community (but not participation in carefully designed health professional obesity treatments, which may include safe restriction in their approach) is known to increase the onset of EDs.6,7 We feel that a number of aspects in the dietary guidelines and accompanying consumer resources conflict with the recommendation on avoiding EDs. First, the foundation diets were based on modelling the nutritional needs of the smallest and least active people
in each age group2 and are thus very restrictive. Second, taller and more active children and adults who are not overweight are told that to meet their energy requirement, extra serves or discretionary choices may be needed, which may stigmatise overweight children, by encouraging restriction
of discretionary foods, which were previously considered a normal
part of all children’s diets in small amounts. Third, the “healthy eating
for children” brochure and the similar brochure for adults list the estimated kilojoule content of core food groups, and the website has calculators for
the public to work out their energy requirements; this encourages dietary restriction. Despite the prevalence of obesity, it is our view that restrictive diets should not be encouraged at
a general population level.

In contrast, the draft guidelines
for obesity had a strong public consultation response, which highlighted omissions in the consideration of EDs. The final guidelines clearly articulate the need to consider body image, EDs and mood disorders in all aspects of obesity care. Practitioners are guided in how to discuss weight management in a way that recognises likely frustration, comorbid conditions and discrimination, which should reduce compounding obesity stigma or body image distress. Finally, EDs are not seen as a contraindication for any kind of obesity treatment, but as
a comorbid condition that needs attention.1

In their recognition of disordered eating, both guidelines make important leaps forward in the integration of physical and mental health care.

A systematic interim assessment of the Australian Government’s Food and Health Dialogue

C hronic diseases are the main causes of premature death and disability in Australia and the world.1 Poor diets — high in salt, saturated fats, added sugar and energy, with inadequate fruits, vegetables and wholegrains — are now the leading cause of this disease burden.1 Adverse levels of these nutrients are driving epidemics of obesity, diabetes, high blood pressure and dyslipidaemia and their clinical sequelae.2,3

The food environment in Australia provides large quantities of cheap and convenient processed and restaurant foods to consumers. These foods are often high in salt, added sugar and fat and are typically delivered in large energy-dense portions.4–6 A predominance of these types of foods has been identified as a key driver of diet-related ill health around the world.7,8 This problem is well understood by public health groups, government, industry and consumers. However, while Australian agencies like the National Health and Medical Research Council (NHMRC) have provided specific guidance about optimal dietary intake, there has been little effective action to change the diet of the community. Most investment has been in interventions targeting individual behaviour modification. While these approaches can be effective when intensively applied to target groups,9,10 there is little evidence that they will have a positive impact on the dietary patterns of the population as a whole.11

Interventions that seek to change the food environment rather than individuals’ behaviour are now advocated as central to delivering real health gains for the community.2,11 Accordingly, in 2009, the Australian Government established the Food and Health Dialogue (the Dialogue).12 In our experience, the Dialogue is now the entity to which state, territory and federal governments and the Australian food industry consistently refer when questioned about actions required to control the large national disease burden caused by poor diet. In the absence of any reported plans for formal evaluation of the Dialogue, our objective was to determine the extent to which the Dialogue is delivering on its initial goals 4 years after its inception and to make recommendations on how its effectiveness might be enhanced.

Methods

We evaluated the Dialogue using the RE-AIM (reach, efficacy, adoption, implementation and maintenance) framework. This method has been used to assess the public health impact of a series of prevention programs and health policies.13,14 The five dimensions of the RE-AIM framework allowed a broad-based assessment of the Dialogue (Appendix 1). Evaluation was preceded by an examination of Dialogue materials and a broader consideration of diet-related ill health in Australia, in an effort to define the scope of the objectives to be assessed and the outcomes that might reasonably be anticipated.

Information about the Dialogue was derived from materials published on the Dialogue website, media releases, communiqués and e-newsletters from its inception in October 2009 to September 2013.12 We systematically searched these Dialogue materials to identify indications of intent, which were then grouped and summarised in terms of the rationale, goals, implementation plans and anticipated outcomes of the Dialogue (Box 1). Progress was evaluated using the RE-AIM framework by systematically reviewing the information collected, defining appropriate metrics for the evaluation of each dimension and, where possible, summarising those metrics in a tabular format. The final set of objectives and the form of the evaluation undertaken were agreed by the authors through an iterative process of review and amendment.

Data describing the processed foods marketed in Australia were extracted from an existing branded food composition database.5 The number of possible food reformulation areas for action (eg, reducing the level of sodium) was calculated by multiplying the number of food categories (n = 22, including five ‘‘other’’ categories comprising products not covered by the Dialogue’s food category definitions; Appendix 2) by the number of action areas (n = 8), then subtracting the 52 combinations where no target was applicable (eg, a sodium target for eggs is unnecessary because the amount of sodium in an egg is not modifiable), leaving a total of 124 areas for action.

Finally, the results were considered in the context of an accountability framework15 and the Australian Competition and Consumer Commission (ACCC) Guidelines for developing effective voluntary industry codes of conduct16 to try to identify recommendations for improvement.

Results

The available data with which to evaluate the Dialogue were limited, with no clear reporting of objectives or planned outcomes, no systematic baseline data collection and little quantitative reporting of progress between October 2009 and September 2013.

Identified goals of the Dialogue

The goals of the Dialogue were identified as “raising the nutritional profile of foods through reformulation, consumer education and portion standardisation” and providing “a framework for government, public health groups and industry to work collaboratively across all levels of the food supply chain to improve dietary intakes” (Box 1).12 Emphasis was given to “food innovation, including a voluntary reformulation program across a range of commonly consumed foods”, seeking to “reduce the saturated fat, added sugar, sodium and energy, and increase the fibre, wholegrain, fruit and vegetable content across nominated food categories”.12

Adoption and implementation

The Dialogue was established as a public–private partnership governed by an Executive Group chaired by the Parliamentary Secretary for Health and Ageing and now comprising representatives from the Australian Food and Grocery Council (AFGC), the Heart Foundation of Australia, Woolworths Limited, the Public Health Association of Australia, the Commonwealth Scientific and Industrial Research Organisation (CSIRO), the Quick Service Restaurant Forum, the Health Promotion Branch of SA Health, and Food Standards Australia New Zealand.

The Reformulation Working Group has identified priority food categories for reformulation and convened a series of industry roundtables to define targets, develop action plans and deliver the agreed outcomes. By September 2013, 11 targets from among the 124 possible action areas (8.9%) had been set (Box 2 and Appendix 3). None of the targets were due to have been achieved, and reporting of progress with their adoption is limited (Box 3). Engagement of the relevant companies in each food category ranges between 60% and 100% (Appendix 4). There have been no reported consumer awareness or education campaigns.

Reach and efficacy

The extent to which the Australian population has obtained access to reformulated foods, foods of standardised portion size and nutrition education has not been reported. There has also been no reporting of the degree to which exposure to reformulated foods and education has affected purchasing patterns, intermediate physiological parameters or measures of diet-related disease burden. Dialogue modelling data project reductions in dietary exposure to sodium from bread, simmer sauces and ready-to-eat breakfast cereals,12 but these claims cannot be objectively substantiated.

Maintenance

The Dialogue Executive Group has recently spoken about plans for a high-level framework for monitoring and evaluation of activities, but there is no documentation describing how this will be funded or delivered. Brief progress reports for some targeted food categories were initially forthcoming (Box 3), but the Dialogue has recently failed to report at the prespecified milestones for most food categories.

Discussion

The Dialogue has highly creditable goals. The emphasis of the work program on making the entire food environment healthier is especially welcome from a public health viewpoint as it represents a significant enhancement to current efforts that focus on trying to persuade individuals to make better food choices. Interventions that change the food environment require only the passive participation of the community and are projected to deliver large health gains for low cost.2,10,11,17,18 In particular, the core strategy of food reformulation has a key advantage over individually targeted behavioural and educational interventions, in that it can be delivered and sustained at scale within a resource-constrained setting.

Unfortunately, while the Dialogue’s goals are laudable, the mechanism for delivering on them has proved inadequate. Few targets have been set, little objective evidence about progress has been provided, and there is a low likelihood that any real health gains have been achieved. Furthermore, the recent decline in submission of progress reports raises concerns that interest is waning. In the context of an industry in which profitability is substantially aided by the addition of salt, sugar and fat to foods, it is perhaps unsurprising that a voluntary model based on a public–private partnership faces these challenges.16,19

Using these findings, we identified a series of suggested actions for strengthening the effectiveness of the Dialogue (Box 4). These recommendations have a focus on transparency and accountability and are substantively underpinned by the Competition and Consumer Act 2010 (Cwlth) and the ACCC guidelines,16 which note that voluntary industry codes must be both well designed and effectively implemented and enforced. The Healthy Weight Commitment Foundation in the United States and the United Kingdom’s Public Health Responsibility Deal have well developed strategies for monitoring and evaluation from which the Dialogue could learn.20,21 In particular, it will be necessary to develop mechanisms that control for the significant conflicts of interest that exist for influential industry umbrella organisations like the AFGC. While it is reasonable for such bodies to argue for a system that maximises profits, the Dialogue was established to reduce health problems, and this is not currently being achieved.

Strengths of our study include its systematic approach and the use of an established framework for assessment. Although the conclusions are limited by the few objective data available about the Dialogue’s progress, it is possible to draw some robust conclusions about the strengths and weaknesses of the process implemented to date. If the listed recommendations (Box 4) can be put in place, a future analysis should be even more informative.

In the meantime, the evidence suggests that the current approach to preventing diet-related ill health in Australia is failing. Australia has an unprecedented burden of disease attributable to poor diet, with no evidence that this is likely to reduce in the near future. The limited effectiveness of entirely voluntary measures in other jurisdictions suggests that some form of responsive regulation is likely to be required.2 While new standards for foods are off the agenda from the food industry perspective, it is clear that regulation can prevent diet-related ill health without harming business.19 Acute food poisoning is now very uncommon in Australia due to extensive but carefully constructed regulations. If the same were done to prevent the “chronic food poisoning” now killing more Australians than even tobacco,1 this would level the playing field for the food industry and make healthy foods the norm.

1 Rationale, approach and potential outcomes of the Food and Health Dialogue

2 Status of Food and Health Dialogue actions on food reformulation and portion size standardisation
4 years after inception

Food reformulation area for action

Food categories*

Sodium

Saturated fat

Added sugar

Energy

Fibre

Whole-grains

Fruit/vegetable content

Portion size

Breads

—

Other bakery products†

—

Ready-to-eat breakfast cereals

Other cereal products†

Simmer sauces

—

Other sauces and spreads†

—

Processed meats

—

Other meat products†

—

Soups

—

Savoury pies

Potato/corn/extruded snacks

—

Savoury crackers

—

Other snack foods†

—

Confectionery

—

Convenience foods

Dairy products

—

Edible oils and emulsions

—

Eggs

—

Fish and fish products

—

Fruit and vegetable products

—

Non-alcoholic beverages

—

Sugars, honey and related products

—

✓

Target achieved

Target set†

No action

—

Not applicable

* Food categories are those defined in the George Institute for Global Health branded food composition database (Appendix 2).5 † Targets set by the Food and Health Dialogue do not always cover all products in the food category (Appendix 3).

3 Time frames for implementation, scheduled reporting and actual reporting for targeted food categories of the Food and Health Dialogue

Food category
(time frame)

Reports
anticipated

Reports published
or missing

Breads
(May 2010 – Dec 2013)

6-monthly in 2010–11, then annually:

Nov 2010

May 2011

Aug 2011 (late*)

Nov 2011

Aug 2012 (very late†)

Nov 2012

Missing

Dec 2013

Ready-to-eat breakfast cereals
(May 2010 – Dec 2013)

6-monthly in 2010–11, then annually:

Nov 2010

May 2011

Aug 2011 (late*)

Nov 2011

Aug 2012 (very late†)

Nov 2012

Missing

Dec 2013

Processed meats
(Jan 2011 – Dec 2013)

6-monthly in 2011–12, then annually:

Jul 2011

Nov 2011 (late*)

Jan 2012

Aug 2012 (very late†)

Jul 2012

Nov 2012 (late*)

Jul 2013

Missing

Dec 2013

Simmer sauces
(Jan 2011 – Dec 2014)

Every 2 years:

Dec 2012

May 2013 (late*)

Dec 2014

Soups
(Dec 2011 – Dec 2014)

Annually from Feb 2012:

Feb 2012

Missing

Feb 2013

Missing

Feb 2014

Dec 2014

Savoury pies
(Mar 2012 – Mar 2014)

6-monthly:

Sep 2012

Missing

Mar 2013

May 2013 (late*)

Sep 2013

Missing

Mar 2014

Potato/corn/
extruded snacks
(Dec 2012 – Dec 2015)

6-monthly for first year, then annually:

Jun 2013

Missing

Dec 2013

Dec 2014

Dec 2015

Savoury crackers
(Dec 2012 – Dec 2015)

6-monthly for first year, then annually:

Jun 2013

Missing

Dec 2013

Dec 2014

Dec 2015

na = not applicable at time of writing (Sep 2013). * ≤ 6 months overdue.
† > 6 months overdue.

4 Recommendations for strengthening the effectiveness and accountability of the Food and Health Dialogue

Agreed objectives

Leadership from ministerial level of government
Coordination with strategy on front-of-pack labelling
Substantial new investment in Dialogue activities
Broader engagement to include all relevant stakeholder groups from government, industry, public health, academia and other organisations
New process for target-setting that removes conflicts between private-sector profit motives and public health objectives, adopts applicable overseas targets in the interim, and sets maximum acceptable levels
Industry roundtables focus on implementation activities

Monitoring and evaluation

Clear and meaningful objectives defined with timelines
Process, intermediate and definitive health outcomes to be specified
Objective third party delegated to measure and report on achievement of objectives
Economic evaluation to be conducted
Representative from Australian Competition and Consumer Commission to be appointed as an independent observer

Reporting

Transparency of Dialogue processes — open meetings of Executive Group, Reformulation Working Group and roundtables, published meeting agendas and minutes
6-monthly scorecards reported for all outcomes
Comprehensive information provided on the website

Enforcement

Agreed Dialogue targets enshrined as Codes of Practice by Food Standards Australia New Zealand
Strategy to reward corporate participation and discourage non-compliance
Consideration of responsive regulation to support Dialogue activities
Documented plan to move from voluntary to regulatory mechanism if objectives not achieved

Iterative modification

Rolling review of each target every 5 years, with resetting as required
Annual review of Dialogue objectives against performance
Mechanism for review and upgrading of Dialogue approach as required