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Nutrition - 2018

07 Jan 2018

AMA Recommendations

  • Improving the nutrition and eating habits of Australians must become a priority for all levels of government. Governments should consider the full complement of measures available to them to support improved nutrition, ranging from increased nutrition education and food literacy programs, through to mandatory food fortification, price signals to influence consumption and restrictions on food and beverage advertising to children.
  • Australian Dietary Guidelines and related resources must reflect contemporary evidence and be reviewed regularly.

 Aboriginal and Torres Strait Islander people

  • Nutrition is an important aspect in efforts to Close the Gap, and efforts to improve nutrition must recognise the importance of increasing food security for Aboriginal and Torres Strait Islander people.

 Children

  • Healthy eating habits and attitudes towards food are established in early childhood. Along with providing nutrition education and support to parents, resources must also be available to other caregivers, and childcare facilities and schools should aim to reinforce clear messages about health eating.
  • Advertising and marketing of unhealthy foods and beverages to children influences their preferences and should be prohibited.

 Elderly

  • Nutrition needs change over time. Good nutrition is an important aspect of healthy ageing, and health care professionals should discuss this with their patients.
  • All aged care facilities should provide fresh nutritious foods to their residents to prevent malnutrition. To ensure that this occurs, the AMA supports the development and implementation of National Nutrition Standards for aged care facilities.

 Health care settings

  • To improve the health of patients, staff and visitors, hospitals and other residential health care facilities should provide access to healthy foods, including plant-based meals and meals that are low in fat, sodium and added sugars, as well as no and low sugar beverages.
  • Vending machines containing sugary drinks and other unhealthy food items should be removed from all health care settings or be replaced with vending machines offering only healthy food and beverage choices.

 Medical Profession

  • Medical practitioners are well placed to identify, educate and support patients who need to improve their nutrition. Engaging, informative and evidence-based nutrition education and support material should be available to support medical practitioners in this work.
  • Allied health professionals, including Accredited Practising Dieticians, can work with medical practitioners to provide additional support and advice to patients around nutrition and eating habits.

 Food and diet industries

  • Water should be promoted and provided as the default beverage option.
  • Continued uptake of the Health Star Rating (HSR) system on packaged foods and beverages must be evident. If this does not occur, the system will need to be mandated.
  • The food industry must act in a socially responsible manner in food promotion and marketing, including realistic portion sizes and reductions in unnecessary sugars, salt and fats from processed foods.
  • Food retailers should work with developers and local councils to reduce food deserts.

 Governments

  • A tax on sugar sweetened beverages should be introduced as a matter of priority.
  • It is vital that fresh, minimally processed foods, such as fruit and vegetables, are affordable for all (including those on low or fixed incomes), even if it contradicts market demands.
  • The Federal Government should continue food fortification programs that benefit the public at a population level, as well as population level monitoring that would identify new and emerging micronutrient deficiencies.
  • Recognising the wealth of information on nutrition, it is vitally important that the relevant authorities regularly review and update dietary guidelines, and associated clinical guidelines.
  • Governments must invest in programs that seek to improve nutrition literacy, including community-wide and more targeted programs with messages that are salient and practical.
  • Governments must support continued research and investment into evidence-based policy responses to food insecurity in Australia. Financial support must extend to local community responses, such as food banks, community gardens and cooking programs.
  • Governments must work with the food industry to improve the ability for people to distinguish between naturally occurring and added sugars. This may be done with refinements of the HSR system.
  • Governments must support Australian research into interventions that improve eating behaviours.
  • Governments must continue to support programs that collect data (including blood and urine samples) to measure Australia’s current nutritional status and identify trends and ongoing needs.

 

Preamble

Nutrition, the intake of food and beverages, is a key determinant of health. Nutrition requirements are influenced by factors such as age, sex, height, weight, physical activity levels and disease status.[1]  Well balanced, adequate nutrition contributes to growth and development in infants and children and contributes to good health in adulthood. Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity.[2]

Nutrition is an important public health issue. Globally, the burden of non-communicable disease has increased significantly and continued growth is expected. Poor nutrition is a significant contributor to the non-communicable diseases such as cardiovascular disease, type 2 diabetes and certain cancers.[3] Poor diet is a factor in one in five deaths around the world, and diet is the second highest risk factor for early death after smoking.[4]

Despite many Australians having access to high quality fresh foods, most do not consume these in the  recommended amounts. Instead, over one-third of food intake comes from highly processed foods and beverages classified as discretionary.[5] These foods are commonly referred to as ‘junk foods’.

Obesity

Given the significant consumption of discretionary foods, and low levels of physical activity, it is not surprising that more than half of Australian adults have a body weight that puts their health at risk. Foods and beverages that are energy-dense are often highly palatable. Even a small persistent food intake that is more than required is enough to cause excess weight gain over time. The AMA has a specific position statement on Obesity – 2016.

What is a healthy diet?

Current Australian Dietary Guidelines emphasise the importance of consuming a variety of foods from each of the five food groups that is sufficient for individual energy needs. The five food groups include: vegetables; fruit; grains; lean meats and poultry, fish, eggs, nuts and seeds, legumes/ beans; and milk, yoghurt, cheese and/or alternatives. Guidelines also recommend that people limit consumption of foods containing saturated fats, added salt, added sugar and alcohol. Consuming a diet that is consistent with the  Guidelines will promote health, protect against disease and reduce the prevalence of nutrient deficiencies.[6]

There is a broad array of ‘diets’ and eating plans that make claims including weight loss, longevity and increased energy. Many of the recommendations contained in these programs are not supported by evidence. Some diets work, often because they involve energy restriction. Unfortunately many of these diets exclude entire food groups, are unnecessarily rigid, require use of expensive supplements and other products, are time consuming and as a consequence are extremely difficult to maintain in the longer term.  Weight that has been lost through such regimes is quickly regained. It is preferable to make small, manageable changes in eating patterns that can be maintained in the longer term.

Vegetarian, or plant-based, diets are increasingly popular, not only due to the perceived health benefits, but also because people believe it is more sustainable and has less impact on the environment. The Australian Dietary Guidelines reference a range of measures that can address these concerns including reducing food wastage, avoiding overconsumption, and eating in a way that recognises the seasonal availability of fruits and vegetables. These measures can be followed by those who continue to consume lean meat. Growing concerns about the health effects of processed meats are noted.[7]

There is ongoing concern about the health implications of a diet high in refined and added sugar.[8] While some sugar is naturally occurring in foods such as fruit, vegetables and dairy, it is the addition of sugar to processed foods that is concerning.[9]

Sugary beverages provide individuals with large quantities of sugar and provide little or no satiety.  Australians consume large quantities of soft drinks.[10] Large container sizes of soft drinks are significantly cheaper than single serving sizes, which also contributes to overconsumption. Flavoured waters, sports drinks and fruit juices also contain significant quantities of added sugars. Energy drinks are popular among young people. These beverages also contain large quantities of caffeine and should not be readily available to those aged under 18 years. The AMA supports proposals to apply a tax or levy to sugar-sweetened beverages in Australia in order to reduce consumption.

People must be encouraged to drink water and it should be the default beverage option, including all instances where a beverage is provided with a meal. Consuming fluoridated tap water provides additional benefits, including the strengthening of tooth enamel, making teeth more resistant and reducing early decay.[11]

Food fortification

There may be times when foods are fortified or enriched with particular micronutrients. This can be done on a voluntary basis, or where it might make a food product more desirable.  When population level public health gains are substantial, the Government may require food manufacturers to add certain vitamins and minerals to foods or specific ingredients. A number of mandatory food fortification initiatives in Australia exist, and recent reviews have found them to be successful.[12]

Food allergies and dietary intolerances

Some individuals suffer from serious, life threatening food-induced anaphylaxis, food allergies and other medical conditions which prevent them from consuming certain foods. These individuals will be in contact with medical practitioners and dieticians to help manage their condition and ensure that they are consuming an appropriately balanced diet. Accurate allergen labelling is vitally important to reduce the harm of accidental food exposures.

Food allergies should not be confused with ‘intolerances’. There has been a significant growth in food intolerances, many of which are self-diagnosed. Individuals concerned that certain foods are making them feel unwell should consult their doctor for appropriate investigation and management. 

Supplements

There is an increasing number of dietary supplements available. Only a small number of these products are medically indicated. Food supplementation is very popular in fitness and sporting spheres, although the reality is that only a small number of high performing athletes actually require it. There are additional safety concerns in relation to those products that are manufactured in countries where food safety and labelling requirements are less stringent.

Food insecurity

Food insecurity occurs when people have difficulty or are unable to access appropriate amounts of food.[13] It has been estimated that four per cent of Australians experience food insecurity,[14] though it is likely the extent of the problem is much higher. Food insecurity is associated with a range of factors, including unstable living situations, geographic isolation and poor health. It is more prevalent in already disadvantaged communities. In households with limited incomes, food budgets can be seen as discretionary and less of a priority. This can result in disrupted eating habits and an over-reliance on less nutritious foods. Food insecurity can have significant health implications, such as increased hospitalisation and iron deficiency anemia (in children) and increased kidney disease, type 2 diabetes and mental health issues (among adolescents and adults).[15]

Aboriginal and Torres Strait Islander people

Poor nutrition has been linked to the reduced health outcomes experienced by Aboriginal and Torres Strait Islander people, contributing to conditions known to disproportionately affect this population, including type 2 diabetes, kidney disease and some cancers.[16]

Twenty two per cent of Aboriginal and Torres Strait Islander people live in a household that has, in the past 12 months, run out of food and not been able to purchase more. Food insecurity increases for Aboriginal and Torres Strait Islander people who live in remote areas.[17]  Efforts to Close the Gap must recognise the potential impacts of improved nutrition on health outcomes, as well as the implications of food insecurity. The development and implementation of potential solutions must be led by Aboriginal and Torres Strait Islander people.

The nutrition of Aboriginal and Torres Strait Islander people living in remote communities may be heavily dependent on Outback Stores. The 2009 Parliamentary Inquiry ‘Everybody's Business: Remote Aboriginal and Torres Strait Community Stores’ resulted in a number of practical recommendations to increase the availability and affordability of healthy foods in Outback Stores, many of which have not been implemented. These Stores, in consultation with local communities, should prioritise and facilitate access to affordable nutritious foods.

Health care settings

Health care settings such as hospitals, provide food for patients, their families, as well as staff and other visitors, and play a key role in reinforcing the importance of healthy eating. Patients and their visitors may be particularly receptive to messages on good nutrition.The food provided in health care settings must be consistent with the goals of improving and maintaining health and should include options that are plant-based, low in fat, salt and added sugars. Vending machines containing sugary drinks must be removed from all health care settings or be replaced with vending machines offering only healthy food and beverage choices. Water and other low sugar beverages should be promoted as the beverages of choice. Health care facilities should provide free access to water for staff, patients and visitors.

Patients with serious and complex health conditions, such as oncology patients, can have very specific nutrition requirements that must be met during their treatment. Health care facilities must ensure that these needs are met.

Nutritional literacy

Australians have low levels of health literacy.[18] Nutrition education and food literacy are important aspects of supporting Australians to make healthier food choices. Education and awareness campaigns should seek to promote simple, easy to understand messages around healthy eating.

Infants and children

Targeting women of child bearing age, and their partners, has the potential to improve their eating habits, as well as that of their children. Good nutrition starts during pregnancy, and continues through infancy and childhood.  Information about infant feeding and the transition to solid foods is provided in the AMA’s position statement Infant Feeding and Parental Health – 2017.

Children learn about food through exposure to a variety of foods, and also observing how the adults around them interact with food. The foods that are available in childcare settings and schools should reinforce messages about healthy eating. Policies about foods brought from home should be complemented with education and support for parents and must not be excessively restrictive. School programs, including canteen policies, home economics and gardening activities can also have a positive impact on children’s dietary behaviours. Programs that incorporate engagement with parents can see benefits of nutrition education and food literacy extend to the broader community.

Elderly

Energy needs decline as people age and, for some individuals, this is accompanied by a decreased appetite. Transition in living circumstances, and income, may also contribute to a decline in eating habits. There is an increased protein requirement in older persons.  Poor nutrition can contribute to many health conditions and the worsening of pre-existing conditions. Lack of appropriate nutrition can also adversely impact the effectiveness of certain medications.  In order to maximise functional capacity in the elderly, ensuring appropriate nutrition is vital. This is particularly important for those in residential aged care, where there can be pressure to reduce amount spent on food. To ensure people living in residential aged care receive appropriate nutrition the AMA supports the development and implementation of national nutrition standards for these facilities.

Food labelling

Food labelling should assist people to understand the content of packaged foods and beverages. It should be easy to understand, noting that certain aspects of this information is known to be perceived as complex and confusing.

The Health Star Rating (HSR) system has been developed to provide shoppers with simplified and uniform ‘front of pack’ labelling to compare similar products, in order to identify the healthiest option. The HSR is currently voluntary, allowing the food industry time to alter their packaging. However, research shows that shoppers want to see HSR on more products.[19] Unless the system is widely adopted, it will need to be mandated.  Research has shown that shoppers use the HSR, and that it helps identify healthier food choices that are maintained in the longer term. The HSR has resulted in some food producers reformulating their products to achieve a higher rating.  The algorithms underpinning the HSR will benefit from continued monitoring and refinement. The AMA believes that the HSR should be adapted to help people to distinguish between added and naturally-occurring sugars in processed foods.

Increased knowledge does not always result in sustained behaviour change.  To achieve any meaningful improvements in the eating habits of Australians, it must be recognised that food choices are not always the result of considered decision-making, and they can be influenced by a range of environmental and other cognitive factors.

The food environment (and food decision-making)

Food deserts are areas where it is difficult to purchase affordable fresh foods due to geographic distances to markets and supermarkets. Instead, food deserts provide a range of less healthy, cheap, takeaway food options. Difficulties in accessing fresh and healthier foods have flow-on effects including increased health complications, as well as overweight and obesity. It should be a goal of town planning and local and State governments to identify food deserts and to work with developers to ensure that access to fresh foods is improved, and to prevent future food deserts from occurring.

Food selection

Food selection is often not the result of considered thinking. More often it is a quick, automatic decision that is vulnerable to various cues. For example, larger portion sizes result in increased consumption. Similarly, it is recognised that supermarket design influences purchasing and consumption patterns. Packaging and produce placement is used to encourage shoppers to purchase certain products.  Even the range of packaged food products offered in supermarkets is known to increase stimulation, which can also impair decision making. Food producers and retailers need to acknowledge their role and become more socially responsible in their activities. Without their engagement it will be extremely difficult to improve the eating habits of Australians in a meaningful way.

Targeted marketing of unhealthy foods and beverages to children

Children are not always able to distinguish between factual information and promotional material, making them particularly vulnerable to the influences of advertising. Children are exposed to unhealthy food and beverage advertising through a range of media avenues, including television and the internet. Despite an Industry Code of Conduct, instances where advertising is complemented by competitions and premiums, such as the provision of small toys to accompany children’s ‘meals’, continue to occur. The AMA calls for these activities to stop.

Like other industries, food producers and retailers exist to sell their products and make profits. Governments are often hesitant to intervene and support measures that may see any reduction in profits. However, increasingly poor nutrition, with the consequences of increases in overweight and obesity with associated health problems, are costing the Australian health system precious resources.  Despite arguments from representatives from the food and beverage industry that they want to be part of efforts to improve nutrition and reduce obesity, the credibility of these statements is undermined by their lack of engagement around evidence-based interventions.

Government

All levels of government play a role in nutrition and food policies. This includes investment in programs that seek to improve nutrition, often via increasing nutrition education and food literacy, as well as reducing obesity. Such investments benefit from strong collaborations with local communities who are aware of the needs at a local level. All programs benefit from consultation with representatives from their target audience to ensure messages are salient and practical.

All governments should be canvassing opportunities to engage with food producers and retailers to further support improved nutrition. The HSR proves that representatives from the health sector, the food industry and governments can work together to support healthier food choices. These efforts must not stop at food labelling. There is strong agreement among health bodies that prohibiting food advertising to children, and a tax on sugar sweetened beverages, are the required next steps. Ideally, the food industry should be part of the process of refining and implementing these interventions, but progress should not be slowed by their unwillingness.

References


1 Australian Institute of Health and Welfare 2012. Australia’s food & nutrition 2012. Cat. no. PHE 163. Canberra: AIHW. Available from: https://www.aihw.gov.au/getmedia/0c26b145-81fa-4a94-af38-d52515885a07/12504.pdf.aspx?inline=true

2 World Health Organisation. (2013) Global nutrition policy review: What does it take to scale it up?. WHO. Available from: http://apps.who.int/iris/bitstream/10665/84408/1/9789241505529_eng.pdf?ua=1

3 World Health Organisation. (2004). Global Strategy on Diet, Physical Activity and Health. WHP. Available from: http://www.who.int/dietphysicalactivity/strategy/eb11344/strategy_english_web.pdf

GBD 2016 Risk Factors collaborators. (2017). Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: A systematic analysis of the Global Burden of Disease Study 2016. The Lancet, 390: 1345-1422. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32366-8/fulltext

Australian Bureau of Statistics.  4364.0.55.007 - Australian Health Survey: Nutrition First Results - Foods and Nutrients, 2011-12 . Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.007~2011-12~Main%20Features~Discretionary%20foods~700

6 National Health and Medical Research Council (2013) Australian Dietary Guidelines. Canberra: National Health and Medical Research Council. Available from: https://www.nhmrc.gov.au/_files_nhmrc/file/publications/n55_australian_dietary_guidelines1.pdf

7 Petemadi, A., Sinha, R., Ward, M. H., Graubard, B. I., Inoue-Choi, M., Dawsey, S. M., & Abnet, C.C. (2017). Mortality from different causes associated with meat, heme iron, nitrates and nitrates in the NIH-AARP Diet and Health Study: Population based cohort study. BMJ, 357, J1957.

8 Yang, Q., Zhang, Z., & Gregg, E.W. (2014). Added sugar intake and cardiovascular diseases mortality among US adults. JAMA Intern Med, 174(4):516-524. Available from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1819573

9 World Health Organisation. (2015). Guideline: Sugars intake for adults and children. WHO. Available from: http://apps.who.int/iris/bitstream/10665/149782/1/9789241549028_eng.pdf?ua=1

10 Hector D, Rangan A, Louie J, Flood V, Gill T (2009). Soft drinks, weight status and health: a review. Sydney: A NSW Centre for Public Health Nutrition (now known as Cluster of Public Health Nutrition, Prevention Research Collaboration, University of Sydney) project for NSW Health. Available from: http://www.health.nsw.gov.au/heal/Publications/soft-drinks-report.pdf

11 National Health and Medical Research Council (NHMRC) 2017, Information paper – Water fluoridation: dental and other human health outcomes, report prepared by the Clinical Trials Centre at University of Sydney, NHMRC; Canberra. Available from: https://www.nhmrc.gov.au/_files_nhmrc/file/your_health/fluoridation/17378_nhmrc_-_information_paper.pdf

12 Australian Institute of Health and Welfare 2016. Monitoring the health impacts of mandatory folic acid and iodine fortification. Cat. no. PHE 208. Canberra: AIHW. Available from: https://www.aihw.gov.au/reports/food-nutrition/monitoring-health-impacts-of-mandatory-folic-acid/formats

13  Rosier, K. (2011). Food Insecurity in Australia. Communities and Families Clearinghouse Australia Practice Sheet. Available from: https://aifs.gov.au/cfca/sites/default/files/publication-documents/ps9.pdf

14 Lindberg, R., Lawrence, M., Gold L., Friel, S., Pegram, O. Food insecurity in Australia: Implications for general practitioners. Australian Family Physician, 44(11): 859-862.  Available from: https://www.racgp.org.au/afp/2015/november/food-insecurity-in-australia-implications-for-general-practitioners/

15 Lindberg, R., Lawrence, M., Gold L., Friel, S., Pegram, O. Food insecurity in Australia: Implications for general practitioners. Australian Family Physician, 44(11): 859-862.  Available from: https://www.racgp.org.au/afp/2015/november/food-insecurity-in-australia-implications-for-general-practitioners/

16 Australian Health Ministers’ Advisory Council, 2015, Aboriginal and Torres Strait Islander Health Performance Framework 2014 Report, AHMAC, Canberra. Available from: https://www.pmc.gov.au/sites/default/files/publications/indigenous/Health-Performance-Framework-2014/tier-2-determinants-health/219-dietary-behaviours.html

17 Australian. Bureau of Statistics. 4727.0.55.005 - Australian Aboriginal and Torres Strait Islander Health Survey: Nutrition Results - Food and Nutrients, 2012-13. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4727.0.55.005~2012-13~Main%20Features~Food%20Security~36

18 Australian Commission on Safety and Quality in Health Care. Health literacy: Taking action to improve safety and quality. Sydney: ACSQHC, 2014. Available from:  https://www.safetyandquality.gov.au/our-work/patient-and-consumer-centred-care/health-literacy/

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Published: 07 Jan 2018