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

Chronic 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.

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.

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.

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