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Promotion of unhealthy foods and beverages to children is a significant, modifiable risk factor for child obesity and development of diet-related non-communicable diseases.1 Comprehensive, independent reviews of the evidence consistently find that commercial food marketing has a direct effect on children s food preferences, purchase requests, consumption patterns and diet-related health.2-4Current marketing practices in New Zealand predominantly promote unhealthy foods and drinks to children.5 The most common categories of food products promoted to children are pre-sugared breakfast cereals, soft drinks, savoury snacks, confectionery and fast foods.3 Estimates of the proportion of food marketing promoting these product categories to children vary from 60% to 90%.3 A US federal Trade Commission survey of industry expenditure reported 63% of the marketing spend directed to children was for carbonated drinks, fast food and breakfast cereals.6 Analysis of UK television channels popular with young people found six of the 10 most frequently advertised food items were fast food, high sugar/low fibre breakfast cereals, confectionery and snack foods.7 A similar study in New Zealand reported that 66% of food advertisements on a free-to-air channel popular with children were for foods high in fat, salt or sugar.8Several national governments and food and beverage manufacturers have acted to restrict unhealthy food marketing to children or to allow the promotion of healthier choices only. Countries such as Norway, Sweden and the province of Quebec, Canada have statutory regulation (a formal legislative requirement by government) restricting the advertising of any product to children, and Ireland, UK and South Korea have regulations to restrict advertising of specified foods and beverages during children s programming or peak viewing times.9 A number of food and beverage companies have also responded with voluntary pledges (non-legislatively required commitments) to change their marketing activities directed to children, and the mix of foods advertised to children.10,11 New Zealand does not have statutory legislation on the advertising of foods to children but 67% of the major packaged food manufacturers and 20% of the biggest fast food restaurants have a voluntary policy on food marketing to children on their company website. However, none of those include an accepted nutrient profiling model.12A systematic review of the impact of statutory and voluntary codes to limit the advertising of foods to children found a sharp division in the evidence however, with scientific peer-reviewed evidence showing small or no reductions in promotion of less healthy foods and children s exposure to food marketing, except in response to statutory regulation. 9 In contrast, industry-sponsored reports indicate high adherence to voluntary codes.9 Discrepancies are likely to be due to lack of complete coverage of voluntary codes across all food companies, differences in audience definitions (times children are likely to be watching television versus children s programming times), and different systems to classify foods as unhealthy or non-core . Adherence to voluntary codes may therefore not sufficiently reduce the advertising of unhealthy foods or children s exposure to such advertising.9An accepted food classification or nutrient profiling system is necessary to classify foods as suitable/unsuitable for marketing to children and to implement restrictions. Examples of systems used for this purpose are the UK Ofcom model, the Scandinavian Keyhole model, the US Interagency Working Group proposals13 and the World Health Organization (WHO) Regional Office for Europe Nutrient Profiling Model.14In February 2016, the Advertising Standards Authority (ASA) announced a review of the ASA Children s Codes (Code for Advertising to Children and Children s Code for Advertising Food).15 The consultation document contained a specific question on the role of nutrient profiling systems in the Children s Codes, Is there a role for a nutrient profiling system such as the health star rating system in the Children s Codes? If yes, in what way and which system would you suggest?To inform our response to this question, we compared three accepted nutrient profiling systems: the Health Star Rating (HSR), the Ministry of Health Food and Beverage Classification System (FBCS) and the World Health Organization (WHO) Regional Office for Europe Nutrient Profiling Model (WHO Model) to identify the best system to protect New Zealand children from exposure to the marketing of unhealthy foods and beverages.MethodsSelection of Nutrient Profiling SystemsThree nutrient profiling systems were selected for comparison. Two were established New Zealand systems: the HSR and the Ministry of Health FBCS, and one was an international system: the WHO Model. Table 1 provides an overview of each system.Table 1: Summary of criteria used under each nutrient profiling scheme. Nutrient profiling system Purpose Scoring Nutrients to limit Nutrients or components to promote Examples HSR16 Front-of-pack nutrition labels on packaged foods to assist consumers in discriminating and comparing foods within categories Products receive a Health Star Rating between \u00bd star and 5 stars from an overall score based on food components with positive or negative associations with chronic disease. Energy, saturated fat, total sugars, sodium Protein, fibre, percentage of food that is fruits vegetables nuts and legumes Sugar sweetened soft drinks = 100% of products receive <3.5 stars Frozen vegetables = 100% of products receive >3.5 stars FBCS18 Guidelines for schools to identify healthy food and drink options for sale on campus Foods are either everyday sometimes or occasional foods depending on alignment with food and nutrition guidelines Added fat, added salt, added sugar Sugar sweetened soft drinks = occasional Frozen vegetables = everyday WHO Model14 Restriction of marketing of unhealthy foods to children Foods are either permitted or not permitted according to nutrient thresholds for different food categories Total fat, saturated fat, total sugars, added sugars, non-sugar sweeteners, salt, energy Sugar sweetened soft drinks = not permitted Frozen vegetables = permitted HSR is an interpretive, front-of-pack nutrition labelling scheme adopted by New Zealand in 2014.16 HSR rates the nutrition content of packaged foods in half-star increments from half a star (least healthy) to 5 stars (most healthy) and is designed to help consumers compare foods within categories. The number of stars is calculated based on the nutritional profile of the food. To calculate the HSR score, a product is placed in one of six HSR food categories; baseline points are calculated based on energy, saturated fat, total sugar and sodium content per 100g; modifying points are calculated based on the amount of fruits, vegetables, nuts and legumes (V points) and in some instances, protein (P points) and fibre (F points). The final HSR score = Baseline points \u2013 (V points) \u2013 (P points) \u2013 (F points). Lower scores indicate a better (healthier) nutrient profile. HSR is a continuous scoring system with scores ranging from approximately -24 to +45 (unpublished analysis of a 2012 database of approximately 17,000 New Zealand packaged products), and a cut point to dichotomise foods as healthy/unhealthy has not yet been widely agreed. However, work commissioned by the New South Wales Ministry of Health on the alignment of HSR with existing Traffic Light schemes and the 2013 Australian Dietary Guidelines reported that \u201chealthy core foods with a HSR of \u22653.5 can be confidently promoted in public settings as healthier choices\u201d.17 This cut point has been proposed for use in New Zealand as a means of identifying packaged foods consistent with District Health Boards Healthy Food Policy and suitable for sale in hospitals.The FBCS was developed by the Ministry of Health in 2007 to support healthy eating environments in New Zealand schools and identify healthy foods suitable for provision in schools.18 The FBCS classifies foods and beverages as everyday , sometimes or occasional foods based on the Food and Nutrition Guidelines for Healthy Children and Adolescents. Everyday foods are from the four core food groups, whilst sometimes foods are mostly processed foods with some added fat and/or salt and/or sugar, and occasional foods are high in saturated fat and/or salt and/or added sugar (eg confectionery, deep-fried foods and sugar-sweetened drinks). The FBCS is the basis for the Heart Foundation s Fuelled4Life programme19 and the TVNZ and Mediaworks ThinkTV children s food advertising guidelines.20The WHO Model was specifically designed for the purpose of restricting the marketing of foods to children and was published in 2015.14 It was developed following extensive consultation with European member states, and is based on three nutrient profile models currently in use in Europe for restricting marketing to children. It encompasses 17 food categories including fruit, vegetables and ready-made meals. Certain food categories are not permitted to be marketed to children under any circumstances. These include chocolate and confectionery, cakes and sweet biscuits, juices and energy drinks. Conversely, unprocessed meat and fish, and fresh/frozen fruit and vegetables can be marked without restriction. Maximum nutrient level cut points are applied to determine the eligibility of foods in all other categories to be marketed to children.A key difference between HSR and the other two systems is that HSR is for packaged foods only whilst the FBCS and the WHO Model also incorporate fresh, mixed and cooked meals.Database of New Zealand packaged foodsIn order to compare nutrient profiling schemes, a common set of products were classified using each scheme and compared. The 2014 New Zealand Nutritrack packaged food database was used for this purpose. Nutritrack food composition data are collected directly from labels of all packaged foods and non-alcoholic beverages available in four Auckland supermarkets during field surveys undertaken between February and May each year. Standardised data collection methods were developed for an international collaborative project to compare and monitor the nutritional composition of packaged foods.21 Supermarkets chosen for data collection represent the biggest retail brands of the main supermarket retailers in New Zealand (Foodstuffs (54% grocery market share) and Progressive Enterprises (38% market share) 22 and stores were selected for their large product ranges. Nutrition information is recorded for all packaged products displaying a Nutrition Information Panel. Alcohol and products that do not carry a Nutrition Information Panel, eg fresh produce, bakery and delicatessen items are excluded.For each packaged product with a Nutrition Information Panel, the brand name, product name, ingredient list and content of energy, protein, total fat, saturated fat, total carbohydrate, sugars, fibre (where available) and sodium per 100 g or mL are recorded in a searchable web-based database. Nutritional information recorded is for products as sold (ie not as prepared ) in order to maximise within-category product comparability (since preparation instructions vary and can have a significant impact on final composition) and different pack sizes of the same product are recorded as separate items. All data are checked and cleaned before analysis. Any data entry errors identified by value range checks and random checks are corrected using source data (product photographs). Each product is assigned to a basic food group (Level 1, 13 groups) and a specific food category (Level 2, 41 categories).21 Level 4, the most finely grained food grouping in the system, has 428 categories. Where fibre content is not listed on a product Nutrition Information Panel (it is not mandatory), we apply the food category average. We also apply a standardised category-specific fruit, vegetable, nut and legume (V Points) value, based on expected content within food category, in order to calculate HSR scores.AnalysisA total of 13,066 packaged food products across 14 broad food categories were analysed after exclusions were made. Food categories in the Nutritrack database not included in the analysis were: alcoholic beverages, herbs and spices, coffee and tea, sugars and baking ingredients, coatings/breadcrumbs, baby food and supplements, as these were not covered by the three nutrient profiling systems.The remaining 13,066 packaged foods were classified as restricted or not restricted as per the WHO model; everyday/sometimes or occasional as per the FBCS model; and <3.5 stars or \u22653.5 stars as per the HSR model. The FBCS does not apply to certain food groups, including cooking oils, sauces and spreads, jam and marmalade, honey, butter and margarine, pickled vegetables, so these were excluded (N/A) for that model. The proportion and types of packaged foods that met the criteria for all three systems or none of the systems and the types of food products classified as restricted under the WHO model but classified as everyday/sometimes (FBCS model) or as having >3.5 stars, were determined.ResultsThere was a fairly even distribution of New Zealand packaged foods across the 10 HSR categories from 0.5 to 5 stars, although proportions of packaged foods with 4.5 stars (5%) or 5 stars (5%) were noticeably lower than those in other HSR categories (range 8\u201314%, mean 10%) (Figure 1).Figure 1: Proportion of New Zealand packaged foods (n=13,066) within each Health Star Rating category. The three nutrient profiling systems were broadly similar in their proportional classification of permitted foods overall with approximately one-third (29\u201339%) of packaged foods meeting the eligibility criteria for each system: 29% under the WHO model, 36% under the HSR system (>3.5 stars), and 39% under the FBCS system (everyday or sometimes foods) (Table 2).Table 2: Classification of New Zealand packaged foods (n=13,066) by each nutrient profiling system. Food category and key sub-categories HSR WHO Model FBCS <3.5 stars \u22653.5 stars R NR O E/S N/A All foods 13,066 63.7 36.3 70.9 29.1 41.4 39.3 19.2 Bread and bakery products 1,603 73.1 26.9 74.3 25.7 63.6 36.4 0.0 Biscuits 736 88.5 11.5 99.7 0.3 89.1 10.9 0.0 Bread 484 30.6 69.4 15.3 84.7 7.0 93.0 0.0 Cakes, muffins and pastries 383 97.4 2.6 100.0 0.0 85.9 14.1 0.0 Cereal and cereal products 1,264 38.8 61.2 50.4 49.6 34.7 65.3 0.0 Breakfast cereals 358 22.9 77.1 66.5 33.5 24.6 75.4 0.0 Cereal bars 221 80.5 19.5 100.0 0.0 92.8 7.2 0.0 Confectionery 804 89.2 10.8 100.0 0.0 94.7 5.3 0.0 Convenience foods 726 44.2 55.8 66.3 33.7 16.7 83.3 0.0 Pre-prepared salads and sandwiches 51 35.3 64.7 92.2 7.8 11.8 88.2 0.0 Pizza 54 74.1 25.9 100.0 0.0 63.0 37.0 0.0 Ready meals 274 31.0 69.0 97.4 2.6 19.3 80.7 0.0 Soups 330 49.7 50.3 29.1 70.9 3.6 96.4 0.0 Dairy 1,743 67.4 32.6 85.9 14.1 39.3 60.7 0.0 Cheese 600 78.0 22.0 86.7 13.3 0.0 100.0 0.0 Cream 50 98.0 2.0 98.0 2.0 98.0 2.0 0.0 Desserts 172 78.5 21.5 100.0 0.0 65.1 34.9 0.0 Ice cream and edible ices 336 96.7 3.3 100.0 0.0 82.4 17.6 0.0 Milk 293 21.5 78.5 70.3 29.7 59.4 40.6 0.0 Yoghurt and yoghurt drinks 292 46.2 53.8 73.6 26.4 25.0 75.0 0.0 Edible oils and oil emulsions 303 46.9 53.1 20.1 79.9 0.0 0.0 100.0 Eggs 76 0.0 100.0 0.0 100.0 0.0 100.0 0.0 Fish and seafood products 484 18.8 81.2 10.3 89.7 12.0 88.0 0.0 Fruit, vegetables and nut products 1,539 35.7 64.3 62.8 37.2 10.1 68.5 21.4 Fresh packaged fruit and vegetables 51 0.0 100.0 0.0 100.0 0.0 100.0 0.0 Dried fruit 179 56.4 43.6 98.9 1.1 19.0 81.0 0.0 Frozen fruit 40 0.0 100.0 0.0 100.0 0.0 100.0 0.0 Fruit bars 35 42.9 57.1 100.0 0.0 100.0 0.0 0.0 Nuts and seeds 198 41.9 58.1 37.4 62.6 40.4 59.6 0.0 Jam and marmalades 151 96.0 4.0 100.0 0.0 0.0 0.0 100.0 Canned vegetables 263 23.2 76.8 44.1 55.9 0.0 100.0 0.0 Frozen vegetables 120 0.0 100.0 0.8 99.2 0.0 100.0 0.0 Frozen potato products 81 4.9 95.1 79.0 21.0 7.4 92.6 0.0 Meat and meat products and alternatives 1,069 69.9 30.1 40.3 59.7 69.6 30.4 0.0 Processed meat 1,005 72.5 27.5 37.9 62.1 73.9 26.1 0.0 Non-alcoholic beverages 1,116 74.6 25.4 89.1 10.9 91.1 8.9 0.0 Beverage mixes 69 100.0 0.0 100.0 0.0 100.0 0.0 0.0 Sugar-sweetened cordials 71 98.6 1.4 95.8 4.2* 100.0 0.0

Summary

Abstract

Aim

Promotion of unhealthy foods and drinks is a significant, modifiable risk factor for child obesity and diet-related non-communicable diseases. We compared three accepted nutrient profiling systems: the Health Star Rating (HSR), the Ministry of Health Food and Beverage Classification System (FBCS) and the World Health Organization (WHO) Regional Office for Europe Nutrient Profiling Model, to identify the best system to protect New Zealand children from exposure to the marketing of unhealthy foods and beverages.

Method

13,066 packaged foods from the 2014 New Zealand Nutritrack database were classified as restricted or not restricted as per the WHO model; everyday/sometimes or occasional as per the FBCS model; and 3.5 stars, were determined.

Results

Under any of the three nutrient profiling systems, approximately one-third (29-39%) of New Zealand packaged foods would be permitted to be marketed to children. The WHO Model would permit marketing of 29% of products; the HSR system would permit 36%; and the FBCS system would permit 39%. The WHO Model restricts marketing of unhealthy foods more effectively than the other two systems. The HSR and FBCS systems would permit marketing of a number of food products of concern, particularly high-sugar breakfast cereals, fruit juices and ready meals.

Conclusion

Conclusion: The WHO Regional Office for Europe Nutrient Profiling Model should underpin the Advertising Standards Authority revised Children s Code for Advertising Food. The effectiveness of the new Code in reducing New Zealand children s exposure to marketing of unhealthy foods and drinks should be subject to evaluation by an independent body.

Author Information

Cliona Ni Mhurchu, Professor & Programme Leader Nutrition, National Institute for Health Innovation, University of Auckland, Auckland; Tara Mackenzie, MHSc Student, School of Population Health, University of Auckland, Auckland; Stefanie Vandevijvere, Senior Research Fellow, Epidemiology & Biostatistics, University of Auckland, Auckland.

Acknowledgements

Correspondence

Professor Cliona Ni Mhurchu, National Institute for Health Innovation, University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142, New Zealand.

Correspondence Email

c.nimhurchu@auckland.ac.nz

Competing Interests

Cliona Ni Mhurchu is a member of the New Zealand Health Star Rating Advisory Group. The New Zealand Health Star Rating Advisory Group had no role in in study design, data collection and analysis, decision to publish or preparation of the manuscript.

-- World Health Organization. Set of recommendations on the marketing of foods and non-alcoholic beverages. Geneva: World Health Organization; 2010. Boyland E, Nolan S, Kelly B, et al. Advertising as a cue to consume: a systematic review and met

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Promotion of unhealthy foods and beverages to children is a significant, modifiable risk factor for child obesity and development of diet-related non-communicable diseases.1 Comprehensive, independent reviews of the evidence consistently find that commercial food marketing has a direct effect on children s food preferences, purchase requests, consumption patterns and diet-related health.2-4Current marketing practices in New Zealand predominantly promote unhealthy foods and drinks to children.5 The most common categories of food products promoted to children are pre-sugared breakfast cereals, soft drinks, savoury snacks, confectionery and fast foods.3 Estimates of the proportion of food marketing promoting these product categories to children vary from 60% to 90%.3 A US federal Trade Commission survey of industry expenditure reported 63% of the marketing spend directed to children was for carbonated drinks, fast food and breakfast cereals.6 Analysis of UK television channels popular with young people found six of the 10 most frequently advertised food items were fast food, high sugar/low fibre breakfast cereals, confectionery and snack foods.7 A similar study in New Zealand reported that 66% of food advertisements on a free-to-air channel popular with children were for foods high in fat, salt or sugar.8Several national governments and food and beverage manufacturers have acted to restrict unhealthy food marketing to children or to allow the promotion of healthier choices only. Countries such as Norway, Sweden and the province of Quebec, Canada have statutory regulation (a formal legislative requirement by government) restricting the advertising of any product to children, and Ireland, UK and South Korea have regulations to restrict advertising of specified foods and beverages during children s programming or peak viewing times.9 A number of food and beverage companies have also responded with voluntary pledges (non-legislatively required commitments) to change their marketing activities directed to children, and the mix of foods advertised to children.10,11 New Zealand does not have statutory legislation on the advertising of foods to children but 67% of the major packaged food manufacturers and 20% of the biggest fast food restaurants have a voluntary policy on food marketing to children on their company website. However, none of those include an accepted nutrient profiling model.12A systematic review of the impact of statutory and voluntary codes to limit the advertising of foods to children found a sharp division in the evidence however, with scientific peer-reviewed evidence showing small or no reductions in promotion of less healthy foods and children s exposure to food marketing, except in response to statutory regulation. 9 In contrast, industry-sponsored reports indicate high adherence to voluntary codes.9 Discrepancies are likely to be due to lack of complete coverage of voluntary codes across all food companies, differences in audience definitions (times children are likely to be watching television versus children s programming times), and different systems to classify foods as unhealthy or non-core . Adherence to voluntary codes may therefore not sufficiently reduce the advertising of unhealthy foods or children s exposure to such advertising.9An accepted food classification or nutrient profiling system is necessary to classify foods as suitable/unsuitable for marketing to children and to implement restrictions. Examples of systems used for this purpose are the UK Ofcom model, the Scandinavian Keyhole model, the US Interagency Working Group proposals13 and the World Health Organization (WHO) Regional Office for Europe Nutrient Profiling Model.14In February 2016, the Advertising Standards Authority (ASA) announced a review of the ASA Children s Codes (Code for Advertising to Children and Children s Code for Advertising Food).15 The consultation document contained a specific question on the role of nutrient profiling systems in the Children s Codes, Is there a role for a nutrient profiling system such as the health star rating system in the Children s Codes? If yes, in what way and which system would you suggest?To inform our response to this question, we compared three accepted nutrient profiling systems: the Health Star Rating (HSR), the Ministry of Health Food and Beverage Classification System (FBCS) and the World Health Organization (WHO) Regional Office for Europe Nutrient Profiling Model (WHO Model) to identify the best system to protect New Zealand children from exposure to the marketing of unhealthy foods and beverages.MethodsSelection of Nutrient Profiling SystemsThree nutrient profiling systems were selected for comparison. Two were established New Zealand systems: the HSR and the Ministry of Health FBCS, and one was an international system: the WHO Model. Table 1 provides an overview of each system.Table 1: Summary of criteria used under each nutrient profiling scheme. Nutrient profiling system Purpose Scoring Nutrients to limit Nutrients or components to promote Examples HSR16 Front-of-pack nutrition labels on packaged foods to assist consumers in discriminating and comparing foods within categories Products receive a Health Star Rating between \u00bd star and 5 stars from an overall score based on food components with positive or negative associations with chronic disease. Energy, saturated fat, total sugars, sodium Protein, fibre, percentage of food that is fruits vegetables nuts and legumes Sugar sweetened soft drinks = 100% of products receive <3.5 stars Frozen vegetables = 100% of products receive >3.5 stars FBCS18 Guidelines for schools to identify healthy food and drink options for sale on campus Foods are either everyday sometimes or occasional foods depending on alignment with food and nutrition guidelines Added fat, added salt, added sugar Sugar sweetened soft drinks = occasional Frozen vegetables = everyday WHO Model14 Restriction of marketing of unhealthy foods to children Foods are either permitted or not permitted according to nutrient thresholds for different food categories Total fat, saturated fat, total sugars, added sugars, non-sugar sweeteners, salt, energy Sugar sweetened soft drinks = not permitted Frozen vegetables = permitted HSR is an interpretive, front-of-pack nutrition labelling scheme adopted by New Zealand in 2014.16 HSR rates the nutrition content of packaged foods in half-star increments from half a star (least healthy) to 5 stars (most healthy) and is designed to help consumers compare foods within categories. The number of stars is calculated based on the nutritional profile of the food. To calculate the HSR score, a product is placed in one of six HSR food categories; baseline points are calculated based on energy, saturated fat, total sugar and sodium content per 100g; modifying points are calculated based on the amount of fruits, vegetables, nuts and legumes (V points) and in some instances, protein (P points) and fibre (F points). The final HSR score = Baseline points \u2013 (V points) \u2013 (P points) \u2013 (F points). Lower scores indicate a better (healthier) nutrient profile. HSR is a continuous scoring system with scores ranging from approximately -24 to +45 (unpublished analysis of a 2012 database of approximately 17,000 New Zealand packaged products), and a cut point to dichotomise foods as healthy/unhealthy has not yet been widely agreed. However, work commissioned by the New South Wales Ministry of Health on the alignment of HSR with existing Traffic Light schemes and the 2013 Australian Dietary Guidelines reported that \u201chealthy core foods with a HSR of \u22653.5 can be confidently promoted in public settings as healthier choices\u201d.17 This cut point has been proposed for use in New Zealand as a means of identifying packaged foods consistent with District Health Boards Healthy Food Policy and suitable for sale in hospitals.The FBCS was developed by the Ministry of Health in 2007 to support healthy eating environments in New Zealand schools and identify healthy foods suitable for provision in schools.18 The FBCS classifies foods and beverages as everyday , sometimes or occasional foods based on the Food and Nutrition Guidelines for Healthy Children and Adolescents. Everyday foods are from the four core food groups, whilst sometimes foods are mostly processed foods with some added fat and/or salt and/or sugar, and occasional foods are high in saturated fat and/or salt and/or added sugar (eg confectionery, deep-fried foods and sugar-sweetened drinks). The FBCS is the basis for the Heart Foundation s Fuelled4Life programme19 and the TVNZ and Mediaworks ThinkTV children s food advertising guidelines.20The WHO Model was specifically designed for the purpose of restricting the marketing of foods to children and was published in 2015.14 It was developed following extensive consultation with European member states, and is based on three nutrient profile models currently in use in Europe for restricting marketing to children. It encompasses 17 food categories including fruit, vegetables and ready-made meals. Certain food categories are not permitted to be marketed to children under any circumstances. These include chocolate and confectionery, cakes and sweet biscuits, juices and energy drinks. Conversely, unprocessed meat and fish, and fresh/frozen fruit and vegetables can be marked without restriction. Maximum nutrient level cut points are applied to determine the eligibility of foods in all other categories to be marketed to children.A key difference between HSR and the other two systems is that HSR is for packaged foods only whilst the FBCS and the WHO Model also incorporate fresh, mixed and cooked meals.Database of New Zealand packaged foodsIn order to compare nutrient profiling schemes, a common set of products were classified using each scheme and compared. The 2014 New Zealand Nutritrack packaged food database was used for this purpose. Nutritrack food composition data are collected directly from labels of all packaged foods and non-alcoholic beverages available in four Auckland supermarkets during field surveys undertaken between February and May each year. Standardised data collection methods were developed for an international collaborative project to compare and monitor the nutritional composition of packaged foods.21 Supermarkets chosen for data collection represent the biggest retail brands of the main supermarket retailers in New Zealand (Foodstuffs (54% grocery market share) and Progressive Enterprises (38% market share) 22 and stores were selected for their large product ranges. Nutrition information is recorded for all packaged products displaying a Nutrition Information Panel. Alcohol and products that do not carry a Nutrition Information Panel, eg fresh produce, bakery and delicatessen items are excluded.For each packaged product with a Nutrition Information Panel, the brand name, product name, ingredient list and content of energy, protein, total fat, saturated fat, total carbohydrate, sugars, fibre (where available) and sodium per 100 g or mL are recorded in a searchable web-based database. Nutritional information recorded is for products as sold (ie not as prepared ) in order to maximise within-category product comparability (since preparation instructions vary and can have a significant impact on final composition) and different pack sizes of the same product are recorded as separate items. All data are checked and cleaned before analysis. Any data entry errors identified by value range checks and random checks are corrected using source data (product photographs). Each product is assigned to a basic food group (Level 1, 13 groups) and a specific food category (Level 2, 41 categories).21 Level 4, the most finely grained food grouping in the system, has 428 categories. Where fibre content is not listed on a product Nutrition Information Panel (it is not mandatory), we apply the food category average. We also apply a standardised category-specific fruit, vegetable, nut and legume (V Points) value, based on expected content within food category, in order to calculate HSR scores.AnalysisA total of 13,066 packaged food products across 14 broad food categories were analysed after exclusions were made. Food categories in the Nutritrack database not included in the analysis were: alcoholic beverages, herbs and spices, coffee and tea, sugars and baking ingredients, coatings/breadcrumbs, baby food and supplements, as these were not covered by the three nutrient profiling systems.The remaining 13,066 packaged foods were classified as restricted or not restricted as per the WHO model; everyday/sometimes or occasional as per the FBCS model; and <3.5 stars or \u22653.5 stars as per the HSR model. The FBCS does not apply to certain food groups, including cooking oils, sauces and spreads, jam and marmalade, honey, butter and margarine, pickled vegetables, so these were excluded (N/A) for that model. The proportion and types of packaged foods that met the criteria for all three systems or none of the systems and the types of food products classified as restricted under the WHO model but classified as everyday/sometimes (FBCS model) or as having >3.5 stars, were determined.ResultsThere was a fairly even distribution of New Zealand packaged foods across the 10 HSR categories from 0.5 to 5 stars, although proportions of packaged foods with 4.5 stars (5%) or 5 stars (5%) were noticeably lower than those in other HSR categories (range 8\u201314%, mean 10%) (Figure 1).Figure 1: Proportion of New Zealand packaged foods (n=13,066) within each Health Star Rating category. The three nutrient profiling systems were broadly similar in their proportional classification of permitted foods overall with approximately one-third (29\u201339%) of packaged foods meeting the eligibility criteria for each system: 29% under the WHO model, 36% under the HSR system (>3.5 stars), and 39% under the FBCS system (everyday or sometimes foods) (Table 2).Table 2: Classification of New Zealand packaged foods (n=13,066) by each nutrient profiling system. Food category and key sub-categories HSR WHO Model FBCS <3.5 stars \u22653.5 stars R NR O E/S N/A All foods 13,066 63.7 36.3 70.9 29.1 41.4 39.3 19.2 Bread and bakery products 1,603 73.1 26.9 74.3 25.7 63.6 36.4 0.0 Biscuits 736 88.5 11.5 99.7 0.3 89.1 10.9 0.0 Bread 484 30.6 69.4 15.3 84.7 7.0 93.0 0.0 Cakes, muffins and pastries 383 97.4 2.6 100.0 0.0 85.9 14.1 0.0 Cereal and cereal products 1,264 38.8 61.2 50.4 49.6 34.7 65.3 0.0 Breakfast cereals 358 22.9 77.1 66.5 33.5 24.6 75.4 0.0 Cereal bars 221 80.5 19.5 100.0 0.0 92.8 7.2 0.0 Confectionery 804 89.2 10.8 100.0 0.0 94.7 5.3 0.0 Convenience foods 726 44.2 55.8 66.3 33.7 16.7 83.3 0.0 Pre-prepared salads and sandwiches 51 35.3 64.7 92.2 7.8 11.8 88.2 0.0 Pizza 54 74.1 25.9 100.0 0.0 63.0 37.0 0.0 Ready meals 274 31.0 69.0 97.4 2.6 19.3 80.7 0.0 Soups 330 49.7 50.3 29.1 70.9 3.6 96.4 0.0 Dairy 1,743 67.4 32.6 85.9 14.1 39.3 60.7 0.0 Cheese 600 78.0 22.0 86.7 13.3 0.0 100.0 0.0 Cream 50 98.0 2.0 98.0 2.0 98.0 2.0 0.0 Desserts 172 78.5 21.5 100.0 0.0 65.1 34.9 0.0 Ice cream and edible ices 336 96.7 3.3 100.0 0.0 82.4 17.6 0.0 Milk 293 21.5 78.5 70.3 29.7 59.4 40.6 0.0 Yoghurt and yoghurt drinks 292 46.2 53.8 73.6 26.4 25.0 75.0 0.0 Edible oils and oil emulsions 303 46.9 53.1 20.1 79.9 0.0 0.0 100.0 Eggs 76 0.0 100.0 0.0 100.0 0.0 100.0 0.0 Fish and seafood products 484 18.8 81.2 10.3 89.7 12.0 88.0 0.0 Fruit, vegetables and nut products 1,539 35.7 64.3 62.8 37.2 10.1 68.5 21.4 Fresh packaged fruit and vegetables 51 0.0 100.0 0.0 100.0 0.0 100.0 0.0 Dried fruit 179 56.4 43.6 98.9 1.1 19.0 81.0 0.0 Frozen fruit 40 0.0 100.0 0.0 100.0 0.0 100.0 0.0 Fruit bars 35 42.9 57.1 100.0 0.0 100.0 0.0 0.0 Nuts and seeds 198 41.9 58.1 37.4 62.6 40.4 59.6 0.0 Jam and marmalades 151 96.0 4.0 100.0 0.0 0.0 0.0 100.0 Canned vegetables 263 23.2 76.8 44.1 55.9 0.0 100.0 0.0 Frozen vegetables 120 0.0 100.0 0.8 99.2 0.0 100.0 0.0 Frozen potato products 81 4.9 95.1 79.0 21.0 7.4 92.6 0.0 Meat and meat products and alternatives 1,069 69.9 30.1 40.3 59.7 69.6 30.4 0.0 Processed meat 1,005 72.5 27.5 37.9 62.1 73.9 26.1 0.0 Non-alcoholic beverages 1,116 74.6 25.4 89.1 10.9 91.1 8.9 0.0 Beverage mixes 69 100.0 0.0 100.0 0.0 100.0 0.0 0.0 Sugar-sweetened cordials 71 98.6 1.4 95.8 4.2* 100.0 0.0

Summary

Abstract

Aim

Promotion of unhealthy foods and drinks is a significant, modifiable risk factor for child obesity and diet-related non-communicable diseases. We compared three accepted nutrient profiling systems: the Health Star Rating (HSR), the Ministry of Health Food and Beverage Classification System (FBCS) and the World Health Organization (WHO) Regional Office for Europe Nutrient Profiling Model, to identify the best system to protect New Zealand children from exposure to the marketing of unhealthy foods and beverages.

Method

13,066 packaged foods from the 2014 New Zealand Nutritrack database were classified as restricted or not restricted as per the WHO model; everyday/sometimes or occasional as per the FBCS model; and 3.5 stars, were determined.

Results

Under any of the three nutrient profiling systems, approximately one-third (29-39%) of New Zealand packaged foods would be permitted to be marketed to children. The WHO Model would permit marketing of 29% of products; the HSR system would permit 36%; and the FBCS system would permit 39%. The WHO Model restricts marketing of unhealthy foods more effectively than the other two systems. The HSR and FBCS systems would permit marketing of a number of food products of concern, particularly high-sugar breakfast cereals, fruit juices and ready meals.

Conclusion

Conclusion: The WHO Regional Office for Europe Nutrient Profiling Model should underpin the Advertising Standards Authority revised Children s Code for Advertising Food. The effectiveness of the new Code in reducing New Zealand children s exposure to marketing of unhealthy foods and drinks should be subject to evaluation by an independent body.

Author Information

Cliona Ni Mhurchu, Professor & Programme Leader Nutrition, National Institute for Health Innovation, University of Auckland, Auckland; Tara Mackenzie, MHSc Student, School of Population Health, University of Auckland, Auckland; Stefanie Vandevijvere, Senior Research Fellow, Epidemiology & Biostatistics, University of Auckland, Auckland.

Acknowledgements

Correspondence

Professor Cliona Ni Mhurchu, National Institute for Health Innovation, University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142, New Zealand.

Correspondence Email

c.nimhurchu@auckland.ac.nz

Competing Interests

Cliona Ni Mhurchu is a member of the New Zealand Health Star Rating Advisory Group. The New Zealand Health Star Rating Advisory Group had no role in in study design, data collection and analysis, decision to publish or preparation of the manuscript.

-- World Health Organization. Set of recommendations on the marketing of foods and non-alcoholic beverages. Geneva: World Health Organization; 2010. Boyland E, Nolan S, Kelly B, et al. Advertising as a cue to consume: a systematic review and met

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Promotion of unhealthy foods and beverages to children is a significant, modifiable risk factor for child obesity and development of diet-related non-communicable diseases.1 Comprehensive, independent reviews of the evidence consistently find that commercial food marketing has a direct effect on children s food preferences, purchase requests, consumption patterns and diet-related health.2-4Current marketing practices in New Zealand predominantly promote unhealthy foods and drinks to children.5 The most common categories of food products promoted to children are pre-sugared breakfast cereals, soft drinks, savoury snacks, confectionery and fast foods.3 Estimates of the proportion of food marketing promoting these product categories to children vary from 60% to 90%.3 A US federal Trade Commission survey of industry expenditure reported 63% of the marketing spend directed to children was for carbonated drinks, fast food and breakfast cereals.6 Analysis of UK television channels popular with young people found six of the 10 most frequently advertised food items were fast food, high sugar/low fibre breakfast cereals, confectionery and snack foods.7 A similar study in New Zealand reported that 66% of food advertisements on a free-to-air channel popular with children were for foods high in fat, salt or sugar.8Several national governments and food and beverage manufacturers have acted to restrict unhealthy food marketing to children or to allow the promotion of healthier choices only. Countries such as Norway, Sweden and the province of Quebec, Canada have statutory regulation (a formal legislative requirement by government) restricting the advertising of any product to children, and Ireland, UK and South Korea have regulations to restrict advertising of specified foods and beverages during children s programming or peak viewing times.9 A number of food and beverage companies have also responded with voluntary pledges (non-legislatively required commitments) to change their marketing activities directed to children, and the mix of foods advertised to children.10,11 New Zealand does not have statutory legislation on the advertising of foods to children but 67% of the major packaged food manufacturers and 20% of the biggest fast food restaurants have a voluntary policy on food marketing to children on their company website. However, none of those include an accepted nutrient profiling model.12A systematic review of the impact of statutory and voluntary codes to limit the advertising of foods to children found a sharp division in the evidence however, with scientific peer-reviewed evidence showing small or no reductions in promotion of less healthy foods and children s exposure to food marketing, except in response to statutory regulation. 9 In contrast, industry-sponsored reports indicate high adherence to voluntary codes.9 Discrepancies are likely to be due to lack of complete coverage of voluntary codes across all food companies, differences in audience definitions (times children are likely to be watching television versus children s programming times), and different systems to classify foods as unhealthy or non-core . Adherence to voluntary codes may therefore not sufficiently reduce the advertising of unhealthy foods or children s exposure to such advertising.9An accepted food classification or nutrient profiling system is necessary to classify foods as suitable/unsuitable for marketing to children and to implement restrictions. Examples of systems used for this purpose are the UK Ofcom model, the Scandinavian Keyhole model, the US Interagency Working Group proposals13 and the World Health Organization (WHO) Regional Office for Europe Nutrient Profiling Model.14In February 2016, the Advertising Standards Authority (ASA) announced a review of the ASA Children s Codes (Code for Advertising to Children and Children s Code for Advertising Food).15 The consultation document contained a specific question on the role of nutrient profiling systems in the Children s Codes, Is there a role for a nutrient profiling system such as the health star rating system in the Children s Codes? If yes, in what way and which system would you suggest?To inform our response to this question, we compared three accepted nutrient profiling systems: the Health Star Rating (HSR), the Ministry of Health Food and Beverage Classification System (FBCS) and the World Health Organization (WHO) Regional Office for Europe Nutrient Profiling Model (WHO Model) to identify the best system to protect New Zealand children from exposure to the marketing of unhealthy foods and beverages.MethodsSelection of Nutrient Profiling SystemsThree nutrient profiling systems were selected for comparison. Two were established New Zealand systems: the HSR and the Ministry of Health FBCS, and one was an international system: the WHO Model. Table 1 provides an overview of each system.Table 1: Summary of criteria used under each nutrient profiling scheme. Nutrient profiling system Purpose Scoring Nutrients to limit Nutrients or components to promote Examples HSR16 Front-of-pack nutrition labels on packaged foods to assist consumers in discriminating and comparing foods within categories Products receive a Health Star Rating between \u00bd star and 5 stars from an overall score based on food components with positive or negative associations with chronic disease. Energy, saturated fat, total sugars, sodium Protein, fibre, percentage of food that is fruits vegetables nuts and legumes Sugar sweetened soft drinks = 100% of products receive <3.5 stars Frozen vegetables = 100% of products receive >3.5 stars FBCS18 Guidelines for schools to identify healthy food and drink options for sale on campus Foods are either everyday sometimes or occasional foods depending on alignment with food and nutrition guidelines Added fat, added salt, added sugar Sugar sweetened soft drinks = occasional Frozen vegetables = everyday WHO Model14 Restriction of marketing of unhealthy foods to children Foods are either permitted or not permitted according to nutrient thresholds for different food categories Total fat, saturated fat, total sugars, added sugars, non-sugar sweeteners, salt, energy Sugar sweetened soft drinks = not permitted Frozen vegetables = permitted HSR is an interpretive, front-of-pack nutrition labelling scheme adopted by New Zealand in 2014.16 HSR rates the nutrition content of packaged foods in half-star increments from half a star (least healthy) to 5 stars (most healthy) and is designed to help consumers compare foods within categories. The number of stars is calculated based on the nutritional profile of the food. To calculate the HSR score, a product is placed in one of six HSR food categories; baseline points are calculated based on energy, saturated fat, total sugar and sodium content per 100g; modifying points are calculated based on the amount of fruits, vegetables, nuts and legumes (V points) and in some instances, protein (P points) and fibre (F points). The final HSR score = Baseline points \u2013 (V points) \u2013 (P points) \u2013 (F points). Lower scores indicate a better (healthier) nutrient profile. HSR is a continuous scoring system with scores ranging from approximately -24 to +45 (unpublished analysis of a 2012 database of approximately 17,000 New Zealand packaged products), and a cut point to dichotomise foods as healthy/unhealthy has not yet been widely agreed. However, work commissioned by the New South Wales Ministry of Health on the alignment of HSR with existing Traffic Light schemes and the 2013 Australian Dietary Guidelines reported that \u201chealthy core foods with a HSR of \u22653.5 can be confidently promoted in public settings as healthier choices\u201d.17 This cut point has been proposed for use in New Zealand as a means of identifying packaged foods consistent with District Health Boards Healthy Food Policy and suitable for sale in hospitals.The FBCS was developed by the Ministry of Health in 2007 to support healthy eating environments in New Zealand schools and identify healthy foods suitable for provision in schools.18 The FBCS classifies foods and beverages as everyday , sometimes or occasional foods based on the Food and Nutrition Guidelines for Healthy Children and Adolescents. Everyday foods are from the four core food groups, whilst sometimes foods are mostly processed foods with some added fat and/or salt and/or sugar, and occasional foods are high in saturated fat and/or salt and/or added sugar (eg confectionery, deep-fried foods and sugar-sweetened drinks). The FBCS is the basis for the Heart Foundation s Fuelled4Life programme19 and the TVNZ and Mediaworks ThinkTV children s food advertising guidelines.20The WHO Model was specifically designed for the purpose of restricting the marketing of foods to children and was published in 2015.14 It was developed following extensive consultation with European member states, and is based on three nutrient profile models currently in use in Europe for restricting marketing to children. It encompasses 17 food categories including fruit, vegetables and ready-made meals. Certain food categories are not permitted to be marketed to children under any circumstances. These include chocolate and confectionery, cakes and sweet biscuits, juices and energy drinks. Conversely, unprocessed meat and fish, and fresh/frozen fruit and vegetables can be marked without restriction. Maximum nutrient level cut points are applied to determine the eligibility of foods in all other categories to be marketed to children.A key difference between HSR and the other two systems is that HSR is for packaged foods only whilst the FBCS and the WHO Model also incorporate fresh, mixed and cooked meals.Database of New Zealand packaged foodsIn order to compare nutrient profiling schemes, a common set of products were classified using each scheme and compared. The 2014 New Zealand Nutritrack packaged food database was used for this purpose. Nutritrack food composition data are collected directly from labels of all packaged foods and non-alcoholic beverages available in four Auckland supermarkets during field surveys undertaken between February and May each year. Standardised data collection methods were developed for an international collaborative project to compare and monitor the nutritional composition of packaged foods.21 Supermarkets chosen for data collection represent the biggest retail brands of the main supermarket retailers in New Zealand (Foodstuffs (54% grocery market share) and Progressive Enterprises (38% market share) 22 and stores were selected for their large product ranges. Nutrition information is recorded for all packaged products displaying a Nutrition Information Panel. Alcohol and products that do not carry a Nutrition Information Panel, eg fresh produce, bakery and delicatessen items are excluded.For each packaged product with a Nutrition Information Panel, the brand name, product name, ingredient list and content of energy, protein, total fat, saturated fat, total carbohydrate, sugars, fibre (where available) and sodium per 100 g or mL are recorded in a searchable web-based database. Nutritional information recorded is for products as sold (ie not as prepared ) in order to maximise within-category product comparability (since preparation instructions vary and can have a significant impact on final composition) and different pack sizes of the same product are recorded as separate items. All data are checked and cleaned before analysis. Any data entry errors identified by value range checks and random checks are corrected using source data (product photographs). Each product is assigned to a basic food group (Level 1, 13 groups) and a specific food category (Level 2, 41 categories).21 Level 4, the most finely grained food grouping in the system, has 428 categories. Where fibre content is not listed on a product Nutrition Information Panel (it is not mandatory), we apply the food category average. We also apply a standardised category-specific fruit, vegetable, nut and legume (V Points) value, based on expected content within food category, in order to calculate HSR scores.AnalysisA total of 13,066 packaged food products across 14 broad food categories were analysed after exclusions were made. Food categories in the Nutritrack database not included in the analysis were: alcoholic beverages, herbs and spices, coffee and tea, sugars and baking ingredients, coatings/breadcrumbs, baby food and supplements, as these were not covered by the three nutrient profiling systems.The remaining 13,066 packaged foods were classified as restricted or not restricted as per the WHO model; everyday/sometimes or occasional as per the FBCS model; and <3.5 stars or \u22653.5 stars as per the HSR model. The FBCS does not apply to certain food groups, including cooking oils, sauces and spreads, jam and marmalade, honey, butter and margarine, pickled vegetables, so these were excluded (N/A) for that model. The proportion and types of packaged foods that met the criteria for all three systems or none of the systems and the types of food products classified as restricted under the WHO model but classified as everyday/sometimes (FBCS model) or as having >3.5 stars, were determined.ResultsThere was a fairly even distribution of New Zealand packaged foods across the 10 HSR categories from 0.5 to 5 stars, although proportions of packaged foods with 4.5 stars (5%) or 5 stars (5%) were noticeably lower than those in other HSR categories (range 8\u201314%, mean 10%) (Figure 1).Figure 1: Proportion of New Zealand packaged foods (n=13,066) within each Health Star Rating category. The three nutrient profiling systems were broadly similar in their proportional classification of permitted foods overall with approximately one-third (29\u201339%) of packaged foods meeting the eligibility criteria for each system: 29% under the WHO model, 36% under the HSR system (>3.5 stars), and 39% under the FBCS system (everyday or sometimes foods) (Table 2).Table 2: Classification of New Zealand packaged foods (n=13,066) by each nutrient profiling system. Food category and key sub-categories HSR WHO Model FBCS <3.5 stars \u22653.5 stars R NR O E/S N/A All foods 13,066 63.7 36.3 70.9 29.1 41.4 39.3 19.2 Bread and bakery products 1,603 73.1 26.9 74.3 25.7 63.6 36.4 0.0 Biscuits 736 88.5 11.5 99.7 0.3 89.1 10.9 0.0 Bread 484 30.6 69.4 15.3 84.7 7.0 93.0 0.0 Cakes, muffins and pastries 383 97.4 2.6 100.0 0.0 85.9 14.1 0.0 Cereal and cereal products 1,264 38.8 61.2 50.4 49.6 34.7 65.3 0.0 Breakfast cereals 358 22.9 77.1 66.5 33.5 24.6 75.4 0.0 Cereal bars 221 80.5 19.5 100.0 0.0 92.8 7.2 0.0 Confectionery 804 89.2 10.8 100.0 0.0 94.7 5.3 0.0 Convenience foods 726 44.2 55.8 66.3 33.7 16.7 83.3 0.0 Pre-prepared salads and sandwiches 51 35.3 64.7 92.2 7.8 11.8 88.2 0.0 Pizza 54 74.1 25.9 100.0 0.0 63.0 37.0 0.0 Ready meals 274 31.0 69.0 97.4 2.6 19.3 80.7 0.0 Soups 330 49.7 50.3 29.1 70.9 3.6 96.4 0.0 Dairy 1,743 67.4 32.6 85.9 14.1 39.3 60.7 0.0 Cheese 600 78.0 22.0 86.7 13.3 0.0 100.0 0.0 Cream 50 98.0 2.0 98.0 2.0 98.0 2.0 0.0 Desserts 172 78.5 21.5 100.0 0.0 65.1 34.9 0.0 Ice cream and edible ices 336 96.7 3.3 100.0 0.0 82.4 17.6 0.0 Milk 293 21.5 78.5 70.3 29.7 59.4 40.6 0.0 Yoghurt and yoghurt drinks 292 46.2 53.8 73.6 26.4 25.0 75.0 0.0 Edible oils and oil emulsions 303 46.9 53.1 20.1 79.9 0.0 0.0 100.0 Eggs 76 0.0 100.0 0.0 100.0 0.0 100.0 0.0 Fish and seafood products 484 18.8 81.2 10.3 89.7 12.0 88.0 0.0 Fruit, vegetables and nut products 1,539 35.7 64.3 62.8 37.2 10.1 68.5 21.4 Fresh packaged fruit and vegetables 51 0.0 100.0 0.0 100.0 0.0 100.0 0.0 Dried fruit 179 56.4 43.6 98.9 1.1 19.0 81.0 0.0 Frozen fruit 40 0.0 100.0 0.0 100.0 0.0 100.0 0.0 Fruit bars 35 42.9 57.1 100.0 0.0 100.0 0.0 0.0 Nuts and seeds 198 41.9 58.1 37.4 62.6 40.4 59.6 0.0 Jam and marmalades 151 96.0 4.0 100.0 0.0 0.0 0.0 100.0 Canned vegetables 263 23.2 76.8 44.1 55.9 0.0 100.0 0.0 Frozen vegetables 120 0.0 100.0 0.8 99.2 0.0 100.0 0.0 Frozen potato products 81 4.9 95.1 79.0 21.0 7.4 92.6 0.0 Meat and meat products and alternatives 1,069 69.9 30.1 40.3 59.7 69.6 30.4 0.0 Processed meat 1,005 72.5 27.5 37.9 62.1 73.9 26.1 0.0 Non-alcoholic beverages 1,116 74.6 25.4 89.1 10.9 91.1 8.9 0.0 Beverage mixes 69 100.0 0.0 100.0 0.0 100.0 0.0 0.0 Sugar-sweetened cordials 71 98.6 1.4 95.8 4.2* 100.0 0.0

Summary

Abstract

Aim

Promotion of unhealthy foods and drinks is a significant, modifiable risk factor for child obesity and diet-related non-communicable diseases. We compared three accepted nutrient profiling systems: the Health Star Rating (HSR), the Ministry of Health Food and Beverage Classification System (FBCS) and the World Health Organization (WHO) Regional Office for Europe Nutrient Profiling Model, to identify the best system to protect New Zealand children from exposure to the marketing of unhealthy foods and beverages.

Method

13,066 packaged foods from the 2014 New Zealand Nutritrack database were classified as restricted or not restricted as per the WHO model; everyday/sometimes or occasional as per the FBCS model; and 3.5 stars, were determined.

Results

Under any of the three nutrient profiling systems, approximately one-third (29-39%) of New Zealand packaged foods would be permitted to be marketed to children. The WHO Model would permit marketing of 29% of products; the HSR system would permit 36%; and the FBCS system would permit 39%. The WHO Model restricts marketing of unhealthy foods more effectively than the other two systems. The HSR and FBCS systems would permit marketing of a number of food products of concern, particularly high-sugar breakfast cereals, fruit juices and ready meals.

Conclusion

Conclusion: The WHO Regional Office for Europe Nutrient Profiling Model should underpin the Advertising Standards Authority revised Children s Code for Advertising Food. The effectiveness of the new Code in reducing New Zealand children s exposure to marketing of unhealthy foods and drinks should be subject to evaluation by an independent body.

Author Information

Cliona Ni Mhurchu, Professor & Programme Leader Nutrition, National Institute for Health Innovation, University of Auckland, Auckland; Tara Mackenzie, MHSc Student, School of Population Health, University of Auckland, Auckland; Stefanie Vandevijvere, Senior Research Fellow, Epidemiology & Biostatistics, University of Auckland, Auckland.

Acknowledgements

Correspondence

Professor Cliona Ni Mhurchu, National Institute for Health Innovation, University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142, New Zealand.

Correspondence Email

c.nimhurchu@auckland.ac.nz

Competing Interests

Cliona Ni Mhurchu is a member of the New Zealand Health Star Rating Advisory Group. The New Zealand Health Star Rating Advisory Group had no role in in study design, data collection and analysis, decision to publish or preparation of the manuscript.

-- World Health Organization. Set of recommendations on the marketing of foods and non-alcoholic beverages. Geneva: World Health Organization; 2010. Boyland E, Nolan S, Kelly B, et al. Advertising as a cue to consume: a systematic review and met

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