A comparison of the Health Star Rating system when used for restaurant fast and packaged foods

Elizabeth K. Dunford a, b, *, Jason H.Y. Wu a, Lyndal Wellard-Cole c, Wendy Watson c a a a, d, e, f , Michelle Crino , Kristina Petersen , Bruce Neal a Policy Division, The George Institute for Global Health, University of , , b Carolina Population Center, The University of North Carolina at Chapel Hill, Chapel Hill, USA c Cancer Council NSW, Sydney, Australia d Charles Perkins Centre, University of Sydney, Sydney, Australia e Royal Prince Alfred Hospital, Sydney, Australia f Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Medicine, Imperial College , UK

* Corresponding author. 137 East Franklin Street, Room 6602, Chapel Hill, NC 27516, USA. E-mail address: [email protected] (E.K. Dunford).

Abstract Background: In June 2014, the Australian government agreed to the voluntary implementation of an interpretive ‘Health Star Rating’ (HSR) front-of-pack labelling system for packaged foods. The aim of the system is to make it easier for consumers to compare the healthiness of products based on number of stars. With many Australians consuming there is a strong rationale for extending the HSR system to include fast food items. Objective: To examine the performance of the HSR system when applied to fast foods. Design: Nutrient content data for fast f o o d menu items were collected from the websites of 13 large Australian fast-food chains. The HSR was calculated for each menu item. Statistics describing HSR values for fast foods were calculated and compared to results for comparable packaged foods. Results: Data for 1529 fast food products were compared to data for 3810 packaged food products across 16 of 17 fast food product categories. The mean HSR for the fast foods was 2.5 and ranged from 0.5 to 5.0 and corresponding values for the comparator packaged foods were 2.6 and 0.5 to 5.0. Visual inspection of the data showed broadly comparable distributions of HSR values across the fast food and the packaged food categories, although statistically significant differences were apparent for s e v e n categories (all p < 0.04). In some cases, these differences reflected the large sample size and the power to detect small variations across fast foods and packaged food, and in others it appeared to reflect primarily differences in the mix of product types within a category. Conclusions: These data support the idea that the HSR system could be extended to Australian fast foods. There are likely to be significant benefits to the community from the use of a single standardised signposting system for healthiness across all fresh, packaged and restaurant foods.

1. Introduction

Diet-related diseases including obesity, type 2 diabetes and cardiovascular diseases are incr easing globally (World Health Organization, 2014) in conjunction with consumption of pack- aged and fast foods (Jacobson, Havas, & McCarter, 2013; Rosenheck,2008). With an i n c r e a s i n g proportion of consumers purchasing meals outside the home, fast food is now an important contributor to intake of dietary salt, sugar, saturated fat and energy (Paeratakul, Ferdinand, Champagne, Ryan, & Bray, 2003; Rangan, Schindeler, Hector, Gill, & Webb, 2009). Fast foods tend to be more energy dense, higher in saturated fat, added sugars and salt, and to be eaten in larger portions compared to other foods (Isganaitis & Lustig, 2005; Nielsen & Popkin, 2003; Pereira et al., 2005) and now provide between one-third and one-

half of daily energy intake, but less than one-quarter of most micronutrients (Australian Bureau of Statistics, 2014; Rangan et al., 2009). Globally, there are a number of initiatives that have been undertaken to try and address the health problems caused by fast foods. Some restaurant chains have made commitments to product reformulation (McDonald's, 2013; Yum! Brands. Yum! Brands, 2014) and others to controls on marketing to children (Australian Food and Grocery Council, 2011). In some countries like the US, the labelling of calories on fast food chain menu boards is required (U.S. Food and Drug Administration, 2016). Other countries such as the UK have voluntary initiatives in p l a c e (UK Department of Health, 2012). In Australia, the state of New South Wales (NSW) now has a statutory requirement for fast food chain restaurants with more than 20 outlets in the state or 50 nationally to display the energy (kilojoule) content of products on menu boards dis- played at the point of sale (NSW Food Authority, 2011). In parallel the Australian Government has implemented a voluntary interpretive front-of-pack labelling system for packaged foods, which is designed to be consistent with, and used alongside, the Australian Dietary Guidelines (Australian Health Ministers' Advisory Council, 2016). The aim of the ‘Health Star Rating’ (HSR) system is to make it easier for consumers to identify healthier products. The system assigns a value between 0.5 and 5.0 stars, in half star increments, with a higher number of stars indicating a healthier product. The algorithm used to calculate the HSR in- corporates energy, saturated fat, total sugar, sodium, fibre, protein, and fruit, vegetable, nut and legume content (FVNL) per 100 g. No other country to date has explored the implementation of a standardised labelling scheme across both packaged foods and fast food menu boards. Although not specifically designed for fast food products, the HSR system may be a tool t h a t can provide information about the relative healthiness of different fast food products to consumers . Further, the use of a single, standard method of signposting across packaged foods and fast foods might simplify decision making for consumers. Accordingly, this study sought to examine the performance of the HSR system when applied to fast foods.

2. Methods

2.1. Data sources

Fast food data - The George Institute and the Cancer Council of New South Wales collated a fast food database with all available nutrition information for leading Australian fast food chains. Methods have been previously described (Dunford, Webster, Barzi, & Neal, 2010; Garcia, Dunford, Sundstrom, & Neal, 2014) but, in brief, data were obtained from the websites of the most popular Australian fast food chains in November 2014. Where available, the company name, product name, nutrient values per 100 g; energy (kJ), protein (g), saturated fat (g), sugar (g), sodium (mg), fibre (g), FVNL% and ingredient lists were recorded. Where per 100 g values were not available, but nutrient values per serving and the serving size was available, the per 100 g values for a l l nutrients were calculated. Accuracy of data entry was examined by selecting a random sample of 5% of the entries and comparing the information in the database against the original source. In addition, all data were subjected to a series of range and logic checks. Packaged food data - were extracted from The George Institute's 2014 FoodSwitch Database (Dunford et al., 2014). Details have been described elsewhere (Dunford et al., 2012), but in brief, n u t r i e n t data are collected each year from the product labels of food items sold in four major Australian supermarkets. All data were subjected to an extensive series of range and logic checks.

2.2. Food categories included

Fast foods - The categories and definitions were based on those used for previous reports on Australian fast foods (Dunford et al.,2010; Garcia et al., 2014) and are derived from the categorizations commonly used by the fast food industry. There are 17 major food categories and multiple additional subcategories into which fast foods were placed (Supplemental Table 1). Packaged foods - Categories of packaged foods that most closely matched the fast food categories were selected by reviewing the packaged food subcategories into which the products included in the FoodSwitch database are placed (Supplemental Table 1). Where several packaged food subcategories matched to one fast food category the packaged food subcategories were grouped and analysed as a single matching

category. For one fast f o o d category (‘burgers’) there w a s no matching packaged f o o d category identified.

2.3. Calculation of the Health Star Rating

Calculation of the HSR was performed using criteria defined by the Guide to the Health Star R a t i n g Calculator endorsed by the Australian Government (Australian Health Ministers' Advisory Council, 2016) . The HSR system requires products to be categorized into Calibration Categories (non-dairy beverages such as fruit juice and sugar-sweetened beverages; core cereals such as rice and pasta; core dairy beverages; core dairy cheeses such as cheddar; core dairy yoghurt and soft cheese, fats and oils, fruit, vegetables, protein foods; and non-core foods). Calibration Categories were determined on the basis of the product name and ingredients list for both fast foods and packaged foods. FVNL content was not available for some products and estimates of FVNL were made using information from the ingredient lists and/or known values for similar food products (Dunford et al., 2014). Fibre content was likewise unavailable for some products and a comparable estimation method was used. The HSR was calculated by (1) assigning baseline points for energy, saturated fat, total sugar and sodium content per 100 g; (2) awarding modifying points for FVNL content, protein and fibre where applicable; (3) calculating an overall score by subtracting modifying points from baseline points, with a lower score reflecting a more nutritious food product; and (4) assigning a HSR (from 0.5 to 5.0 stars in half-star increments) according to the overall score using the defined scoring matrix (Australian Health Ministers' Advisory Council, 2016).

2.4. Statistical analysis

Analyses were performed using Stata v14.1. The mean HSR value and the range of the HSR values were calculated for each fast food category and the corresponding packaged food category. Evidence of differences between the mean HSR of the fast foods compared to the processed foods was sought using unpaired t-tests. The distributions of HSR values were compared by graphing the proportions of products in each category assigned 0.5e1.5 stars, 2.0e3.0 stars and 3.5e5.0 stars. The graphical representations were inspected visually for comparability of the distribution of HSRs and statistical comparisons of the proportions of products in each stratum were made using Fisher's exact tests. Where the pattern of HSR values assigned to products appeared to be different between fast food products and packaged food products the distributions in sub- categories were explored to determine the likely impact of product mix on the observed differences. Because FVNL values were imputed for many products an analysis was done comparing the HSR obtained with and without inclusion of the FVNL values in the algorithm.

3. Results

There were 1786 fast food products identified and 1529 used in the analyses. The 257 products not included were removed because data on a nutrient required for the baseline point calculation of the HSR (i.e. energy, saturated fat, total sugar, sodium) were missing or not available in the required format (n ¼ 122), the products were ‘single ingredient’ (n ¼ 26), a ‘dressing or condiment’ (n ¼ 61) or ‘a meal pack’ including a and sides in addition to the main item (n ¼ 63) and an HSR could not therefore be calculated according to the HSR guidelines. Fast food products were from 13 different companies Coffee Club, Crust, Domino's, Gloria Jean’s, Hungry Jack's, KFC, McCafe, McDonald's, Muffin Break, Oporto, , and and the number of products in each main fast food category ranged from three in seafood to 449 in beverages. There were 3810 packaged food products that were matched to 16 of the 17 main fast food categories. For one of the fast food categories (‘burgers’) there was no matching packaged food cate- gory identified. For the ‘sides’ category only the subcategory ‘French fries’ had a direct matching packaged food category. In the ‘break- fast’ category there were no matching packaged products available for hot items and there was only one muesli and one fruit item in the fast food category and therefore no comparisons were made with packaged items for these products. The number of packaged food products in each comparator category ranged from five in ‘wraps and ’ to 1300 in ‘beverages’.

3.1. Health Star Ratings of fast foods and matching packaged foods

The mean HSR for the 1529 fast food products was 2.5 (range 0.5e5.0) and remained almost identical for all food categories if the FVNL values were excluded from the algorithm. For the 16 fast food categories and 1444 products to which packaged food categories could be matched the mean HSR was 2.4 and the range 0.5e5.0. The corresponding mean HSR for the 3810 matched packaged food products was 2.6 and the range was 0.5e5.0 (Table 1). Mean HSR values were significantly different between fast foods and matched packaged foods for ten categories (all p < 0.03) with better HSR values for packaged beverages (þ1.0), breakfast items (þ0.6), chicken (þ0.4), French fries (þ0.4), pizza (þ0.3), wraps, sandwiches and savoury bread (þ0.6) and yoghurt and dairy desserts (þ1.5) but worse HSR values for ice-cream and frozen desserts ( 0.4), muffins ( 0.6) and salads ( 0.2). Visual inspection of the distribution of HSR values showed broadly similar spreads of grouped (0.5e1.5, 2.0e3.0 and 3.5e5.0) across most food categories for fast foods and packaged foods although there were statistically significant differences in the distributions for beverages, breakfast items, chicken, ice cream and frozen desserts, pastries, pizzas, and yoghurt and dairy desserts (all p < 0.04) (Fig. 1). The relatively large difference between the mean HSR of fast foods and packaged foods in the beverage category (1.0 higher for packaged beverages) was driven primarily by higher mean HSR values for packaged cold milk beverages (HSR ¼ 3.5) compared to fast food cold milk beverages (HSR ¼ 2.2) (Fig. 2). Within the beverage category water and fruit juices were the only subcategories with products receiving 3.5 stars or more and nearly all (98%) sugar sweetened beverages received <1.5 stars. There was also a moderate difference between the mean HSR of fast food and packaged items in the ‘breakfast’ category (0.6 HSR) that mostly resulted from differences between the HSR values of packaged and fast foods in the subcategories ‘fruit bread’, ‘pancakes and pikelets’, and ‘hash browns’ (Fig. 3). The large discrepancy in the HSR values of fast foods and packaged foods in the ‘yoghurt and dairy dessert’ category results from a difference in the HSR of dessert products. The mean HSR value of fast food desserts was 0.5 compared with 2.3 for packaged items (p < 0.001). The mean HSR of yoghurt was not different between packaged and fast foods (3.5 vs. 3.0; p ¼ 0.46).

3.2. Health Star Rating by company

Mean HSRs and the distribution of HSRs varied across the 13 fast food companies included in the analyses (Fig. 4). Subway and Oporto had the highest average HSR (3.4 stars) followed by Red Rooster (3.1 stars). Gloria Jean's had the lowest average HSR (2.0 stars) followed by McCafe (2.1 stars) and Muffin Break (2.2 stars). Generally, cafe -style chains had lower average HSRs than burger and pizza chains with chicken and chains faring best. Table 1 Mean Health Star Ratings (HSR) for 1529 fast food products and 3810 packaged food products from matching food categories.

Category Fast foods Packaged foods n HSR with estimated HSR no estimated FVNL n HSR FVNL Mean (SD) Range Mean (SD) Range Mean (SD) Range Beverages 449 1.9 (1.0) 0.5e5.0 1.8 (0.9) 0.5e5.0 1300 2.9 (1.6) 0.5e5.0 Biscuits/cookies 32 0.9 (0.4) 0.5e2.0 0.9 (0.4) 0.5e2.0 545 1.1 (0.7) 0.5e4.0 Breakfast 72 2.8 (0.7) 1.5e4.5 2.8 (0.7) 1.5e3.5 70 3.4 (0.8) 1.5e5.0 Burgers 85 3.0 (0.7) 1.5e4.0 3.0 (0.7) 1.5e4.0 e e e Cakes 60 1.6 (0.8) 0.5e3.5 1.6 (0.8) 0.5e3.5 216 1.6 (0.7) 0.5e4.0 Chicken 54 3.2 (0.6) 2.0e4.0 3.2 (0.6) 2.0e4.0 48 3.6 (0.6) 2.0e4.5 Ice cream and frozen desserts 21 2.3 (0.3) 2.0e3.0 2.3 (0.3) 2.0e3.0 310 1.9 (0.7) 0.5e4.5 Muffins 214 2.7 (0.4) 1.5e3.5 2.7 (0.4) 1.5e3.5 24 2.1 (0.2) 1.5e2.5 Pasta dishes 6 3.4 (0.4) 3.0e4.0 3.4 (0.4) 3.0e4.0 136 3.5 (0.2) 3.0e4.0 Pastries 62 1.8 (0.8) 0.5e3.5 1.8 (0.8) 0.5e3.5 80 1.8 (0.6) 0.5e3.0 Pizza 222 2.7 (0.6) 1.0e4.0 2.7 (0.6) 1.0e4.0 85 3.0 (0.6) 1.5e4.0 Salads 31 3.6 (0.5) 3.0e4.5 3.5 (0.4) 3.0e4.0 65 3.4 (0.4) 2.5e4.0 Seafood 3 3.8 (0.3) 3.5e4.0 3.8 (0.3) 3.5e4.0 184 3.7 (0.4) 2.0e4.5 a,b c c Sides 48 3.3 (1.0) 1.5e5.0 2.9 (0.7) 1.5e4.0 44 4.0 (0.3) 3.5e5.0 Soups 7 3.4 (0.2) 3.0e3.5 3.4 (0.2) 3.0e3.5 203 3.5 (0.2) 3.0e5.0 Wraps and sandwiches 153 3.2 (0.6) 1.5e4.0 3.2 (0.6) 1.5e4.0 5 3.8 (0.3) 3.5e4.0 Yoghurt and dairy desserts 10 1.4 (1.4) 0.5e3.5 1.4 (1.4) 0.5e3.5 495 2.9 (1.3) 0.5e5.0 Total for matched categories 1444 2.4 (1.0) 0.5e5.0 2.4 (0.9) 0.5e5.0 3810 2.6 (1.4) 0.5e5.0 a TOTAL 1529 2.5 (1.0) 0.5e5.0 2.4 (0.9) 0.5e5.0 3810 2.6 (1.4) 0.5e5.0 a p ¼ 0.05 for HSR with estimated FVNL vs. HSR with no estimated FVNL. b French fries only results 3.6 (0.4) vs. 3.1 (0.4) p < 0.001. c French fries only.

Fig. 1. Proportions of products with each Health Star Rating (HSR) for fast food products compared to similar packaged food products. Values are mean (standard deviation) unless otherwise stated; 1Includes estimated FVNL value; 2Independent samples t-test; 3Fisher's exact test.

4. Discussion

In this first study to investigate the potential application of the packaged food HSR system to fast foods we show considerable potential for an expanded scope of the HSR system. Mean HSR values for fast food categories were mostly very similar to the comparator packaged food categories and the HSR system provided a spread of HSR values within most fast food categories. While there were statistically significant differences in the mean HSR values and HSR distributions for some fast food and comparator packaged food categories the system assigned a range of HSR values within and across categories. This suggests that the HSR system has the same capacity to differentiate between fast food based on their nutritional characteristics as it does for packaged foods. None of the findings of our research suggest that the HSR system could not be applied to fast foods although a broader and more in depth evaluation to explore for potential outliers would be warranted before formal expansion of the HSR program was implemented.

Kilojoule labelling on fast food chain menu boards has been in effect in New South Wales since 2011 with some indication that it may have led to decreases in the energy content of fast food purchases, although consumer understanding of how to interpret kilojoules and select healthy foods based solely on data about energy content remains limited (Sinclair, Cooper, & Mansfield, 2014; TNS Social Research, 2016). Several other countries have kilojoule or calorie menu board labelling and a few require more comprehensive information about the nutritional content of products to be

Fig. 2. Proportions of beverage products with each Health Star Rating (HSR) for fast food products compared to similar packaged food products. Values are mean (standard deviation) unless otherwise stated; 1Includes estimated FVNL value; 2Independent samples t-test; 3Fisher's exact test.

Fig. 3. Proportions of breakfast products with each Health Star Rating (HSR) for fast food products compared to similar packaged food products. Values are mean (standard deviation) unless otherwise stated; 1Includes estimated FVNL value; 2Independent samples t-test; 3Fisher's exact test; Fast food hot breakfast items (n ¼ 50) had an HSR 3.0 (0.70) no comparable packaged hot breakfast items; There was only one muesli and one fruit item in the fast food category and therefore no comparisons were made with packaged items.

displayed (World Cancer Research Fund International, 2016). In Singapore the ‘Healthier Choice’ logo is displayed on food stalls and in restaurants to show products which are lower in fat, sugar and salt (The Health Promotion Board, 2016). New York in the USA has recently introduced legislation for a salt warning label to be dis- played when a product exceeds 2300 mg of sodium per serving. The New South Wales law presages the addition of information about salt and fat to menu board labelling but the addition of this information has been rejected to date, mainly because placing multiple nutrient signposting on menu boards has been deemed impractical. The HSR system was the result of a review of Australian labelling law and policy undertaken in 2011 (Blewett, Goddard, Pettigrew,Reynolds, & Yeatman, 2011). In June 2014 the government endorsed the HSR system as a way to better inform consumers as to the healthiness of packaged foods and beverages (Australian Health Ministers' Advisory Council, 2016). The single summary symbol employed by the HSR has the joint benefits of being simple for consumers to understand and requiring minimum real estate on food packaging or menu boards. In conjunction with the benefits to the community from the use of a single standardised signposting system for healthiness across all fresh, packaged and restaurant foods the HSR system may be a practical way of providing more comprehensive information about the healthiness of fast foods within the physical confines of in-store menu boards.

Fig. 4. Proportion of products with each Health Star Rating (HSR) for each fast food company. Values are mean (standard deviation) unless otherwise stated.

Our data suggest that the HSR already distinguishes between healthy and less healthy fast food items, but there may be an opportunity to enhance discriminatory capacity for fast foods by incorporating serving size into the algorithm. Analyses based upon a per 100g basis do not provide consumers with guidance about the serving size of product choices. While this is less of an issue for packaged foods, which typically includes multiple serves in a pack, fast food items generally come in individual servings and smaller servings are likely to be better options compared to larger servings. For example, French fries are often available in a range of serving sizes (one chain offers individual serving sizes that range from 74 g to 159 g) but all received the same HSR under the current algorithm based upon per 100 g data. As an alternative possible solution, the Yale Rudd Center for Food Policy and Obesity in the US has suggested energy content limits for meals and sides targeted at children and teens (Yale Rudd Center for Food Policy & Obesity, 2013), which could be incorporated into a signposting system. A challenge with this approach

might be the large number of fast food categories and the potentially large number of different energy caps that would be required. Another approach to enhancing the HSR for fast foods (and also packaged foods) might be to cap the maximum HSR that products defined as “discretionary” by the Australian Dietary Guidelines can achieve. Application of the existing HSR algorithm to packaged foods items such as frozen potato products, fruit juices and potato crisps has been criticised for providing scores that are widely viewed as too high and the same issue is present for some fast foods. The high vegetable content of French fries clearly does not mean they warrant a high HSR and the application of dietary guideline-based definitions in this way might provide an immediate and simple solution. The substantial variation in the HSR of similar products within and across companies was anticipated on the basis of prior work showing wide variations in the nutrient content of fast food items, both in Australia and internationally (Garcia et al., 2014). There seems a high likelihood that the HSR could help direct consumers' choices towards the healthier versions of a range of fast food items. It would also be anticipated that transparent labelling of fast food items would encourage retailers to reformulate their products to healthier compositions in the same way that has been reported for packaged foods (Sacks, Rayner, & Swinburn, 2009). Of the various companies included in the survey, Subway had the highest number of products with a HSR of 3.5 or greater followed by Oporto. Both these chains have menus dominated by sandwiches or burgers with grilled ingredients. On the other hand, the cafe -style chains Gloria Jean's, Muffin Break and McCafe had the highest proportion of products receiving a low HSR, due to pastry and cake dominated menus high in saturated fat and sugar (Watson, Piazza, Wellard, Hughes, & Chapman, 2015). If the HSR system were to be extended to fast food menu boards, it will be important to ensure that it is undertaken in conjunction with existing healthy eating strategies. For example, consumer education is an important factor with the implementation of any scheme aimed to support consumers making healthier food choices. Currently, the NSW government has an ‘8700’ campaign to support the implementation of kilojoule labelling menu boards (NSW Food Authority, 2011). The campaign attempts to educate consumers on what kilojoules are, and how many should be consumed in a day. Similarly, the Australian government has a consumer education campaign done in tandem with the HSR implementation on packaged foods to educate consumers on how to use the system. The use of two systems and two consumer education campaigns risks causing confusion for consumers. The implementation of a single standardised scheme across both fast food and packaged food would likely help by providing a consistent message to consumers. Our study was based on the data provided on company websites and we relied on the reported data being accurate. Several companies use accredited laboratories for analysis, but random and systematic errors in the reporting of nutrient values is possible. The study included all foods available on the menus of major fast food chains in November 2014 but this is likely to have changed subsequently and the data reported here were not sales-weighted and do not reflect actual patterns of fast food consumption in Australia. Fast food categories were matched to packaged food categories as closely as possible but there were nonetheless discrepancies - either because the products were not direct matches or because the mix of product types within a given category varied between fast foods and packaged foods.

5. Conclusions

These data support the idea that the HSR system for packaged foods could be extended to fast foods. There are likely to be significant benefits to the Australian population from the use of a single standardised signposting system for healthiness across all fresh, packaged and restaurant foods. Some modifications to the existing HSR algorithms might improve the system for packaged and fast foods. The early extension of the HSR system to fast foods would seem likely to incentivise a positive response from the fast food system in the same way that it is doing for packaged foods (Hawkes et al., 2015).

Disclaimers None.

Sources of support Elizabeth Dunford is supported by a National Health and Medical Research Council Early Career Fellowship (APP1088673). Bruce Neal is supported by a National Health and Medical Research Council of Australia

Principal Research Fellowship (APP1106947). He works within a NHMRC Centre for Research Excellence (APP1041020) and holds an NHMRC Program Grant (APP1052555).

Authors' contributions ED and BN designed research; ED, KP, MC, LW and WW con- ducted research; ED and KP analyzed data; ED, BN, LW, KP, JW and WW wrote the paper; BN and ED had primary responsibility for final content. All authors read and approved the final manuscript.

Conflict of interest All authors have no conflict of interests to declare.

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