Policy Document

Food and Nutrition BACKGROUND

The Australian Medical Students' Association (AMSA) is the peak representative body of Australia's medical students. AMSA believes that all communities should have the right to the highest attainable level of health. Accordingly, AMSA advocates on issues that impact local, national and global health outcomes. Nutrition is key to human health and access to nutritious food is a human right. The ongoing health impacts of the double burden of malnutrition in Australia and around the world warrant debate and action. Double burden of malnutrition Malnutrition can be defined as deficiencies, excesses or imbalances in a person’s caloric or nutrient intake (1). Malnutrition is broadly subdivided into two main categories. The first is undernutrition, which causes conditions such as stunting (low height for age), wasting (low weight for height), underweight (low weight for age) and vitamin or mineral micronutrient deficiency. The second is overnutrition, leading to states of obesity and overweight (1,2). This double faceted nature of malnutrition is referred to as the ‘double burden’ of malnutrition. Health effects of malnutrition Globally, malnutrition continues to cause widespread and significant morbidity and mortality. Undernutrition increases the frequency and severity of common infections, delays recovery from disease and is associated with an increased risk of death (2). It is the primary cause of immunodeficiency worldwide, leaving people susceptible to infections, especially pneumonia, malaria, diarrhoea, measles and HIV/AIDS (3). Overweight and obesity are associated with a myriad of negative health and social effects, including, perhaps counterintuitively, key micronutrient deficiencies (4, 5). Overweight and obesity are major risk factors for numerous noncommunicable diseases (NCDs), including cardiovascular disease, type 2 diabetes, some musculoskeletal conditions and some cancers (5). The risk of developing these conditions increases proportionally with the amount of excess weight (4, 5). Being overweight or obese can also deteriorate one’s ability to manage chronic conditions (5). Malnutrition around the world More than 795 million people remain chronically undernourished (6) and over two billion people suffer from micronutrient deficiencies, while 1.9 billion are overweight or obese (7). Without change, non-communicable disease morbidity and mortality will continue to worsen. 70% of global deaths in 2015 were due to NCDs (8). Indeed, according to projections from the World Health Organization (WHO), the total annual number of deaths from NCDs will increase to 55 million by 2030 if current trends continue (9). Malnutrition is estimated to cost the global economy USD $3.5 trillion per year (10). Malnutrition in Australia

Overnutrition and its associated NCDs are the dominant form of malnutrition in Australia, costing the Australian health system AUD$27 billion every year, and accounting for a reduction of 2.5 million disability adjusted life years (DALYs) (4). More than 63% of Australians are overweight or obese – the fourth highest prevalence among Organisation for Economic Co-operation and Development (OECD) countries (5). While many factors contribute to this trend, one of the principal causes is an increase in dietary fat and sugar intake (11, 12). Further, the burden of disease disproportionately affects those of low socioeconomic status – particularly the Indigenous population (5). Compared to the non-Indigenous population, the Indigenous population experiences 1.7 times higher rates of child malnutrition, 1.6 times higher rates of child obesity and 1.7 times higher rates of adult obesity (13). In terms of NCDs, the Indigenous population experiences higher prevalences of cardiovascular disease, diabetes and kidney disease (13). Food security and nutrition Food security is defined by the UN Food and Agricultural Organisation (FAO) as the state when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life (14). Therefore, food security encompases both aspects of malnutrition: overnutrition and undernutrition. According to UNICEF (14), the four pillars of food security are availability of food, physical and economic access to food, stability of food supply and access and utilisation of food. These pillars are useful in understanding the determinants of malnutrition both in Australia and globally.

Overnutrition in Australia Although fresh fruits and vegetables are adequately available in many high-income countries (HIC), many members of the Australian population do not consume the recommended daily intake of these foods. Instead, they are tending towards fast-food and highly processed foods to meet their energy requirements. In Australia, it is estimated that “junk foods” account for one third of the population’s daily intake (15) while only 6% of Australians over 16 years of age are consuming the recommended amounts of fruit and vegetables (16). This, along with other factors such as physical inactivity, is contributing to an increase in the proportion of overweight or obese but undernourished Australians. 63% of adults and 25% of children in Australia are overweight or obese, which has drastically increased since 1995 (17). This is in keeping with an increasing global trend with 52% of adults and 18% of children falling into an overweight or obese BMI category (18). In addition to the above factors contributing to overweight and obesity in HIC, there are other drivers in low and middle income countries (LMIC). These include a transition away from traditional diets towards more nutrient poor, energy dense foods which often containing obesogenic sweeteners, as well as early-life undernutrition and a rapid dietary shift to highly processed foods (19). Education and creating healthy food environments Health literacy and education in schools In Australia, there are a number of State and Federal Government policies and initiatives which intend to to provide food education to the public. As childhood obesity is a risk factor for obesity in adulthood, many Australian policies are directed towards children and education in schools, providing healthy food options in school canteens, and encouraging physical activity (20,21,22,23). WHO’s framework for nutrition includes nutritional education in schools and supports the aforementioned initiatives (24). Food labelling

Food and nutrition education remains an important public health issue. Although most Australian-sold foods are required to carry labels (25), laws regarding food labelling vary between countries with respect to whether labelling is mandatory, the type of labelling and how much information is required. Globally, there is need for evidence on the effectiveness of food-labelling and which types are more effective than others. The comprehensibility of food labelling plays a role in how informed consumers are, thus easily understood classifications should be implemented to maximise benefit. Although there is an agreement that labelling food offers the opportunity for healthier food choices, the broader issue remains that even when consumers are presented with information, some will continue to make unhealthy choices due to the many factors that contribute to behaviour surrounding food (26). With regard to sodium intake, the chronic disease consequences of excessive intake include hypertension, each year responsible for 9.4 million deaths globally (27), stroke, and CVD (28). As such, the adoption of the WHO-developed SHAKE policy initiative (27) to reduce individual salt intake, with a goal of less than 5g daily, in Australia would aid in addressing the NCD burden, as Australian adult salt intake exceeds this limit (29). The WHO initiative includes the promotion of food content reformulation by industry according to set standards, improvement of nutrition labelling systems located on the front of food packaging, and educational health-awareness programs concerning sodium sources and effects to affect behavioural change. In addition, trans fatty acid consumption increases the risk of CHD and metabolic syndrome, while saturated fatty acid consumption may increase LDL cholesterol, the risk of type II diabetes, and CHD relative to unsaturated fatty acids (30). Thus, the above SHAKE measures may also be extended to saturated and trans fatty acids. Furthermore, the Health Star Rating system, currently under review (31), is of limited efficacy in influencing consumer decision making according to product nutritional value(32) and thus may be strengthened by the addition of the above. Availability of food options In schools Education in schools also helps to combat the effects of food insecurity, as community initiatives such as (e.g. school gardening projects, healthy breakfast programmes and canteen food guidelines,) can improve children’s fruit and vegetable intake and knowledge of foods. (33) These canteen food guidelines have been criticised due to several factors. For example, adherence to the guidelines is not mandatory, and they are poorly enforced and implemented (34). This may potentially be attributed to the complexity of the guidelines themselves (34). It is recommended that Governments continue to investigate the efficacy of such interventions (35). As there are multiple contributing factors to children’s diets it is important that there is a holistic, multi-sector preventative approach to the diets of all (36). It may be of use to consider adapting successful measures that were implemented in other settings, such as the Healthy Food and Drink in NSW Health Facilities for Staff and Visitors Framework, which was implemented by NSW Health and led to the removal of 95% of SSBs from sale in the Murrumbidgee Local Health District in 2016/17 (37). In healthcare settings Health facilities and hospitals are in the unique position to be able to model healthy eating to patients, visitors and staff. The “Healthy Hospital Food Initiative” is a world leading example of a multi-faceted policy aimed at improving the nutritional standard of hospital food in New York (38). Since its implementation in 2010, this voluntary program has seen drastic improvements in the nutritional standard in over 60 New York hospitals across the four target areas of patient meals, cafeterias, and food and beverage vending machines (38). Key examples include a reduction in sodium and fat content of the available meals, and a more than 600% increase in the fresh fruit available (39). Positive policy changes can also be seen in Australian hospitals - the

New South Wales government is implementing and will continue to monitor the effectiveness of the “Healthy Food and Drink in NSW Health Facilities for Staff and Visitors Framework”, a policy framework that provides a benchmark of best practice regarding the provision of healthy food options in hospital. To date, this resulted in 95% of SSBs removed from sale in the Murrumbidgee Local Health District in 2016/17 (40). Key elements of this framework include the removal of sugary drinks from sale, ensuring 75% of available food is classified as an “everyday” food by the Australian Dietary Guidelines, that foods have clearly labelled Health Star Ratings, providing smaller portion sizes, and tactical marketing techniques and product placement (41). Similar Victorian guidelines for healthy choices in hospitals and health care services have helped to launch the trial of a traffic light system for Alfred Health. The implementation of this trial lead to a 20% reduction in the sale of “red” (limit consumption) beverages (42). Sugar-sweetened beverage taxation Sugar-sweetened beverages (SSBs) provide minimal nutritional value, and their excessive consumption has been linked to obesity and the development of NCDs (43). The WHO encourages countries to consider implementing taxes on food products in order to decrease consumption by consumers (44). Several countries currently have taxes on SSBs including Finland, France, Mauritius, Mexico, Hungary and the United States of America, and many have reported a decline in purchases of taxed products (44). For example, a sugar sweetened beverage tax was introduced in Mexico in 2014. During 2014, purchase of taxed beverages decreased 5.5 percent, and 9.7 percent during the following year (45). Furthermore, households at the lowest socioeconomic level had the largest decreases in purchases of taxed beverages (45). Modelling studies for a SSB tax in Australia have been conducted. One demonstrated that a 20% tax on sugar sweetened beverages would generate $400 million revenue per year, reduce new cases of type two diabetes mellitus by 800 per year, and reduce the burden of cardiovascular and cerebrovascular disease (46). Additionally, over the lifetime of an adult, such a tax would result in a gain of 112,000 and 56,000 health adjusted life years for men and women respectively, and reduce healthcare expenditure by $609 million (46). More evidence outlining the specific details of the taxation must be further investigated by the Australian Government to ensure that such a taxation has an optimal benefit on public health outcomes in an Australian context. It should be noted that SSB taxes are expected to have impacts across all socioeconomic status (SES) groups, with greater impacts seen amongst lower SES groups (47). It is important to acknowledge that implementing a sugar-sweetened beverage tax is not the only solution to reducing the intake of these products, but that its implementation should be part of a wider approach towards the prevention of obesity and other NCDs. One study found that taxing SSBs would prevent further increases in obesity prevalence, but that by itself the tax would not lead to an overall reduction in current obesity prevalence, highlighting the need for other policy measures to be implemented in conjunction with the SSB taxation (48). Research suggests that revenue generated from a SSB taxation could be used specifically for improving public health outcomes for diet and non-communicable diseases, which has been investigated in other countries with SSB taxations including Mexico (49). Such subsidies have been effective in increasing fruit and vegetable consumption in low-income groups(50), and modelled to reduce CVD and cancer mortality when paired with a consumption tax via revenue earmarking (51). Marketing regulations The WHO has recommended that marketing regulations are a key policy area that can be targeted to help reduce the burden of obesity and diet-related NCDs (52). Exposure to food advertising influences the food choices and food intake of children

but not adults (53). Food advertising aimed at children frequently promote energy dense and nutrient poor foods (53). Advertising is not limited to material in public places, with television advertising predominating and increasing use of technology (e.g. online advertising) (54). Currently in Australia, standards for commercial broadcasting to children are regulated by a Federal Government via the Australian Communications and Media Authority (ACMA), and self-regulated by the initiatives set up by the Australian Food and Grocery Council (AFGC) (43). Recent research suggests that the implementation of the measures outlined in these standards has not seen a reduction in unhealthy food advertising to children and recommends that stricter regulations are required to ensure that Australian children are protected (55). Given that food advertising to children is highly effective as discussed above, advertising can be used in a positive way to promote healthy alternatives to children (56,57,58). One study found that when promotional toys were provided with healthy meals, but not with unhealthy meals, the number of children selecting healthy options increased (44). This is one example of how advertising can be used to help improve children’s food choices. By increasing the advertising for healthy food products rather than advertising unhealthy products, it may be possible to improve dietary choices of children.

Food Insecurity and Malnutrition Food insecurity in Australia Determinants of food insecurity in Australia Food security can be defined as “access to sufficient, safe and nutritious food that is required to maintain a healthy and active life” (59), and a person is said to be food insecure if, in the past twelve months, they have run out of food and have been unable to purchase more (60). While we commonly associate issues of food security with the developing world, food insecurity affects approximately 5% of Australians (61). Food insecurity can lead to either overnutrition or undernutrition. A multitude of factors predispose Australians to food insecurity including lack of financial resources, poor education regarding the constituents of a nutritious diet, and poor access to outlets selling affordable nutritious food due to lack of access to transportation or geographical isolation (62). Certain groups of Australians are predisposed to food insecurity: approximately 15% of young people, 25% of people of low socioeconomic status, and 25% of Indigenous Australians and those living in remote Australia (62,63). Food insecurity in young people Young people, including babies and children are particularly susceptible to the effects of food insecurity. Children from food-insecure households perform poorer academically and miss more days of school annually than their food-secure counterparts (64). Moreover, health issues such as childhood obesity and childhood anaemia are more prevalent amongst the food insecure, due to greater consumption of energy dense nutrient poor foods, containing fewer micronutrients and higher levels of salt, sugars and fat being cheaper than more nutritious food (65). Food insecurity in low socioeconomic status populations Low Socioeconomic Status (LSES) predisposes to food insecurity and poor food choices. It has been found that the average welfare-dependent Australian family would have to spend 33% of their weekly income on food to abide by the diet stipulated by the Australian Guide to Healthy Eating (see Appendix), compared to an average dual-income family who must only spend 18% (66). Affordability has

consistently been found to be the most significant contributor to food insecurity in Australia, with nutritious food being too costly for those of LSES. It has been estimated that the financial cost of a good quality diet, compared to an poor quality diet is approximately an extra $1.50 more per person per day (approximately $550 more per year) (67). Given that socioeconomic status is a key determinant of food insecurity, subsidisation of good quality food could enable LSES individuals and families to purchase nutritious fresh food, as high prices may pose a barrier to healthy eating (66,67).When subsidised fruit and vegetable packages were distributed to Australian LSES children, their levels of intake significantly rose, hence suggesting that Australia following the UK and USA in subsidising healthy food could increase its consumption amongst LSES families (68). Another way of improving the nutrition of LSES individuals would be providing packages of non-perishable food, freeing up income to buy essential fresh produce (69,70). Improving education regarding budgeting for food, and maximising yield when purchasing food on limited funds has also shown positive results, with LSES families frequently deprioritising the purchasing of food when finances are low (70). Community kitchens, such as one in Frankston, Victoria, through teaching home economics, dietary requirements and cooking techniques to local members, have shown a 43% increase in fruit and vegetable consumption and a 64% fall in fast food consumption (71). Furthermore, non-profit organisations such as OzHarvest and SecondBite may play an important role in addressing undernutrition by redistributing food that would have otherwise been wasted to food insecure populations (72). Additionally, current practices by the private food sector are limiting the availability of fresh produce in Australia, such as the wasteful practice of selecting produce based on its appearance. A landmark Australian study found that up to 86.7% of edible, healthy tomatoes are rejected by large supermarket chains due to their cosmetic appearance and to fluctuating market demands in size and shape, with producers discarding the majority of these edible products to landfill (73). Minimal research has been performed into this avoidable food wastage in the developed world, however global studies show similar worldwide trends in the wastage of edible produce (74,75). Nations such as France have legislated against discarding unsold produce, mandating that it be donated to charity or used as animal feed, minimising food wastage by retailers (76). Despite Australian supermarket chains Coles and Woolworths purporting collaboration with food rescue organisations to redistribute ‘ugly’ produce, this is not consistently achieved as the supermarkets do not pay for the food to be sent to these charities, leaving producers to bear this expense (76). Moreover, the strict selection criteria of retailers leaves prices of ‘premium’ supermarket produce high, putting it out of reach of many LSES Australians (76). In Australia poor general health, increased hospitalisations and poor mental health are all associated with food insecurity, with parents unable to feed their families frequently experiencing anxiety and depression as a result of this (78). There is currently a paucity of research regarding the link between food insecurity and food choices, and NCDs in Australia (69). This must be improved, so that assistance can be specifically adapted to an Australian context. Food insecurity among Aboriginal and Torres Strait Islander populations Food insecurity in Aboriginal and Torres Strait Islander populations predominantly results in conditions of overweight and obesity (13). Aboriginal and Torres Strait Islander adults consume an average of 2.1 serves of vegetables per day, less than half of the 5-6 recommended by the Australian Dietary Guidelines and almost one serve less than non-Indigenous Australians (79). Indigenous adults are less likely than non-Indigenous people to be eating adequate amounts of fruit (ratio 0.9) and vegetables (ratio 0.8). In 2012-2013 only 16% of Indigenous children met the recommended vegetable intake (79). 41% of population’s total daily energy intake came from energy-dense, nutrient-poor “discretionary foods” such as sweetened beverages, alcohol, cakes, confectionery and pastry product, equating to over six serves per day (80). 22% of Aboriginal and Torres Strait Islander people had run out

of food and had not been able to afford to buy more, compared to 3.7% of non-Indigenous people. These levels were higher in remote than non-remote households (80). Interestingly, it has been found that Indigenous Australians are not directly predisposed to food insecurity, and are only food insecure if they are LSES (69). Access to food in remote communities is poor, with food transport being inefficient, costly, and rendering food of poor quality. Moreover, Indigenous Australians are less likely to be aware of the importance of choosing nutritious food(80). Since the large supermarkets typically service exclusively high population-density areas, stores in remote areas often have limited opening hours and pass raised operating costs onto customers, making a typical food ‘basket’ in rural Western Australia 23.5% more costly than in Perth. This leaves nutritious food out of reach for many residents in remote Australia, who turn to processed, unhealthy food as a dietary staple (81). Governmental attempts to improve these stores have been unsuccessful due to underfunding and a lack of insight into cultural diets (82). It has been found that a 10% price reduction in fruit and vegetables increases their consumption by 7%, and therefore, in the interest of improved Australia-wide nutrition, efforts should be made to improve affordability of fresh produce, especially in remote Australia (83). Indigenous leadership is important in addressing malnutrition among Aboriginal and Torres Strait Islander populations. The National Aboriginal Controlled Health Organisation (NACCHO) is using the 2012-13 Australian Aboriginal and Torres Strait Islander health Survey data to identify new research and strategies to improve nutrition (84). Community-led programs may also be successful. Healthy Jarjums Make Healthy Food Choices, an early years and primary school-based program, focused on Indigenous traditional and contemporary food practices and was shown to improve nutrition knowledge and preferences for healthier choices. Over 100 community-based nutrition projects have been started in Indigenous communities, but many have failed because of inadequate resourcing and evaluation (82). Global food insecurity As of March 2017, 37 countries are facing food insecurity, 28 of which are in Africa; food demand is projected to rise at least 20% of the next 15 years, especially in sub-Saharan Africa, South Asia and East Asia (85). Food security in developing countries predominantly results in undernutrition (86). The WFP Global Report on Food Crises 2017 identified the three main factors driving acute food crises in 2016 as conflict, record-high food prices and abnormal weather patterns fueled by El Nino. For example, the conflict in Yemen has made 14.1 million people food insecure through disruption of agriculture (further exacerbated by floods), disruption of the economy, leading to high inflation and rising food prices, and large scale displacement protracting food insecurity and burdening host communities with already overstretched limited resources (87). Many factors contribute to long-term food insecurity. Poverty, which may be the precipitated or exacerbated by conflict, leaves people unable to afford food (66,67). Women are at greater risk of malnutrition in food insecure households and this can perpetuate intergenerational cycles of malnutrition (88). Furthermore, sanitation and hygiene is important as diseases such as cholera and malaria can exacerbate malnutrition (89). Australia provides humanitarian food assistance through organisations such as the World Food Programme (WFP) and the FAO, as well as other national and international NGOs (90). The 2017-18 Budget Estimate of assistance for agriculture and food security related aid is $243.4 million (0.05% of the total budget), however since 2012-13 Australia’s total aid budget has decreased from $5.2 billion to AUD$3.9 billion (90,91). Climate change and food insecurity Climate change is an emerging factor to influence food security both in Australia and globally. More frequent and intense extreme weather events and changing weather patterns affect agricultural productivity and may also affect infrastructure, disrupt

livelihoods and increase poverty; this reduces availability and access to produce and leads to unstable markets (92). Globally, recent climate-driven food crises include those across east and southern Africa, driven by droughts attributed to El Nino (88). In Australia in 2017, hot, dry weather reduced average mungbean yields from 1-1.5 tonnes per hectare to 0.1-0.5 tonnes per hectare (93). Many other crops are vulnerable to these weather changes, as the yields of species such as wheat, rice and maize are reduced at temperatures more than 30°C (94). This can raise the prices of produce, such as in 2006 when Cyclone Larry destroyed 90% of the North Queensland banana crop, increasing prices by 500% for nine months (94). The 2011 Queensland floods also demonstrated the vulnerability of towns such as Rockhampton to extreme weather events, where food supply was cut off for up to two weeks (94). This illustrates the urgency of finding ways to mitigate the effects of climate change on food security as well as increase the resilience of crops to already changing weather patterns.

POSITION STATEMENT

In addition to that covered by the AMSA Non-Communicable Diseases Policy, AMSA believes that:

● The double burden of malnutrition negatively impacts health in low-income, middle-income and high-income nations, and contributes significantly to the growing physical and economic burden of non-communicable diseases.

● In Australia, malnutrition plays a key role in the morbidity and mortality associated with non-communicable diseases, and remains an underinvested and under-prioritised area of public health policy.

● Access to a wide range of nutritious food, in line with individual dietary and cultural requirements, is a human right. An individual’s postcode or country of residence should not determine their level of food security.

Overnutrition

● Australia requires coordinated educational campaigns – directed at both school children and the broader public – so that people are best positioned to make informed choices about food and nutrition.

● Food labelling can be an effective tool that helps people make healthy food decisions, so it is essential that food information is displayed in a comprehensible way.

● Public sector organisations – especially hospitals and schools – can and should act as role models for other organisations in improving employee, patient and/or student nutrition. This could be achieved by increasing the availability of healthy food options and implementing behavioural interventions to encourage healthier food and beverage consumption.

● Sugar-sweetened beverages (SSBs) have little nutritional value, and present a significant physical and economic burden to Australia and other countries. Governments must take active measures to reduce the consumption and impact of SSBs on society. Implementation of an evidenced based taxation on SSBs is one measure that has been shown to improve public health outcomes in other countries, and such a tax should be considered and optimised for the Australian context.

● Advertising plays an influential role in food and beverage choices, particularly among children. Stricter regulations regarding the advertising of unhealthy foods to children are required, including commercially, online and at sporting events.

Food Insecurity and Malnutrition

● More research is required into the links between food insecurity, food choices

and NCDs in Australia in order to develop strategies to address food insecurity specific to an Australian context.

● All individuals and families, regardless of socioeconomic status should have adequate access to nutritious food and no individual should have to suffer the physical or mental stresses of food insecurity.

● Culturally appropriate solutions are needed to address food insecurity in Aboriginal and Torres Strait Islander populations and these solutions require local leadership and consultation, transparency and adequate funding, resources and support.

● Structural and regulatory changes are also needed to increase access to healthy, affordable food in remote Aboriginal and Torres Strait Islander populations.

● The determinants of food insecurity globally are multifactorial and include poverty, gender and lack of food safety. Conflict, increasing food prices and changing weather patterns are key causes of acute food crises.

● Climate change is emerging as a determinant of food insecurity both in Australia and globally. Action is needed to mitigate the effects of and build resilience to climate change.

POLICY

AMSA will: 1. Ensure that healthy foods are present and limit the presence of unhealthy

foods at all affiliated events; 2. Take steps to minimise food waste at all events. AMSA event teams should

consider the viability of engaging a non-profit organisation, such as OzHarvest, to distribute any food waste at events to be redistributed to undernourished populations;

Work with the community, especially the student community and local organisations, to increase awareness of malnutrition and food insecurity on an Australian and global scale. AMSA calls upon: The Federal and State Governments to:

1. Implement an evidence-based tax on sugar sweetened beverages, to reduce consumption of SSBs, with a commitment to regular reviews to assess effectiveness and potential negative impacts (particularly for low SES groups).

2. Consider using revenue from a SSB tax to support programs that enable or support more nutritious diets and healthy eating (such as those described in point 13 below), especially among low socioeconomic populations;

3. Implement guidelines for the sale of food and drink in health care centres, including hospitals, nationwide, such as an institution-appropriate adaptation of the Healthy Food and Drink in NSW Health Facilities for Staff and Visitors Framework.

4. Implement and mandate stricter strategies that prohibit the advertising of unhealthy food to children through all means, including television, online advertising, games, promotions and sporting events;

5. Regulating authorities should ensure that more specific advertising standards are created, defining what foods are considered healthy and can be advertised, and what foods cannot be, particularly to children;

6. Construct wide-ranging food educational campaigns, especially in schools, so

that children are equipped with the nutritional knowledge they need to lead healthy lives. For example, creating school and community garden programs to encourage fresh food intake, and developing parental educational programs;

7. Develop strategies to increase implementation and adherence by school canteens to the National Healthy School Canteen Guidelines;

8. Continue to review current methods and develop new mechanisms, to convey food, caloric and nutritional information in an optimal manner to consumers, and mandate that food and beverage manufacturers comply with these standards;

9. Adopt the WHO SHAKE policy recommendations with regard to salt intake. 10. Extend, and make mandatory, the WHO SHAKE recommendations for front-

of-pack labelling to added sugars, saturated and trans fatty acids. 11. Commit to the regular review and refinement of the Health Star Rating system

following its current review period. 12. Research the broad effects of food insecurity on physical and mental health in

Australia, in order to take action to address nutritional deficiencies; 13. Improve access to nutritious food for those who are struggling to afford it, such

as through subsidised healthy food (such as fruit and vegetables) in local stores or the provision of food packages;

14. Improve standardisation of healthy food supplies in rural, remote and urban Australian communities to ensure food is reasonably-priced, acceptable in quality and readily available;

15. Work with the food and agricultural industry to develop cost-efficient ways to store and transport fresh produce to rural and remote communities;

16. Regulate food wastage and food disposal strategies used by commercial food retailers

17. Partner with Aboriginal Community Controlled Health Organisations (ACCHOs) and community leaders to develop culturally appropriate nutrition education and promotion programs and provide sufficient and sustainable funding, resources and support to these programs;

18. Increase Australia’s foreign food and agricultural aid budget; 19. Consider the impact that Government policies, that either aggravate or

mitigate climate change, have on global food security; 20. Encourage and fund research into ways to improve food security on a local

and international level, including the development of heat and drought resistant crops;

Private sector companies to:

1. Integrate health promotion strategies into advertising campaigns and product promotion;

2. Consider the harmful impact of unhealthy food and drinks when introducing new products to market;

3. Minimise food wastage by selling, rather than rejecting, edible, yet cosmetically-imperfect produce ;

4. Provide front-of-pack labelling of food and beverage item content in accordance with the SHAKE recommendations, with regard to salt, added sugars, sodium, saturated and trans fatty acids.

5. Increase adoption of the Health Star Rating System (and update it as the system is reviewed) on the front of all food and beverage product packaging.

Health professionals and healthcare providers, including hospitals, to:

1. Recognise the significant impact of unhealthy diets and advocate for

evidence-based strategies to increase awareness and action to combat this; 2. Adopt nutrition guidelines regarding the sale of food and drink, such as an

implementing an institution-appropriate adaptation of the Healthy Food and Drink in NSW Health Facilities for Staff and Visitors Framework, in all health care centres.

3. Educate patients around the wide-ranging health impacts of food, and promote strategies for healthy eating;

4. Provide a variety of nutritious foods choices within healthcare facilities at an affordable cost, as well as continuing to research and implement behavioural interventions that encourage healthy food and drink consumptions;

5. Recognise health issues in food insecure individuals and refer patients to relevant services where appropriate;

Medical schools, universities and educational institutions to:

1. Encourage and promote healthy food choices through education and awareness;

2. Deliver specific, detailed nutritional education to medical students and empower them to improve their own health and nutrition, and to pass this knowledge on to their patients;

3. Continue to advocate for proactive policy measures that will improve healthy food choices amongst the broader population;

4. Provide affordable, nutritious food options and limit the availability of unhealthy processed foods and sugar sweetened beverages on all school and university campuses;

5. Increase monitoring by school and canteen staff to ensure healthy options are provided at school canteens, in accordance with Government recommended guidelines, such as the traffic light system;

6. Become involved in community and school garden programs to increase fresh food intake;

7. Incorporate understanding of the social factors determining food security and nutrition into public health curricula.

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APPENDIX Australian Guide to Healthy Eating

https://www.eatforhealth.gov.au/sites/default/files/content/The%20Guidelines/n55_agthe_large.pdf The Australian Guide to Healthy Eating is a visual representation of the proportion each food group should occupy in a healthy Australian meal, in a format that is easily accessible by people of all ages and cultures. It also stipulates foods that should be consumed in strict moderation and should not constitute part of a regular healthy diet, such as alcohol, deep-fried foods and SSBs. However, adhering to these guidelines is a costly affair for LSES and welfare-dependent Australians, hence the government must devise and implement strategies to make healthy eating a right rather than a luxury.

POLICY DETAILS Name: Food and Nutrition Policy Category: G- Global Health History: Adopted Council 3, 2016. The previous version of the policy was repealed and updated version was adopted at First Council, 2018 R. Harris, J. San Juan, D. Daudu, A. Rottler, I. Woodruff, A. Wijetunga, R. Mahesh