1

A RATIONALE FOR THE RECOMMENDATIONS OF THE HEALTHY FOOD PARTNERSHIP’S FOOD SERVICE WORKING GROUP

MAY 2018

2

CONTENTS

Food Service Working Group members ................................................................................................... 3

Executive Summary .................................................................................................................................. 3

Context ..................................................................................................................................................... 4

The Food Service Working Group (FSWG) ................................................................................................ 6

Principles for the FSWG’s work: ........................................................................................................... 7

Existing domestic and international initiatives ..................................................................................... 7

Introducing a food service pledge scheme in Australia ............................................................................ 9

Developing innovative, flexible and ambitious pledges ......................................................................... 12

The food service pathway in Australia – understanding and working with the different stakeholders 12

How consumers can influence change ................................................................................................... 13

Incentives and recognition ..................................................................................................................... 14

Measuring awareness of the pledge scheme ......................................................................................... 15

Measuring the Impact of the Pledges .................................................................................................... 15

Company Reporting ............................................................................................................................ 17

Government Survey – product offerings ............................................................................................ 18

Government survey – A Food Service Week ...................................................................................... 18

Optimising existing Biomedical and Dietary Surveys .......................................................................... 19

The proposed food service pledge scheme ............................................................................................ 20

The pledges ............................................................................................................................................ 22

Better choices ..................................................................................................................................... 22

Better ingredients ............................................................................................................................... 23

Better awareness ................................................................................................................................ 25

Attachment A: Program logic for the food service strategies (as at 2 May 2017) ................................. 27

Attachment B: United Kingdom Public Health Responsibility Deal ........................................................ 28

Attachment C: Example of a monitoring initiative: Salt in salads ........................................................... 30

References .............................................................................................................................................. 31

3

FOOD SERVICE WORKING GROUP MEMBERS

Mr Rohan Greenland (Co-chair)

Mr Ben Miles (Co-chair)

Ms Coral Colyer

Ms Denise Cruikshank

Mr Mathew Dick

Ms Deanna Mak

Ms Belinda Royds

Ms Helen Vidgen

EXECUTIVE SUMMARY

Consuming meals which are not prepared at home has become a regular part of life for many Australians. Working with food services to improve the nutritional quality of the foods provided is an important step towards addressing nutrition and diet at the population level.

The Healthy Food Partnership’s Food Service Working Group has developed a strategy to improve the food supply for which the food service sector is responsible. The focus is on simple and effective voluntary commitments (‘pledges’) by industry. These are designed to optimise the nutritional profile of food and beverages provided in food service settings, with consideration to placement and promotion of healthier options; a range of portion sizes; product reformulation; and availability of information for consumers.

Activities which support Better choices, Better ingredients and Better awareness, and touch all parts of the food service supply chain (including consumers), will promote meaningful and sustainable changes to the Australian food services sector.

Nine high-level pledges are proposed, with companies across the food services sector asked to identify activities they can undertake to achieve the pledge; commit to action; and report annually on progress. This will allow monitoring and reporting of the effect the pledges are having on optimising the nutritional profile of foods and beverages supplied; and (indirectly) better alignment of consumer consumption with the Australian Dietary Guidelines.

4

There is a recognition that to meaningfully change the food offerings to Australians, all key stakeholders must be involved. The Partnership is a collaboration between government, food industry and the public health experts to identify mutually beneficial changes that will result in a sustained change in the diet quality of the food supply in Australia. The food service sector is a growing and important contributor to this broad aim of the Partnership.

This document outlines the Food Service Working Group’s deliberation process, rationale for the proposed scheme, and the draft pledges.

CONTEXT

Every year, non-communicable diseases (NCDs) cause the deaths of 15 million people between the ages of 30-70. By 2023 the World Health Organization aims to support countries to reduce premature deaths to achieve the Sustainable Development Goals.i

The World Health Organization (WHO) has identified reduction of salt and sugar, elimination of trans-fats and reformulation of food products to make them conducive to a healthy diet as among the most cost-effective and affordable “best buys” for the prevention of NCDsii

It is widely acknowledged that chronic disease is the major health challenge facing our nation, and that poor nutrition is among the leading modifiable risk factors that contribute to the Australian disease burden. Australian Health Survey data (National nutrition and physical activity survey, 2011-12iii showed that, at the population, level Australians under-consume all five food groups, and over consume non-five food group foods (often referred to as discretionary or ‘treat’ foods). This means that we are eating too much of the foods with a demonstrated contribution to chronic disease and under-consuming the foods we need to maintain good health It is therefore critical that governments, industry and health groups work to improve the nutrition of the food supply and, in doing so, help more Australians to achieve diets that align with the Australian Dietary Guidelines (ADGs).

Improving the food supply results directly in saved lives. In the United States, the Food and Drug Administration says Americans still eat about a gram of trans-fat every day and their plan to phase out artificial sources could prevent 20,000 heart attacks and 7,000 deaths each yeariv.

Similarly, the Spanish government and the country’s food industry have announced plans to cut the content of sugar, salt and fat across more than 3500 products over

5

the next three years resulting in a 10% reduction in these ingredients and significant reductions in death and diseasev.

The Healthy Food Partnership (Partnership) aims to improve the dietary habits of Australians by making healthier food choices easier and more accessible and by raising awareness of better food choices and portion sizes. All activities developed through the Partnership will be voluntary.

The Partnership’s Food Service Working Group (FSWG) has developed a strategy to improve the food supply for which the food service sector is responsible. The focus is on sustainable and effective voluntary commitments (‘pledges’) by industry which demonstrate an improvement in the diet quality of food and beverages offered in food service settings, with consideration to placement and promotion of healthier options; a range of portion sizes; reformulation; and availability of nutrition information for consumers. The range of pledges give all food service businesses scope to participate, with the cumulative impact of many actions expected to change the food service sector, and associated consumption, overall and over time.

Food service outlets are making an increasing contribution to the diets of Australiansvi. It is acknowledged that food prepared and consumed outside the home tends to be higher in total energy, sodium (salt), fat and sugar; and lower in fruits and vegetables than similar foods prepared and eaten at home. Improvements in the nutritional quality of foods in the food service sector, therefore have great potential to improve the diets and health of Australians overall. With an estimated 51.5 million visits to quick service restaurants (‘fast food’) outlets each month (including more than one million visits to McDonald’s restaurants each day), it is fundamentally important that the $45bn food service sector with its 82,000 eating-out establishments is engaged in a meaningful way to improve the nutritional profile of the products they offer and market to consumers.

Number of eating-out establishments, Australia (2016)vii

Fast food outlets 29,400 Restaurants 22,000 Cafes 20,500 Pubs and bars 7,000 Clubs 6,400

Total: 82,000

The food services industry comprises businesses and institutions which are mainly engaged in providing meals, snacks and beverages for customers, both on- and off-

6

site. The Australian Bureau of Statistics (ABS) industry classification includes cafes, restaurants, takeaways, catering services, pubs, bars and clubsviii. Casinos, sporting clubs, caravan parks, theatre restaurants, bakeries, amusement parks, cinemas and vending machines are also relevant food service settings where improvements identified in the pledge scheme can be made.

As such, relevant priority areas of the food services sector include:

1. Quick service restaurants and fast casual dining 2. Ready to eat convenience foods (e.g. supermarket and convenience store

settings, vending machines) 3. Independent fast food outlets/takeaway stores and sandwich bars 4. Distributors and corporate caterers 5. Dining out (including restaurants, cafes, pubs, clubs and function centres) 6. Event/leisure (including event, leisure, travel and accommodation) 7. Institutional corporate and education (including workplaces and schools) 8. Institutional other (such as defence or correctional facilities)

Institutional settings where food choices are determined by other nutritional requirements, or there is no consumer choice, are out of scope. For example, residential care facilities, aged care and in-patient hospital services are out of scope. However public and staff cafes at hospitals / institutions, where visitors and staff may purchase meals, are in scope, and some progress is already being made in such government-owned institutions.

Further, because different types of food service outlet market towards or appeal to different customer or demographic groups, activity by different food businesses has the potential to act on the nutritional risk profile of certain population sub-groups in a very targeted way.

There are some good examples of food service companies who are taking action – for example, reducing the salt, saturated fat, added sugar or energy content of their products and adding more fruit and vegetables to their offerings [future case studies should be developed]. However these are largely ad hoc measures. Significant improvements to Australia’s health could be achieved with a systematic government-led voluntary program that engages and encourages action across the sector.

THE FOOD SERVICE WORKING GROUP (FSWG)

To help develop a way forward, the FSWG has, through the Federal Health Department, commissioned a reviewix to guide its work in what is, surprisingly, an area where comparatively little has been tried and evaluated across the globe.

7

PRINCIPLES FOR THE FSWG’S WORK:

1. Recommendations to improve the foods offered, promoted, purchased and consumed out of home should be based on the Australian Dietary Guidelines (ADGs).

2. Voluntary recommendations should aim to: • ensure healthier choices are the easy choices (in terms of access, price and

appeal); and • ensure consumers are informed at point of purchase.

3. Recommended activities should be transparent and sustainable in their implementation, monitoring and evaluation of impact and reach;

4. Approaches should be pragmatic, adopting the 80:201 approach to achieve the greatest gains;

5. Collaboration and early engagement should be a priority; 6. Goals should be achievable within the set time frame yet aspirational; 7. The food services sector is diverse and successful engagement will require a

range of approaches. As some businesses are more advanced than others, pledges of action to meet the general aim/theme/goal should be presented as what they will stop doing, start doing and continue to do.

EXISTING DOMESTIC AND INTERNATIONAL INITIATIVES

In Australia, legislation to mandate the display of kilojoule content on fast food menu items has been implemented in New South Wales, South Australia, the Australian Capital Territory and Queensland. Victoria has also passed legislation and is due to introduce the scheme on 1 May 2018. All states and territories are implementing approaches to guide the availability and promotion of food and drinks in public settings such as schools, early childhood education and care and health care facilities.

In addition to the above, the FSWG was aware of a limited number of food-service related initiatives in place in Australia and internationally. To better understand those initiatives, in order to learn from and improve upon those experiences, the FSWG commissioned an evidence check on International Food Service Initiativesx; and liaised with staff at Public Health England about the UK Responsibility Deal.

Significantly, the reviewxi found:

1 Recognising that 100% adoption rate is unlikely, efforts may prioritise businesses with the largest share in food service - the top 80% based on number of outlets, sales etc.

8

“that awareness raising schemes when used in isolation are ineffective, and actions beyond increasing awareness are needed to effect change. Although some schemes did employ strategies that were structural in nature, thereby modifying the food environment to improve consumer health, the effect of these schemes on consumer health was not measured. The evidence included in this review suggests that some businesses will engage in schemes to improve consumer health, particularly if the changes are imperceptible to consumers and have little impact on revenue. Few schemes were pledges, and the evidence of efficacy of pledges was limited and mixed. The evidence indicates that organisations have engaged in pledge based schemes, but chose strategies that were ineffective, or targets that required little change.” (page 5)

and

“Schemes employed within the food service sector to improve consumer dietary health offer considerable potential [emphasis added] to improve the nutritional quality of foods offered, promoted, purchased and consumed out of the home; [in order to] reduce the public health burden of obesity and diet-related health problems in Australia over the longer term.”(page 5)

This is supported by a study published in 2017 that examined the progress made in fast food restaurants over the past decade in implementing strategies to achieve healthier food environments. It found the United States’ restaurant sector had “many under-utilised opportunities to combine marketing-mix and nudge strategies to promote healthy food environments”. The study tested a novel marketing-mix and choice-architecture framework to evaluate the nature and extent of voluntary strategies used by United States chain and non-chain restaurants to promote healthy food environments for customers.xii

In the United States, there are encouraging signs that the food service sector appears keen to support change. A new study reports that, in advance of the introduction of menu labelling in May 2018, thousands of items have been dropped from the largest American chain restaurants and the mean calories among the items that were dropped was higher, on average, than the items that remained on the menu.xiii There appears to be an appetite for change in the Australian food services sector as well, with industry newsletters suggesting healthier options are gaining in popularity.

The report, Eating Out In Australia 2017, lists the ‘top 10’ trends in the food service sector, as assessed through sector-wide surveys. ‘Healthier food is not a fad’ is listed as Trend No 2, declaring “People are eating healthier food. Venues are reporting a

9

growing interest in healthy food and cuisines, with less healthy offerings in decline. Traditional fast food is down, with chains increasingly offering healthier options”.xiv

Consistent with the Australian government’s regulatory reform agenda, all initiatives under the Healthy Food Partnership, including for food service settings, are designed for voluntary implementation. International experience of voluntary schemes has been mixed, as highlighted in the reviewxv, and countries are seen to shift from voluntary initiatives to co-regulatory and regulatory models if targets are not achieved. The United Kingdom provides an example of this, with a target introduced in 2017 to reduce the sugar content of a range of food categories in retail and food service settings by 20%. Industry implementation will be closely monitored, and alternate levers considered if progress is inadequate.

The Australian food industry has experience of voluntary, government-led collaborative efforts to improve food through the Food and Health Dialogue which established voluntary reformulation targets for certain food categories; the Health Star Rating nutrient profiling system for packaged food products; and the Food Standards Australia New Zealand Allergen Collaboration which supports non-regulatory measures that can improve the management of food allergens. xvi

The FSWG findings - based on collective experiences, evidence and industry trends - suggests that a pledge-based system can be developed that builds on the approaches attempted to date and addresses their short-comings. A pledged-based system offers good prospects of engaging industry to achieve meaningful change over time in the absence of legislated initiatives.

INTRODUCING A FOOD SERVICE PLEDGE SCHEME IN AUSTRALIA

Population-level nutrition data shows that the majority of Australians under-consume five food group foods, and over-consume discretionary foodsxvii. Compounding this problem is the questions of serving and portion size – with bigger meals served on a regular basis and people eating bigger portions, with a financial value perception of ‘bigger is better’. The approach of the Healthy Food Partnership addresses portion size and reformulation through other streams of work, but a significant nexus is in food service.

Having considered published and grey literature, the FSWG concluded that a voluntary pledge scheme, targeting all components of the food service pathway could make significant progress, creating the impetus for change and recognising incremental improvements to the nutritional quality of foods. The FSWG believe a system of pledges could help create the ‘enabling environment’ needed to drive change here in Australia, particularly if those pledges build on the lessons from the

10

UK and elsewhere. Such food sector initiatives could form part of an effective suite of measures when implemented in conjunction with reformulation for processed food, portion size guidance, food labelling and education campaigns, such as those for the Healthy Food Partnership and the Health Star Rating system. The contribution that the voluntary pledge scheme can make to improving overall population health and nutrition outcomes is set-out in the logic-model at Attachment A.

Pledge categories have been developed in response to modelling of strategies where the greatest health gains can be made within Australian dietsxviii, including a focus on children (within each pledge category, actions can be taken to improve the dietary intakes of Australian children). The focus is on aligning food and beverage offerings in food service with the Australian Dietary Guidelinesxix, specifically:

1. To achieve and maintain a healthy weight, be physically active and choose amounts of nutritious food and drinks to meet your energy needs

2. Enjoy a wide variety of nutritious foods from these five food groups every day

• Plenty of vegetables of different types and colours, and legumes/beans

• Fruit • Grain (cereal) foods, mostly wholegrain and/or high cereal fibre

varieties, such as breads, cereals, rice, pasta, noodles, polenta, couscous, oats, quinoa and barley

• Lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans

• Milk, yoghurt, cheese and/or their alternatives, mostly reduced fat • And drink plenty of water

3. Limit intake of foods containing saturated fat, added salt, added sugars and alcohol

The approach recommended by the FSWG embraces ‘pledges’ in order to build momentum and change. In other words, businesses would be asked to develop pledges that make business-specific commitments to achieve the goals outlined in each of the pledge areas set out in this document. This is similar to the pledges used in the UK’s Responsibility Deal (Food area – see Attachment B) and also in the UK Food Foundation’s ‘Peas Please: Making a pledge for more veg’ program launched in England, Scotland and Wales in October 2017.xx

Under the ‘Peas Please’ program, quick service, food-on-the-go and casual dining businesses can commit to increase the number of portions of vegetables they sell.

11

Annual reporting is to be made to monitor commitments and an awards scheme is provided as an incentive for participation.

The UK Responsibility Deal, commenced in 2011, offered companies the opportunity of committing to act in five key areas:

• provide calorie information on menus for food and drinks when eating out • reduce salt in food sold across the retail and catering sector • remove artificial trans-fats from all foods • support and enable customers to eat and drink fewer calories through a

range of actions • increase the consumption of fruit and vegetables

The Responsibility Deal has been criticised by some sectors as allowing food industry too much flexibility for it to succeed in public health policy objectives. From the UK experience, it is important that the voluntary Australian system strikes a balance between flexibility for industry that they can participate while still remaining financially viable (by selling products that people want to eat) and achieving public health objectives. Implementation options need to consider the provider type and the size of the business, with reporting and transparency key requirements in order to motivate businesses and engender trust in the system. Pledge activities also need to incorporate robust monitoring and evaluation arrangements, to comprehensively describe change in the Australian foodservice sector and ensure accountability.

As such, while a voluntary pledge scheme is recommended, it is important to learn from the international experience:

• Flexibility of the pledges will enable all businesses to introduce and maintain relevant changes within their business practices, making this a long-term strategy rather than a brief policy shift;

• ‘Stop, start, continue’ pledges are designed to motivate and stretch businesses towards continual improvement as they gain confidence and build upon their successes; and

• Transparency (of pledges, actions and achievement) and regular public reporting will be integral to the success of the pledge scheme. SMART Principles should apply to the pledges - encouraging businesses to make pledges which are Specific, Measurable, Achievable, Relevant and Time-bound.

12

DEVELOPING INNOVATIVE, FLEXIBLE AND AMBITIOUS PLEDGES

Food businesses form an integral part of the pledge scheme and are ultimately the key stakeholders responsible for successful execution of the individual pledges and promotion of healthier choices.

In order to achieve public health outcomes, pledges must stretch businesses to innovate beyond their current offers so that a positive change in consumer consumption is achieved. Given the importance of their role, it is essential that food businesses are motivated and empowered to ensure that the implementation of voluntary pledges is effective and sustainable.

Offering a set of pledges that is realistic, sustainable and commercially viable will help food businesses achieve a motivated and innovative mind-set.

THE FOOD SERVICE PATHWAY IN AUSTRALIA – UNDERSTANDING AND WORKING WITH THE DIFFERENT STAKEHOLDERS

The food service sector is broad and encompasses a number of distinct players with specific roles. Identifying these players, their dependencies, their purpose, their motivations and possible demand points for leveraging change to healthier food options is critical to achieving the outcomes of the Healthy Food Partnership.

A simplified sector analysis is illustrated via the following diagram:

In the food service sector there are a number of drivers. One significant driver is sales – which are directly generated by the customer, but can also be manipulated

13

by the food service outlet via marketing, availability and price. Sales feedback through the supply chain via the distributer to the manufacturer and this is a significant communication channel that has the potential to be leveraged for the production and distribution of healthier food products. Ensuring both the food service business and the distributer are aware of, have the knowledge and capability, and more importantly are motivated to communicate demand for healthier food products to the manufacturer may be a key intervention. Marketing and regulation by government is another avenue to motivate and drive the food service sector to offer healthier food options.

The other driver is consumer demand. Market research, generally undertaken by manufacturers, but also some larger food service outlets (notably quick service restaurant chains), can provide significant influence in the manufacture of healthier food products which then feed through the supply chain. This demand can also be influenced by the manufacturer via marketing and price. There is a further opportunity to drive the demand for healthier food products in the market via educating and marketing to the public the advantages of healthier food options in the food service sector.

Food service pledges will ideally have applicability and relevance to all players in the food service sector, connecting all parts the food system to common goals. Engaging distributors is a longer-term ambition of the pledge system, recognising that they are an important enabler of change by food service businesses, especially small and medium-sized enterprises.

HOW CONSUMERS CAN INFLUENCE CHANGE

Many Australian food services have already made significant changes to the products they provide, in response to consumer demand for healthier food. Much of this change is unpublicised and unrecognised.

The food service pledge scheme provides a mechanism for food services to commit to change. Consumers will be able to access information about the changes being made, and can further motivate businesses on the change pathway by asking for and choosing healthier options, different serving sizes, or discussing with the businesses the changes they are making. Business may even wish to engage with consumers about the changes they would like to see and support, such as through a customer ‘vote’ or social media engagement before making a pledge. Ultimately businesses are unlikely to sustain a change which is financially damaging. So honest but constructive consumer feedback about the changes being made is important.

14

Consumers are asked to recognise that the food service changes are ultimately about providing food and beverage choices that better align consumption with the Australian Dietary Guidelines. So a smaller muffin or piece of cake isn’t about being financially ‘ripped off’; and doesn’t mean you should eat two pieces. Rather the changes are about providing more appropriate serving sizes of a discretionary food, or a healthier proportion of vegetables to meat.

By choosing to purchase from food services that participate in Healthy Food Partnership activities, consumers can encourage other businesses to also sign up. And choosing healthier food options consumers will encourage businesses to keep those items on the menu, and make further healthier changes.

The Healthy Food Partnership and participating businesses need to communicate about eating patterns that align with the Australian Dietary Guidelines (food types and portion sizes), changes being made through the food services, and the way that consumer purchasing behaviours can positively motivate and reinforce changes.

INCENTIVES AND RECOGNITION

The Healthy Food Partnership understands that recognition can be, in different circumstances, both an incentive and a disincentive for food businesses. Consumers may say they want healthier products, but also don’t want their favourite foods to taste any different or feel that their meal is of lesser value because it is slightly smaller or has a greater ratio of salad / vegetables to meat. In those circumstances a ‘health by stealth’ approach is sometimes taken, with small incremental changes over an extended period of time. However, Australia is also reaching a point where, from a health policy perspective, we need to create an enabling environment for significant changes to happen much more quickly.

The proposed food service pledges are structured around ‘stop, start, continue’ activities, which enables businesses to identify and be recognised for previous positive activities. For example, a business that has already significantly reduced the sugar or sodium content of breads they use as component ingredients can continue with those low levels, and may be able to make further smaller reductions. By contrast another business may not yet have made any changes to a similar bread component, so has further scope for larger change and is encouraged to do so. The first business may be used as a case study or example of how products can be improved nutritionally. Both businesses can recognised and make public information about their product improvements, and the corresponding time periods, under the proposed pledge scheme.

15

Recognition can also be at a more general level, by businesses identifying that they are participating in the Healthy Food Partnership food service pledge scheme. Annual reporting of activities, positive media coverage, and messaging through social media about the need for healthier food will all act as incentives and provide recognition to businesses involved in the Healthy Food Partnership.

The FSWG acknowledges that some businesses in the food service supply chain, such as food distributors, are largely unseen by the general public and thus the potential to receive public recognition is not a large incentive for these businesses to participate in the pledge scheme. While large food outlets can order customised ingredients from distributors, smaller and medium size food outlets are only able to select from a distributors’ standard product range. Food distributors can therefore make an important contribution to enabling small and medium food outlets to achieve their pledges through provision of healthier ingredients, including their ‘own brand’ products. In recognising this opportunity, some of the pledges proposed in the pledge scheme relate to food distributors. Working with these businesses is a longer-term ambition for the FSWG and other businesses will be prioritised to adopt the pledge scheme in the first instance.

MEASURING AWARENESS OF THE PLEDGE SCHEME

Much of the monitoring will be directed towards actions of participating food service businesses; however there needs also to be a measure of food industry awareness of the pledge scheme. Aspects of this will relate to the success of communication and outreach activities to promote awareness; and conversion rate of ‘aware’ businesses to ‘participating’ businesses.

Consideration should be given to whether consumer awareness of food service businesses making changes is a reliable or meaningful measure. Most consumers only experience the front end ‘sales’ changes and communications, not those of the manufacturing and distribution businesses. Further, some businesses or practices may choose ‘health by stealth’ where consumers are not even aware that a nutritional improvement has been made. Consumer perceptions are therefore likely to underestimate the actual impact of the pledges.

MEASURING THE IMPACT OF THE PLEDGES

Measuring change is critical to the success of any public health intervention. While the predecessor of the Healthy Food Partnership – the Food and Health Dialogue - achieved some significant success, there was criticism that there were “no clear reporting of outcomes, no systematic baseline data collection and little quantitative reporting of progress”.xxi xxii

16

A review of the UK’s Responsibility Deal, published in 2015, argued that – to ensure gains to public health were produced that would not otherwise have occurred – the Government needed to:

• increase participation and compliance through incentives and sanctions • create visibility of voluntary agreements, and • increase scrutiny and monitoring of partners’ pledge activities.xxiii

It is important, therefore, that the proposed system of food services sector pledges include a robust process for monitoring and evaluation the initiative. While robust, it should avoid being complicated and onerous for the participating companies, not least because engagement will involve cost and time, which will be borne by the company.

Measuring the impact of the pledges at both the Program and Participant levels, is proposed to be addressed by a focus on the Medium Term Outcomes, as per the Logic Model (Attachment A).

The pledge scheme and monitoring / measurability have been designed to align with the Principles (see page 6) and to address the following needs:

1. Transparency – building on experiences of food supply change programs (e.g. Heart Foundation Tick, Food & Health Dialogue), the process of measuring and reporting the impact must be transparent in order to alleviate any stakeholder concerns and build trust in both the participants and food service pledge scheme as a whole.

2. Incentive –The basic act of tracking progress against milestones in itself provides an incentive for both participants and the food service pledge schemas a whole. The subsequent reporting of progress, and rate of progress, also provides incentive to continue with the work and potentially draw new participants in, by way of publicity generated.

3. Sustainable – Participant reporting can be used as case studies for the HFP to drive awareness, increase participation and demonstrate outcomes at individual level, while food service pledge scheme reporting can be used at the broader public health level to demonstrate effectiveness to keep the program running. The natural market competition between food service participants also has the effect of continually raising the bar.

4. Relevance – by ensuring the nature of the impact areas measured have meaning at consumer, participant and food supply levels, the food service pledge scheme will remain relevant to all stakeholder areas. The suggestions to track improvements to the nutritional composition of menu items (consumer), increase in serves of vegetables being provided (participant) and reduction in sodium across sector (food supply) work to address this.

5. Accountability – recognising the principle of ‘What gets measured gets done’. Food service participants are publically held to their pledges and the food

17

service pledge scheme as a whole is held to progress each year via the market reports it releases.

A three-level process is proposed: company reporting; government surveys; and biomedical and dietary data. While there will be short, medium and long term measures of success, monitoring should first focus on pledges that support the “Better choices” pledges- kilojoule reduction, food and beverage sizes and availability of water. Medium-term outcomes reflected in the logic model (Attachment A) include increased availability and accessibility of healthier food, drink and meal options; increased availability and accessibility of food, drink and meal options in appropriate portion sizes; and increased consumer awareness and motivation of consumers to change their purchasing behaviours. In the first instance, changes are expected to most closely reflect the ‘kilojoule reduction’, ‘food and beverage sizes’ and ‘availability of water’ pledge themes.

COMPANY REPORTING

Participating companies will be asked to work with the Department of Health to develop individual pledges which align with the identified pledge themes, which will then be placed on a dedicated web-based pledge registry. The pledges should be time-specific and companies are encouraged to develop delivery plans explaining how the pledges will be implemented. Pledges should include a statement on the context of the pledge which describes the likely impact towards the achievement of the dietary outcomes of the pledge theme e.g. As a result of this pledge we expect to remove x kg of added sugars from our menu.

An annual company self-report on progress implementing their pledges should be provided to the Department of Health, and will be published.

The intention is that an over-arching, annual report will be undertaken, which will summarise progress across the pledges made by all participating companies with additional analysis to estimate the population health implications and impacts of the collective pledges, or the impact of pledges made by sub-groups of the food services sector (e.g. quick service restaurants, casual dining restaurants, catering companies, etc.).

The Partnership will also consider, on a case-by-case basis, permitting the details of some pledges to be kept confidential at the request of businesses wishing to take a ‘health by stealth’ approach. Acknowledging the importance of accountability and transparency, these businesses would still be required to provide a confidential annual progress report to the Department of Health on their progress towards

18

achieving their pledges. The results from these reports would be de-identified and incorporated into the over-arching annual report.

GOVERNMENT SURVEY – PRODUCT OFFERINGS

To measure progress towards the pledge themes, it is recommended that an annual or rolling survey be commissioned that will examine the health of the food supplied by the food services sector. Because this would be a major and costly undertaking if conducted across the entire food services sector, it is proposed that different sectors and food product categories be examined each year on a rolling basis. Information about a United Kingdom example is at Attachment C. For example, the survey may sample ‘beef hamburgers’ across a range of both participating and non-participating food service sector companies to assess a range of measures relevant to the pledges (e.g. reduced sugar, sodium, saturated fat, increased proportion of salad and dairy). This survey could be repeated in, say, two years to assess progress. The next survey may sample pizzas, followed by the availability of water, or restrictions of sodium availability or other measurable practices that are the subject of pledge commitments. Priority could be to high-volume products and high-impact practices. Further detail about the most effective way to conduct this monitoring should be developed in consultation with the organisation contracted to conduct it.

A similar rolling product category survey could collect evidence of improvement over time. By targeting a few products or practices each year, costs will be contained, but importantly, trends can still be established over time.

The food services sector survey is likely to have an added public health benefit above and beyond recording the impact of the pledge scheme. Evidence suggests it has the potential to drive change in its own right by measuring and reporting on individual products and practices over time. This will encourage reformulation and improved practices in the food services sector.

GOVERNMENT SURVEY – A FOOD SERVICE WEEK

Using an Australian Market Basket Survey style concept to compare the “Average Australian Food Service Week” at participating outlets vs non-participating. This could also track increased awareness and motivation in consumers to change purchase behaviours. This population level assessment of food supply and behaviour impact while in the first few years will focus at the Medium Term Outcomes level, in time it should be able to move to demonstrate the Longer Term Outcomes identified in the program logic (Attachment A).

19

OPTIMISING EXISTING BIOMEDICAL AND DIETARY SURVEYS

Understanding the impact of the improvements expected from the Healthy Food Partnership, such as the Food Service Pledge Scheme; and through the Health Star Rating System, should ideally be determined through a systematic and coordinated national system of food and nutrition monitoring, biomedical surveys and food composition data.

The UK Government has over the past decade conducted a series of statistically valid population-level salt surveys using 24-hour urinary sodium excretion methodology. This has been conducted to assess the impact of national food reformulation programs and other salt-reduction strategies. The surveys have found that adults in England have cut their average salt consumption by 0.9 grams per day in the decade from 2005 to 2014. Average salt consumption for adults in 2014 was 8.0 grams a day, down from 8.5 grams in 2011 and 8.8 grams in 2005-06, with overall salt intake falling by 11%.xxiv

The 2014 survey – conducted as part of the National Diet and Nutrition Survey - involved a random sample of 689 adults aged 19 to 64 years via 24-hour urine collections. Public Health England have estimated that a reduction in average salt intake from 8g a day to the recommended maximum of 6g a day could prevent over 8,000 premature deaths each year and save the National Health Service more than £570m annually.

The survey provides an independent national assessment of the impact of population level nutrition interventions for a single nutrient (sodium). The Australian Government could introduce regular sodium surveys as part of the National Health Measures Survey.xxv or other surveys, including those conducted by the States and Territories.

Reporting at the national level can also be achieved for consumption of other nutrients using existing processes conducted by the Australian Bureau of Statistics under the Australian Health Survey. The 2011-12 National Nutrition and Physical Activity Surveyxxvicollected three different types of dietary data:

24-hour dietary recall of food, beverages and supplements (on two separate days)

usual dietary behaviours

whether currently on a diet and for what reason.

This data would also be useful in providing population health benchmarks that may inform assessment of impact of Healthy Food Partnership initiatives.

20

It is important to note that the objectives for the collection and reporting of food and nutrition data in the NNPAS were to:

determine food and nutrient intakes in the population as a whole

enable monitoring and reporting of the adequacy of food and nutrient intakes against national dietary guidelines and nutrient reference values (NRVs) for appropriate age groups

enable comparison of food and nutrient intakes to those reported in previous national surveys

inform the development and evaluation of national food regulatory standards.

Existing surveys could be considered for inclusion of questions about the frequency of eating out, types of food consumed from food services, and types of food services involved - encompassing the wider range of relevant food settings considered by the FSWG (e.g. including from vending machines, at sporting venues). Questions such as ‘where did you buy that’ could be insightful.

THE PROPOSED FOOD SERVICE PLEDGE SCHEME

Consuming meals which are not prepared at home has become a regular part of life for many Australians. Working with the food service sector to improve the nutritional quality of the foods provided is an important step towards addressing overall nutrition and diet at the population level.

Under the Food Service Pledge Scheme, the Healthy Food Partnership (the Partnership) will work with Australian food service businesses to assist them to sign up to pledges and commit to voluntary actions designed to address overconsumption of certain nutrients of public health concern; and to better balance five food group foods and discretionary foods in meals served.

In time and in the context of total consumption this will assist with achieving appropriate energy and nutrient intake; and increase consumption (at the individual and population level) of the five food group foods in accordance with the Australian Dietary Guidelines, at the population level.

The Food Service Working Group acknowledges that these voluntary food service pledges need to be implemented in a commercially viable way, within a realistic timeline. We also acknowledge that working with food services to achieve public health objectives is not without its critics; yet it reflects the reality of how we eat, and therefore an opportunity to help Australians to eat more healthily.

21

A major focus for government and health groups is to recognise companies who make genuine attempts to reach their goals, highlighting the positive impact they are making on population health.

The proposed pledge scheme envisages that:

• Food service businesses will be able to choose which pledge to commit to, from a list available through the Partnership website.

• They will then be asked to provide information about what action they will take to enact that pledge. Examples of how the pledges could be enacted are provided below, and are suggestions only.

• A ‘free text’ field would allow each business to describe their own planned action.

• Pledges would align with the concept of ‘SMART commitments’: Specific, Measurable, Achievable, Relevant, Time-bound.

• Food service businesses would be asked to report annually on their progress (after having made a pledge, and outlined the action to be taken).

• Company reports will be reviewed, including by the Department of Health, for the purpose of monitoring and reporting achievements under the pledge scheme. Non-business sensitive information may be published in individual or aggregated formats.

Recognising that changes will take time to implement and have effect, participating businesses are asked to make at least three reports; including of the ‘continue’ pledges, so that the longer term improvements achieved by the Partnership can be effectively measured.

Pledging and reporting through the Partnership website will allow information to be made publicly available about the pledges and progress of food service businesses who are involved in the Healthy Food Partnership.

22

THE PLEDGES

Nine pledges within the three areas of Better choices, Better ingredients, and Better awareness are outlined below, with examples of how these pledges could be enacted. ‘Continue’ pledges marked with an # allow businesses to recognise significant previous activities / changes, but companies are asked to commit to new actions in addition to these.

BETTER CHOICES

Theme: Food and Beverage Sizes Aim: Provide a range of sizes for meals, snacks and beverages (e.g. child, full and half servings) Serving Size Pledge: We will support and enable our customers to choose food and beverage sizes which are appropriate for their age and dietary intake requirements.

Examples of how the Serving Size Pledge could be enacted:

a) Introducing smaller sizes for beverages and side dishes (e.g. chips) b) Introducing a wider range of meals in ‘entrée’ / half size (not just for ‘seniors’), with

comparable price point c) Indication of relevant current activities, and that these will be maintained # d) introducing smaller plates for smorgasbord /all-you-can-eat venues e) stop supersize eating competitions f) including a range of beverage size options in vending machines

Theme: Availability of water Aim: Increase availability of water, including tap water Water Pledge: We will support and enable our customers to choose water as the drink of choice.

Examples of how the Water Pledge could be enacted:

a) In [restaurants / table service], offering water to all customers b) Promoting water over sugar sweetened drinks c) Free tap / filtered water to be readily available and accessible d) Vending machines to include water as an option, and placed at eye level. e) All ‘meal deals’ to offer water (including sparkling water) as an option f) All ‘meal deals’ to offer water (including sparkling water) as a default option g) Indication of relevant current activities, and that these will be maintained #

Theme: Kilojoule reduction Aim: Reduce total kilojoules across product range Kilojoule Reduction Pledge: We will support and enable our customers to eat and drink fewer kilojoules through actions such as product/ menu reformulation, reviewing food and drink sizes, education and information, and actions to shift the marketing mix towards lower kilojoule options.

23

Examples of how the Kilojoule Reduction Pledge could be enacted:

a) Providing a range of lower kilojoule and regular products b) Offering more low kilojoule or no added sugar drinks as a percentage of total c) Making lower kilojoule options the default: e.g. smaller packs and servings, reduced

fat milk used for standard beverages, low kilojoule beverages d) ‘Meal deals’ (and similar) to incorporate mid-sized offerings rather than the largest. e) Removing the largest size of soft drinks, popcorn etc. at entertainment venues f) Removing free soft drink refills g) Licensed venues to have available / identify low kilojoule alcoholic beverage options h) Working to reduce the amount of added sugar in food products prepared and sold i) Limiting the active promotion of offers containing added sugar e.g. Do not actively

promote sugar sweetened beverages in any media j) Actively promote reduced/no added sugar offer k) Indicating level of kilojoule reduction already achieved across product range / subset

of products, and how much more it will further be reduced by / maintain current behaviours #

l) Reduce the kilojoule content of ‘children’s meal’ deals

BETTER INGREDIENTS

Theme: Encourage a wide variety of nutritious foods as recommended by the Australian Dietary Guidelines. Aim: Use five food group foods as the basis to menu items Five Food Groups Pledge: We will support and enable our customers to enjoy a wide variety of nutritious foods as recommended by the Australian Dietary Guidelines.

Examples of how the Five Food Groups Pledge could be enacted:

a) Adjust meal offerings to decrease the proportion of discretionary food components (e.g. chips, fried foods) compared to five-food group foods (e.g. wholegrains/milk, yoghurt, cheese and alternatives / non-potato vegetables and legumes/ fruit/ lean meats, fish and alternatives)

b) Having a bowl of fresh, whole fruit on the counter c) Identifying on the menu card standard items which include 1, 2, 3 serves of fruit /

vegetable or wholegrain [bread] products. d) Providing healthier ‘children’s meals’ which

i. Include at least 1 serve (1/2 cup) of non-potato vegetables; ii. Include yoghurt or other healthy dessert when dessert is part of a meal deal; iii. Include a unsweetened beverage option, when beverage is part of a meal

deal e) Wholemeal / wholegrain is a standard option for bread / rice / pasta f) Home meal delivery kits to offer wholemeal / wholegrain options for bread / rice /

pasta

Theme: Sodium (salt) reduction Aim: Reduce the amount of added sodium (salt) in food products prepared and sold Salt Pledge: We will support and enable our customers to further reduce their sodium (salt) intake by continuing to review and lower levels of salt in food

Examples of how the Salt Pledge could be enacted:

24

a) Reducing the amount of salt used in our manufacturing and kitchens by: i. Changing kitchen practices: vegetables and boiled starchy carbohydrates

such as rice, potatoes and pasta to be cooked without added salt ii. Using herbs and spices as alternatives to salt iii. Consistent measurement: Chefs to be provided with specific ingredient and

salt quantities as well as equipment to control salt dosage so that known and consistent salt levels are used in food products and meals

iv. Training staff: Commit to train all our chefs / staff on awareness of foods or ingredients (such as stock, soy sauce, processed meats) which are high in salt or contribute significantly to the intake of salt; and development of menus which are lower in salt and include lower salt options

b) Not actively offering / providing salt i. Not having salt on tables ii. Not actively offering salt (asking ‘Would you like pepper?’ instead) iii. Providing a sachet of salt, rather than salting chips

c) Indicating how much sodium has already been reduced, and how much more it will further be reduced by / maintain current behaviours #

d) ‘Children’s meal’ deals to include low-salt condiments (where provided) e) Provide low-salt condiments (e.g. BBQ and tomato sauce, soy sauce, margarine,

salad dressing)

Theme: Healthier oils and fats Aim: Improve fats and oils used throughout product range to reduce the amount of saturated fat and trans-fat served to consumers Fats & Oils Pledge: We will support and enable our customers to consume less saturated fat and trans-fat through actions such as product/menu reformulation, using healthier fats and oils in our processes, and incentivising customers to choose healthier options.

Examples of how the Fats & Oils Pledge could be enacted:

a) Use healthier oils in cooking e.g. monounsaturated/polyunsaturated. (Guidance / tips document to support this)

b) Limiting use of unhealthy fats e.g. trans/saturated and foods high in them (e.g. cakes, pastries, pies, fried foods, biscuits)

c) Not using tallow based fats for deep frying d) Not using/ will work to remove artificial (added) trans fatty acids from products in next

12 months e) Providing items which include lean cuts of meat, skinless chicken etc. f) Limiting active promotion of offers containing saturated and trans fatty acids g) (for distributors) providing information about healthier fats and oils that are available

for purchase h) Indicating how much saturated fat / trans fat has already been reduced, and how

much more it will further be reduced by / maintain current behaviours #

Theme: Supply Chain Aim: Food distributors to support and enable access to healthier ingredients and products to help consumers achieve dietary patterns that are consistent with the Australian Dietary Guidelines Supply Chain Pledge: We will support and enable food businesses to offer menu items that are consistent with the Australian Guide to Healthy Eating through access to healthier ingredients and products

25

Examples of how the Supply Chain Pledge could be enacted:

a) Providing information to [businesses / purchasers / customers] about healthier options in the product range that are available for purchase

b) Reformulating ‘own brand’ components/ingredients to reduce the added saturated fat, added sugars and/or sodium content and/or increase the five food group foods, in particular vegetables, fruit (not juice), wholegrains and/or reduced fat no added sugar dairy

c) Making nutrition information about supply items readily available and talk to [businesses / purchasers / customers] about identifying healthier fats and oils, or products with lower sugars, saturated fat and sodium

d) Adopting Health Star Rating system on packaged food products, especially those not further modified (e.g. for school canteen distribution)

e) stock and promote salt-reduced condiments and healthier oils f) Indication of relevant current activities, and that these will be maintained #

BETTER AWARENESS

Theme: Promotion of healthier choices Aim: Make the healthier option the easier choice Healthier Choices Pledge: We will support and enable our customers to select the healthier choice through the active promotion of healthier menu options.

Examples of how the Healthier Choices Pledge could be enacted:

a) Highlight ‘healthier’ menu options on the menu to enable easy identification by customers

b) Standard items on menus (including menu cards and online and app-based menu systems) to identify which items include 1, 2, 3 serves of fruit / vegetables; or include wholegrain bread products

c) Increased marketing of healthy/healthier food options as proportion of total marketing d) Include healthy options at front of store, in front of menu e) Provide discounts on healthy options f) Provide special offers on healthy options g) Incentive for healthier options, e.g. similar to a coffee card idea but it could be ‘buy 5

healthy lunches and get the 6th free’ h) Only promote options to children that are consistent with the Australian Dietary

Guidelines through all communication channels.

Theme: Access to information Aim: Increase availability of easy to read nutrition information Information Pledge: We will support and enable our customers to make informed choices about the food they eat by increasing the availability of easy to read nutrition and allergen information.

Examples of how the Access to Information Pledge could be enacted:

a) Providing point of sale kilojoule labelling in line with the relevant provisions of jurisdiction, even if not mandatory for jurisdiction / business type

b) Having nutrition and allergen information available for all menu items upon request c) Indication of relevant current activities, and that these will be maintained #

26

ATTACHMENTS Attachment A: Program logic for the food service strategies (as at 2 May 2017) (insert web link for accessible word version)

Attachment B: United Kingdom Public Health Responsibility Deal

Attachment C: Example of a monitoring initiative: Salt in salads

27

ATTACHMENT A: PROGRAM LOGIC FOR THE FOOD SERVICE STRATEGIES (AS AT 2 MAY 2017)

28

Attachment B: United Kingdom Public Health Responsibility Deal

The UK Responsibility Deal (2011-2015) was a public–private partnership aimed at tapping into the potential for businesses and other influential organisation’s to make a significant contribution to improving public health within the UK. The Responsibility Deal embodied the UK’s then-Government ambition for a more collaborative approach to tackling the challenges created by our lifestyle choices.

The Responsibility Deal was based on five networks: food, alcohol, workplace health, physical activity, and a behaviour-change group which supported the other four networks. There were three central parts of the deal: core commitments; collective and individual pledges; and supporting pledges which all coincided with the principles that underpinned the Deal. All Responsibility Deal Partners signed up to the core commitments and in doing so they confirmed their support for the Deal’s ambitions and committing to take action in support of them where they could. Participants were expected to write “delivery plans” that describe the activities undertaken in support of the collective pledges they signed, to monitor their progress against agreed indicators, and to report annually on progress. The UK Department of Health published annual updates on the Responsibility Deal’s website.

FOOD NETWORK

The food network was designed to help people eat a healthier diet, promoting and encouraging a programme of transformational change across the food industry in support of a healthier food environment. The network included partners from across different sectors – retailers, caterers, manufacturers and suppliers.

FOOD PLEDGES

In accordance with the responsibility deal there were 10 collective food pledges which all had a strong focus on actions in which manufacturers, retailers, out of home dining/catering and bars and pubs could deliver. The food pledges also supported the core commitments to support and encourage and enable people to adopt a healthier diet. Each pledge is listed on the website, and Partners could sign up to the pledge – they were then listed online and provided reports of progress against each pledge.

However, an article published by ‘The Guardian’ on 13 May 2015xxvii reported that researchers from the London School of Hygiene and Tropical Medicine found that the Responsibility Deal, which ministers claimed would boost public health, had largely involved initiatives that have a limited effect on the problem of poor diets.

This highlights that the pledges need to be more than just ambitions, and need to be structured in such a way that they will make a real difference to diet-related public health problems. Companies need to be held to account one they have made a commitment. Some criticism can be expected, given the longitudinal and multi-factorial nature of diet-related chronic disease, it is difficult to know whether individual measures are effective.

Key highlights on food in the UK were the reductions in salt, adoption rates for the recommended Front of Pack scheme (with over two thirds of the retail packaged food market committed) and how partners had ‘changed the default’ under the calorie reduction pledge to help customers make a healthier choice.

29

Infographics such as ‘The salt story’ (below) were used to communicate the public health and economic benefits of reducing salt consumption, celebrating reduction achievements to date and highlighting work in progress.

30

ATTACHMENT C: EXAMPLE OF A MONITORING INITIATIVE: SALT IN SALADS

Salt in salads (United Kingdom, 2014)

This UK example show how targeted surveys can be used to assess the effectiveness of programs to improve the health of the food supply. Consensus Action on Salt and Health surveyed 650 pre-prepared salads available in British supermarkets, restaurants, cafes and fast food restaurants in 2014 (data shown above). Many salads were found to be high in salt. Previous salad and salt surveys were conducted by CASH in 2005 and 2010. There had been a significant reduction (35%) in the salt content of supermarket salads across the three surveys, declining from 1.66g per portion in 2005 to 1.26g in 2010 and 1.05g in 2014.xxviii

A Marks & Spencer spokesperson said: "We’ve lead the way on salt reduction in many products including salads, and this product does meet the Government’s current salt targets. The salt content is also clearly labelled on the front of pack allowing customers to make an informed choice. We are committed to continuing to review the salt in our products, reformulating where possible and providing labelling and information that helps consumers and employees take action to reduce the salt in their diet. The Daily Telegraph, July 30, 2014

31

REFERENCES

i World Health Organization, Draft thirteenth general programme of work 2019-2023. 2018. ii World Health Organization, Technical Annex: The updated Appendix 3 of the global action plan for the prevention and control of non-communicable diseases 2013-2020 12 April 2017. Adopted by the World Health Assembly in resolution WHA70.11. 2017. iii Australian Bureau of Statistics. 4364.0.55.007 - Australian Health Survey: Nutrition First Results – Food and Nutrients, 2011-12. 2014. iv US Food and Drug Administration. Final determination Regarding Partially Hydrogenated Oils (Removing Trans fats). 2015. v Coyne A. Spain to cut sugar, salt and fat in food items. Just Food. 2018. vi Respondent Summary: Eating Out in Australia 2017. Intermedia Group. 2017. vii Ibid

viii Australian Bureau of Statistics. 1291.0 Australian and New Zealand Standard Industrial Classification. 2006, pp. 264-266. ix Kraak V et al. Progress evaluation for the restaurant industry assessed by a voluntary marketing-mix and choice-architecture framework that offers strategies to nudge American customers toward health food environments, 2006-2017. Int J Environ Res Public Health. 2017. x Carins, J et al. A rapid review of evidence: International food service initiatives. The Sax Institute. 2017. xi Ibid xii Kraak V et al. Progress evaluation for the restaurant industry assessed by a voluntary marketing-mix and choice-architecture framework that offers strategies to nudge American customers toward health food environments, 2006-2017. Int J Environ Res Public Health. 2017. xiii Bleich S et al. Higher-calorie menu items eliminated in large chain restaurants. Am J Prev Med. 2018; 54:(2) pp. 214-220. xiv Ibid xv Carins, J et al. A rapid review of evidence: International food service initiatives. The Sax Institute. 2017.

xvi Food Standards Australia New Zealand. Allergen Collaboration. 2018. xvii Australian Bureau of Statistics. 4364.0.55.007 - Australian Health Survey: Nutrition First Results – Food and Nutrients, 2011-12. 2014.

xviii Wycherley T et al. Nutritional impact of discrete strategies to reduce discretionary foods in the Australian adult population. 2017, pp. 91-92. xixNational Health and Medical Research Council. Australian Dietary Guidelines: Summary. 2013. xx Food Foundation. Peas Please: making a Pledge for More Veg. 2018. xxi National Heart Foundation of Australia. Report on the Evaluation of the Nine Food Categories for which reformulation targets were set under the Food and Health Dialogue. 2016. xxii Elliott T et al. A systematic interim assessment of the Australian Government’s Food and Health Dialogue. Med J Aust. 2014; 200(2) pp. 92-95.

32

xxiii Durand MA et al. An evaluation of the Public Health Responsibility Deal: ‘Informants’ experiences and views of the development, implementation and achievements of a pledge-based, public-private partnership to improve population health in England. Health Policy. 2015; 119 pp. 1506-1514. xxiv Public Health England. New PHE data on salt consumption levels. 2016. xxv Australian Bureau of Statistics. About the National Health Measures Survey. 2013. xxvi Australian Bureau of Statistics. 4364.0.55.007 - Australian Health Survey: Nutrition First Results – Food and Nutrients, 2011-12. 2014. xxvii Campbell D. Food industry 'responsibility deal' has little effect on health, study finds. The Guardian. 2015. xxviii Action on Salt. Salads Survey. 2014.