Focussing on positive messages is a good strategy for public health.

Public health nutrition evidence

There is overwhelming evidence that there is more public health gain to be made from increasing healthy foods rather than reducing less healthy foods. The Global Burden of Disease (GBD) 2017 study published in The Lancet found the top three global dietary risk factors in Australasia were:

• Low intake of whole grains
• Low intake of nuts and seeds
• Low intakes of vegetables

These three factors accounted for 50% of deaths and 66% of DALYs (Disability Adjusted Life Years).

Globally, the largest shortfalls in consumption are for healthy foods such as nuts, seeds, milk and whole grains. Across all 15 dietary factors, more deaths were associated with not eating enough healthy foods such as wholegrains, fruit, nuts and seeds than by diets with high levels of trans fats, sugary drinks and high levels of red and processed meats.

The authors confirm the greater effect of promoting an adequate intake of healthy foods rather than singling out sugar and fat. To do this they say dietary policies should work with multiple sectors of the food system to focus on production, distribution and consumption of healthy foods, and collaboration between a variety of actors in the food system. Any changes must be sensitive to the environmental effects of the global food system to avoid adverse effects. They say coordinated global efforts to improve diet are urgently needed.

The Australian Institute of Health and Welfare (AIHW) assessed dietary risk factors in 2015 and found similar results, with the top three dietary risk factors being:

• Diet low in wholegrains and high fibre cereals (accounting for 1.6% of DALYs)
• Diet low in fruit (1.4% DALYs)
• Diet low in nuts and seeds (1.3% of DALYs)

A diet high in sugar sweetened beverages was number 11 on the list accounting for 0.2% of DALYs.

Australia does not have a national nutrition policy and this would be an important first step in establishing national priorities. New Zealand developed their National Healthy Food and Drink Policy in 2016 and released a second edition in 2019.

Increasing wholegrains intake is important to achieve public health gain, so what can be done? The Danish Wholegrain Partnership (WGP) commenced in 2008 to encourage higher wholegrain intake. It’s a collaborative program between government, NGOs and industry that has achieved a doubling of the population average intake of wholegrains in Denmark, now at 63g per day. Wholegrain promotion in Australia is limited to the efforts of a small team of dietitians employed at Grains and Legumes Nutrition Council (GLNC), a health promotion charity funded by grain growers that receives no government funding.

Increasing intake of nuts and seeds could also achieve significant health gain. Once again, it is the tree nut industry (with some government grant funding) promoting increased nut intake via a small team of dietitians and a limited budget. The Nuts for Life program is educating health professionals and consumers about the health benefits of a handful of nuts a day.

There is no national fruit and vegetable promotion campaign, with the Western Australian Government going it alone with ‘Go for 2 n 5’ and the NGO Nutrition Australia doing their best with dedicated dietitians and limited resources with their ‘Tryfor5’ campaign. Recently the fruit, veg, mushroom and nut industry via Hort Innovation kicked off their ‘The Good Mood Food’ campaign in an effort to lift the spirits of the nation as well as increase consumer sales in the wake of a slump in the hospitality sector caused by COVID-19. In heartening news, a fruit and vegetable consortium was announced in May bringing together key players to coordinate a national approach to promote consumption. It is made up of 11 members including Nutrition Australia, AUSVEG, The Cancer Council Victoria and various government bodies. And continuing with the positivity theme, the group intends to be creative in finding delicious ways to eat fresh produce as well as practical tips on purchase and storage. They also intend to address cost, availability and supply, including government subsidies to boost access and affordability; Literally using a carrot, not a stick.

Consumer research

In their article on overcoming consumer inertia to dietary guidance, Webb and Byrd-Bredbenner lament the lack of change in compliance with US dietary guidelines since their first guidelines were released in 1980. They conclude that for guidance to be effective it must be realistic. It must be appreciated that taste and convenience are the strongest determinates of food choice (despite the abundance of information about food and health). Their conclusions about how to communicate with consumers focus on making messages realistic, positive, easy to understand and actionable without having to give up favourite foods.

The Health Star Rating (HSR) is an example of a simple and positive approach to front-of-pack-labelling (FOPL) for packaged foods. The premise of choosing more stars for a healthier choice has been embraced by consumers and has a good take-up by industry. The HSR five-year review found most consumers found it easy to understand and use. An Australian study evaluating different FOPL labels with consumers found HSR was perceived to be the best, and a more negative label with a warning statement was not rated as highly

The International Food Information Council (IFIC) forecasts food trends for the year ahead with a team of nutrition experts and consumer researchers. In January this year (2020) they identified five broad trends for food and nutrition, including ‘Intuitive eating and the Un-Diet’. This trend predicts fad diets and strict regimens will lose out to more wholistic and behaviourally sustainable changes. The dichotomy of good and bad foods will be left behind on the path to eating according to natural cues and developing a healthier attitude to food, especially in the 49% of Millennials familiar with mindful and intuitive eating. The wise old tenets of balance and moderation have not gone out of style. Consumers are tired of weight loss messages and have moved to ‘healthy eating’ even if the advice is the same, it’s all about the packaging.

Health psychology

The public health messaging around strategies to reduce obesity are often negative and this has been contentious, particularly among dietitians and nutritionists working in disordered eating. We have a food culture that has restrictive eating embedded within it and this may have adverse consequences for those at risk of disordered eating. Is an increase in disordered eating collateral damage of the anti-obesity juggernaut? A recent systematic review on this question found anti-obesity messages stigmatise large people and reinforce thin ideals. Messages promoting smaller meals were found to be potential triggers for disordered eating. The authors found more research is needed to determine longer term impact.

The National Eating Disorders Collaboration (NEDC) recommend several goals to prevent eating disorders in the community. The first is improving general health, nutrition and psychological wellbeing, such as self-esteem and positive body image. And in children, promoting the adoption of healthy balanced attitudes on body image, eating and weight, and psychoeducation on balanced nutrition and physical activity. It may be argued that a negative, punitive approach to discretionary foods does not meet the criteria for a preventive socio-cultural environment, but rather reinforces a dieting mentality that can be a slippery slope toward disordered eating in the vulnerable.

While a food environment that prevents obesity may be seen as different to that which prevents eating disorders, Sonneville and Rodgers suggest there is common ground. They say food policies that emphasise health should be paramount. Food industry could assist by reducing hyper-palatable nutrient-poor processed foods, avoiding overly large portions and “diet” foods because they can encourage preoccupation with weight and shape, dietary restriction, binge-eating behaviors, and cravings.

However, there are points of contention between obesity prevention and eating disorder prevention efforts. Firstly, health authorities use weight (and obesity) as the primary indicator of population health status which further stigmatises people in larger bodies and ignores a wholistic approach to health. Secondly, obesity prevention policy approaches often focus on demonising specific “bad” foods such as sweetened beverages and fast food and this is inconsistent with the principals of moderation and trusting internal hunger, taste and fullness cues. Often, obesity prevention advocates say there are bad foods, whereas eating disorders prevention advocates say there aren’t any “good” or “bad foods”. The debate continues.

Conclusion

Looking at the public health nutrition evidence, the consumer mindset and mood, and health psychology principles, it appears prudent to promote positive nutrition messages – what foods to eat more of - to achieve gains in population eating patterns. Food and nutrition messages focussed on the goal of vitality and wellbeing rather than weight support better mental health outcomes.