Let’s face it, Australians are surrounded by an unhealthy food environment that normalises and promotes poor eating habits. Nowhere is this more obvious than when shopping for groceries or dining out where there are lots of unhealthy food choices marketed beautifully to consumers, sometimes with deceptive health claims. But we need to be realistic in that unless we’re willing to buy only fruits and veggies, bake our own bread, milk our own cows, and slaughter our own cattle, we’re in some way dependent on buying processed foods. But that’s ok because not all processed foods are bad. In fact, there’s a difference between non ultra-processed foods and ultra-processed foods¹ or what we call junk food. Non-ultra-processed foods have had very little processing done to them to extend their shelf life and have been consumed by cultures known to promote long and healthy lives.¹ The same can’t be said for ultra-processed foods that make extensive processing and changes to raw products to make them attractive to the sight, taste, smell and touch.¹ In Australia, 40% of what consumers eat daily is ultra-processed foods,² a contributing factor to the epidemic of overweight/obesity and chronic disease.^2,3 People in industrialised countries choose processed foods because they’re working longer hours, don’t have enough time, don’t cook as much, and can buy convenience foods.⁴  Add to this fact, the reality that some Australians don’t have adequate nutrition literacy⁵ and we have a problem because Australian consumers may be unwittingly choosing ultra-processed foods that are harming them.

The Health Star Rating system

Enter the Health Star Rating (HSR) system. The HSR system has a little picture on the front of processed food packages. The picture shows how healthy the food is by comparing its nutritional profile to similar products in the same part of the shop.⁶ The rating is calculated using an algorithm and starts from a half star going up in half-point increments to five stars, with five stars being the healthiest option in that product category.

The HSR is based on calculating a product’s 1. total energy (i.e., kilojoules), 2. the amounts of saturated fats, salt, and sugar (which are linked with overweight/obesity, some cancers, heart disease and diabetes), and 3. fibre, protein, fruit, vegetable, nut and legume content which are good for health.⁷ If we think about it, this rating is trying to be in line with the World Health Organization’s guidelines to limit sugars, salt and energy intake from processed foods while increasing the amount of fruit and veggies, as well as legumes, whole grains and nuts consumed.⁸

This rating system was developed by two levels of the Australian government and public health, consumer, and industry groups, to combat overweight and obesity by helping consumers make healthier choices more easily.⁶  A survey of 1000 consumers by Choice, showed that most consumers felt confused by the inconsistencies in the HSR system and so two-thirds of them relied disproportionately on marketing messages, that made absent or misleading claims,⁹ to decide whether a product was healthy. In fact, without the star ratings, consumers in the study found it difficult to rate how healthy a product was.⁹ This finding backs other studies^10,11 that show that images and symbols that provide some sort of evaluation of how healthy a product is, are better understood by consumers, than nutrition information on the back of food packages.

What’s wrong with the Health Star Rating system?

The HSR system is only one type of rating; there are others.¹² One weakness of the HSR system is that it doesn’t base its ratings on the amount of processing and type of ingredient added to the raw product which can make it an ‘ultra-processed’ food. Another rating system called NOVO does this. It rates a product according to four levels of processing with the fourth level classifying foods that have undergone major processing as ultra-processed foods.¹² NOVO defines an ultra-processed food as a food that, after processing, has five or more ingredients, and these can include added substances, colours, flavours, non-sugar sweeteners, and processing aids.¹² But even this rating system isn’t perfect with research showing that it’s difficult to categorise products into one or another of these four categories because it’s of its descriptive nature.¹³

I recently browsed the frozen pizza range of one of the giant supermarket chains knowing that packaged pizza is an ultra-processed food to be eaten occasionally. I wasn’t disappointed with my thinking because the HSR on different brands in this product category ranged from no stars (surprise, surprise!) to three or three and a half star ratings – obviously not very healthy food. There was only one product claiming to have a health rating of 4.5 stars and I was immediately dubious of this health claim. So I quickly browsed the nutrition information and ingredients list on the back to check for the red flags of ultra-processed foods.¹ What I noted was this brand did have much less fat content than the other brands, which would have contributed to its higher rating, but it still was an ultra-processed food with heaps of weird-sounding ingredients that are not in my kitchen.

Ultimately, the HSR system is relatively new and further refinements to improve it are inevitable. In fact, there have already been calls from various health advocacy groups like the Obesity Policy Coalition¹⁴  to mandate the HSR, monitor it and align it more closely with the Australian dietary guidelines.^6,7 But what’s important to understand is that this rating system has already resulted in improvements with 79% of manufacturers reformulating their ingredients for the healthier between 2014 and 2019 when the review of the system was completed and reported.¹⁵ In fact, research showed that products displaying the HSR were 6.5 per cent more likely to improve their product’s nutrition content and thus improve their rating by 0.5 stars.¹⁶

My takeaway learning

So long story short, my view is that unless we want to make our own foods, we have to rely on buying some processed foods, and the HSR system can help Aussies make healthier choices when shopping. This rating system is just one of a number of rating systems and like anything, it has its strengths and weaknesses. But it’s what we have in Australia at present to help us make healthier choices and, without it, we struggle to know what’s healthy or not and are at the mercy of whatever spurious health claims marketers make about their products and brands. So, given these issues, this is how I proceed when I go shopping:

• Buy mostly fruits and veggies, legumes, and nuts – mostly fresh but also canned and frozen.
• Avoid, as much as possible, the ultra-processed foods that I know of, such as pies, sausage rolls, pizzas, ice creams, cakes, biscuits and so on. If I really want to eat something a little less healthy, I pick the one with the highest star rating.
• If I’m not sure about whether a product is considered ultra-processed (for example, in product categories like dairy, cereals, bread etc.), I start by picking the brand, for a given product, with the highest HSR. Next, I check the ingredient list to see if it has five or more ingredients that I don’t recognise in my own kitchen pantry or fridge. Another way would be to check if it has any of these red-flag ingredients in it. With this knowledge, I then decide whether to even buy from this product category or not. If I do decide to buy, I buy the version with the highest star rating.

Red flag ingredients

I leave you with this list of some red-flag ingredients:

• varieties of sugars - fructose, high-fructose corn syrup, “fruit juice concentrates”, invert sugar, maltodextrin, dextrose, lactose;
• modified oils - hydrogenated or interesterified oils (you’ll see these words on the package);
• protein sources - hydrolysed proteins, soya protein isolate, gluten, casein, whey protein and "mechanically separated meat"); and
• cosmetic additives - flavours, flavour enhancers, colours, emulsifiers, emulsifying salts, sweeteners, thickeners, and anti-foaming, bulking, carbonating, foaming, gelling and glazing agents.¹

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References

1. Monteiro CA, Cannon G, Levy RB, Moubarac JC, Louzada ML, Rauber F, et al. Ultra-processed foods: what they are and how to identify them. Public Health Nutrition [Internet]. 2019 Apr [cited 2023 Feb 11];22(5):936–41. Available from: https://www.cambridge.org/core/journals/public-health-nutrition/article/ultraprocessed-foods-what-they-are-and-how-to-identify-them/E6D744D714B1FF09D5BCA3E74D53A185?fbclid=IwAR1i2vNSmrzB5CT6wPqPt0RlPfCeD4HPiq15qO_fHUOVa-eLwNOiXvDnkMk

2. Machado PP, Steele EM, Levy RB, Sui Z, Rangan A, Woods J, et al. Ultra-processed foods and recommended intake levels of nutrients linked to non-communicable diseases in Australia: evidence from a nationally representative cross-sectional study. BMJ Open [Internet]. 2019 Aug 1 [cited 2023 Feb 11];9(8):e029544. Available from: https://bmjopen.bmj.com/content/9/8/e029544

3. Contreras-Rodriguez O, Solanas M, Escorihuela RM. Dissecting ultra-processed foods and drinks: Do they have a potential to impact the brain? Rev Endocr Metab Disord. 2022 Aug;23(4):697–717.

4. Dana LM, Chapman K, Talati Z, Kelly B, Dixon H, Miller C, et al. Consumers’ Views on the Importance of Specific Front-of-Pack Nutrition Information: A Latent Profile Analysis. Nutrients [Internet]. 2019 May 23 [cited 2023 Feb 11];11(5):1158. Available from: https://www.mdpi.com/2072-6643/11/5/1158

5.  Watson WL, Chapman K, King L, Kelly B, Hughes C, Louie JCY, et al. How well do Australian shoppers understand energy terms on food labels? Public Health Nutrition [Internet]. 2013 Mar [cited 2023 Feb 11];16(3):409–17. Available from: https://www.cambridge.org/core/journals/public-health-nutrition/article/how-well-do-australian-shoppers-understand-energy-terms-on-food-labels/DE45E4A625C65442281220276C4B9F58#

6. Health AGD of. Healthy produce [Internet]. Australian Government Department of Health. Australian Government Department of Health; 2018 [cited 2022 May 28]. Available from: https://campaigns.health.gov.au/healthyproduce

7.  BR AGD of HPPHP. How to use Health Star Ratings [Internet]. Australian Government Department of Healt; [cited 2023 Feb 12]. Available from: http://www.healthstarrating.gov.au/internet/healthstarrating/publishing.nsf/Content/How-to-use-health-stars

8. World Health Organisation. Global strategy on diet, physical activity and health - 2004 [Internet]. [cited 2022 Jul 15]. Available from: https://www.who.int/publications-detail-redirect/9241592222

9 Choice. Health star ratings - Nutrition [Internet]. CHOICE. 2015 [cited 2023 Feb 14]. Available from: https://www.choice.com.au/food-and-drink/nutrition/food-labelling/articles/health-star-ratings

10. Kanter R, Vanderlee L, Vandevijvere S. Front-of-package nutrition labelling policy: Global progress and future directions. Public Health Nutrition [Internet]. 2018 Jun [cited 2022 Jul 21];21(8):1399–408. Available from: https://www.cambridge.org/core/journals/public-health-nutrition/article/frontofpackage-nutrition-labelling-policy-global-progress-and-future-directions/E24D6BBF326D3D78BFF28779457F5D6D

11. Roberto CA, Khandpur N. Improving the design of nutrition labels to promote healthier food choices and reasonable portion sizes. Int J Obes [Internet]. 2014 Jul [cited 2022 Jul 21];38(1):S25–33. Available from: https://www.nature.com/articles/ijo201486

12. Food Standards Australia New Zealand. Diet quality and processed foods [Internet]. 2020 [cited 2023 Feb 12]. Available from: https://www.foodstandards.gov.au/consumer/nutrition/Pages/Diet-quality-and-processed-foods.aspx

13. Braesco V, Souchon I, Sauvant P, Haurogné T, Maillot M, Féart C, et al. Ultra-processed foods: how functional is the NOVA system? Eur J Clin Nutr [Internet]. 2022 Sep [cited 2023 Feb 12];76(9):1245–53. Available from: https://www.nature.com/articles/s41430-022-01099-1

14. Three in four support mandatory Health Star Ratings: new survey - Obesity Policy Coalition [Internet]. [cited 2023 Feb 11]. Available from: https://www.opc.org.au/media/media-releases/three-in-four-support-mandatory-health-star-ratings-new-survey.html

15. MP Consulting. Health Star Rating System Five Year Review Report [Internet]. 2019 May [cited 2023 Feb 11]. Available from: http://www.healthstarrating.gov.au/internet/healthstarrating/publishing.nsf/Content/D1562AA78A574853CA2581BD00828751/$File/Health-Star-Rating-System-Five-Year-Review-Report.pdf?fbclid=IwAR38BQQ1lRju-HEAiKw_wanUxb-sv0vZl9aEFAHFCqc-eu5cECW4hrngGDY

16. Aubrey S. Not just a pretty face: Food labels could make you healthier [Internet]. The Sydney Morning Herald. 2020 [cited 2023 Feb 11]. Available from: https://www.smh.com.au/lifestyle/health-and-wellness/food-labels-can-make-you-healthier-without-you-even-realising-20201118-p56fsm.html