3. Prevention of diabetes and obesity

Overview

3.1Throughout the inquiry, excess weight, poor diet and insufficient physical activity were identified as key modifiable factors associated with Type 2 diabetes and gestational diabetes. Maintaining a healthy weight through appropriate diet and levels of physical activity are, however, beneficial for all patients regardless of diabetes type.

3.2This chapter examines health prevention measures for diabetes and obesity that focus on diet and physical activity. Systematic changes are examined, along with strategies that can empower individuals to make healthier lifestyle choices.

3.3In examining diet-related approaches to prevention, the Committee focused on current Australian Dietary Guidelines (ADG), dietary interventions for diabetes, food labelling practices, and the consumption of sugar-sweetened beverages. The marketing of unhealthy foods and the impact of this marketing is also considered.

3.4While a healthy diet is critical for patients with diabetes and obesity, access to healthy food remains a challenge for many Australians. Accordingly, the Committee has considered the availability and affordability of healthy food in urban, rural and remote communities.

3.5Much of the evidence received by the Committee during this inquiry demonstrates that many Australians lead sedentary lives, and that levels of physical activity are decreasing across all age groups. The final sections of the chapter thus foreground the question of how to best support our communities to become more physically active.

The importance of prevention

3.6The National Preventative Health Strategy 2021–2030, the National Diabetes Strategy 2021–2030 and the National Obesity Strategy 2022–2032 all recognise that prevention is vital for meeting the rising tide of chronic diseases such as diabetes and obesity.[1]

3.7The prevention of diabetes also emerged as a dominant theme through the course of the inquiry.[2] Preventive action, as the Australian Medical Association (AMA) emphasised, saves lives, reduces the impact of diabetes on Australia’s economy, and takes pressure off the health system.[3]

3.8Preventing diabetes is also financially advantageous. The submission from the Rural Doctors Association of Australia cited modelling by Price Waterhouse Coopers, which indicated that diabetes prevention could result in a net economic benefit of $4.65 per $1 invested.[4]

3.9Although the transformative potential of prevention is widely recognised, inquiry evidence suggests that the Australian health system is more oriented towards reaction rather than prevention. In its submission, the Alice Springs Hospital Endocrinology Department emphasised this point:

Diabetes is a preventable problem and we are currently pouring money into reactive services at the “bottom of the cliff” such as renal and cardiology, and missing the opportunity to prevent disease with practical solutions at the “top of the cliff”.[5]

3.10The question of whether emphasis should be placed on system-wide changes or efforts to empower individuals to make better health choices was also foregrounded as part of the inquiry.

3.11Multiple submissions described policies and programs that aim to educate and support individuals to make healthier choices as focusing on ‘personal responsibility,’ and expressed the opinion that such approaches have limited effectiveness.[6] Elaborating upon this view, the Australian Centre for Behavioural Research in Diabetes submitted that the ‘hyperfocus on ‘personal responsibility’ for diabetes and obesity has led to limited systems-level action (i.e. policy, regulation, industry implementation) […].’[7]

3.12The George Institute for Global Health shared a similar perspective:

Successive Australian policies to prevent and disrupt the prevalence of diabetes has [sic] focused predominantly on encouraging individuals to change their lifestyle through education and health promotion. Policies focused on voluntary regulation have been unsuccessful in changing behaviour. A paradigm shift is required: from personal responsibility to shared responsibility and requires greater accountability from government and industry leaders.[8]

3.13In appearing before the Committee, Professor Steve Robson, President of the AMA, highlighted that ‘individual responsibility is important… but it’s got to be more than that’ and cautioned against placing the onus on individuals to tackle complex problems such as diabetes and obesity:

I personally think that in many areas of endeavour the individual responsibility argument is actually a cop-out used by people who have a vested interest in things.[9]

3.14Ms Tiffany Petre, Director of the Obesity Collective, the peak body for obesity in Australia, told the Committee that there were ‘many false dichotomies’ which often derail discussion about chronic conditions, such as prevention versus treatment, or personal versus social responsibility, when in fact action is required across all areas.[10]

Public health approaches to diabetes and obesity

3.15The benefits of taking a population-wide approach to tackling diabetes and obesity have been foregrounded throughout the inquiry. The Cancer Council Australia submitted that:

Strategies that take population wide approaches to address the environmental drivers of obesity have the maximum potential to achieve positive health improvements.[11]

3.16Diabetes Australia argued that there was a need for both population health interventions ‘that mitigate the impact of the obesogenic environment and support people’s ability to make healthier choices,’ and specific Type 2 diabetes prevention programs.[12]

3.17The Committee heard about opportunities to tailor public health messaging targeted at diabetes and obesity in a manner similar to the messaging aimed at reducing smoking. In its submission, the Department of Health and Aged Care stated that:

There is an opportunity to learn from past and ongoing preventive health success stories to address complex health issues such as obesity. Australia has made significant progress in reducing smoking prevalence over many years, through a multifaceted and multilayered approach to tobacco reform that has resulted in a significant decline in smoking prevalence over the past 20 years. Consistent with this approach, long-term, sustainable funding is needed to support a universal, whole-of-population approach to preventive health challenges such as obesity, complemented by targeted initiatives, which will reduce inequities and result in more effective prevention action.[13]

3.18This approach is particularly important for addressing diabetes risk factors in children.[14] Deakin University’s Institute for Physical Activity and Nutrition (IPAN) reported that youth is a particularly important period, since ‘lifestyle behaviours contributing to obesity originate and track from infancy and early childhood.’[15] IPAN further noted that physical activity during childhood is essential to prevent obesity both in the short- and long-term.[16]

3.19Exercise and Sports Science Australia submitted that on average, individuals have insulin resistance for 10 to 15 years before receiving a Type 2 diabetes diagnosis.[17] There is thus a significant window of time in which preventative measures can be gradually and systematically introduced to support an individual in developing healthy habits. Public health measures can play an important role in this process.

3.20In recent times, particular focus in the treatment for and research into diabetes has been placed on Type 2 diabetes remission.[18] Remission can be achieved via dietary interventions or bariatric surgery.[19] The Australian and New Zealand Metabolic and Obesity Surgery Society explained that ‘weight loss has proven beneficial effects on insulin resistance’ and noted that studies have shown that weight loss can lead to Type 2 diabetes remission in some individuals.[20]

3.21In 2021 Diabetes WA surveyed the beliefs and knowledge about diabetes remission. Two-thirds of respondents believed that everyone living with Type 2 diabetes has the potential to achieve remission.[21]Diabetes Australia, however, submitted that ‘remission is not achievable for everyone with type 2 diabetes.’[22] The organisation further explained:

Remission does not mean diabetes is cured or reversed and over time, or if weight returns, type 2 diabetes may return. However, any amount of time a person spends in remission lowers their long-term risk of developing diabetes-related complications.’[23]

3.22Diet and physical activity are also modifiable risk factors for gestational diabetes.[24]Moreover, NSW Health stated that although ‘there are no modifiable risk factors which increase the risk for type 1 diabetes […] maintaining a healthy lifestyle is important for managing the symptoms and long-term complications.’[25]

3.23Healthy diet and regular physical activity can thus prevent, put in remission, and assist management of diabetes. The Committee heard, however, that such strong emphasis on diet can increase risk of eating disorders for some patients. The Butterfly Foundation explained that indeed management of Type 1 diabetes ‘involves a focus on diet, meal planning and monitoring of carbohydrate intake. Restriction and precise monitoring of food intake are risk factors for the development of eating disorders.’[26] People with Type 2 diabetes are also at a higher risk of eating disorders compared to the general population due to the ‘need for strict dietary control and weight management.’[27]

3.24Individuals living with diabetes who are at risk of eating disorders or have pre-existing eating disorders may thus require multidisciplinary care that addresses both physical and mental health, potentially including referral to specialised mental health care professionals.[28]

Diet related measures

3.25‘Our poor diet,’ Dr James Muecke AM submitted, ‘is responsible for more disease and death than alcohol, tobacco and inactivity combined.’[29] The Committee heard that Australians do not eat enough fruit or vegetables,[30] with the Public Health Association of Australia (PHAA) noting that ‘less than 10% of adults and children eat the recommended amount’ of these foods.[31] In contrast, sugar, refined carbohydrates and unhealthy fats in ultra-processed foods are consumed in excess in Australia.[32]

3.26The subsequent sections examine systematic measures that can assist Australians in developing healthier eating habits, such as the ADGs and food labelling practices. In examining sugar intake as a contributing factor in the development of Type 2 diabetes, the ensuing discussion also considers regulatory measures that might reduce sugar intake. The marketing and advertising of unhealthy foods is also examined.

Australian Dietary Guidelines

3.27The Australian Dietary Guidelines (ADG) provide advice about the types and amounts of food that an individual should eat to maintain good health.[33] The current ADG were developed by the National Health and Medical Research Council (NHMRC) and the Department of Health and Aging and published in 2013 to help Australians reduce their risk of developing chronic health problems.[34]

3.28In 2023, the Australian Government tasked the NHMRC to review the 2013 ADG to ‘…ensure the Guidelines remain a trusted resource by considering the best and most recent scientific evidence.’[35] The review is due to be finalised by 2026.[36]

3.29Professor Jonathan Shaw, Deputy Director of Clinical and Population Health at Baker Heart and Diabetes Institute told the Committee:

I think the guidelines themselves are quite reasonable. Other people will have different perspectives, particularly because there are obviously many recommendations within that. The challenge with that sort of thing is really that they are bits of advice for individuals, and the reality is that, for many aspects of lifestyle, individual choice is only a pretty small part of what influences what eventually happens. I think the successes for these sorts of things come from population-level interventions. Some of them involve regulation, but not all of them do.[37]

3.30Some submissions and witnesses also expressed concerns about the applicability of the ADG to people living with diabetes or obesity. Sydney Low Carb Specialists, for example, suggested the ADG do:

…little to change the trajectory of our patients with Type 2 diabetes… The ADG low fat guidelines are asking people to eat in a way that works against their human physiology – higher carbs that trigger insulin which is a fat storing hormone.[38]

3.31Professor Peter Brukner, furthermore, called for an independent analysis of current nutrition research that could inform the guidelines:

The problem with the previous dietary guidelines is that they responsibility for them was given to the dieticians' association. Obviously the majority of dieticians are employed in the food industry, so there's a huge conflict of interest there. So we need completely independent people to analyse the evidence. There is a huge amount of evidence. A lot of it is not super high quality—that's a problem with nutrition research—but there is now an abundance of evidence to show that a restricted carbohydrate approach is extremely beneficial, not just for type 2 diabetes and obesity, but for a whole range of other chronic diseases which are related to insulin resistance.[39]

3.32Multiple stakeholders recommended the ADG be updated to include emerging best practice evidence about diet and nutrition for patients with diabetes, either as a part of this document or as separate guidelines.[40] As Dr Alan Barclay, Health and Nutrition Consultant at the National Retail Association explained:

There's… a misconception that the [ADG] are handed out by all dieticians and other health professionals to people with diabetes. In fact, the dietary guidelines didn't include people with diabetes in their systematic literature reviews, and they certainly shouldn't be using carte blanche to recommend either prevention or management. There are… guidelines from around the world that we should be following, and perhaps, when the current dietary guidelines are upgraded, they can specifically look at diabetes, but the current ones certainly excluded people with complex health conditions.[41]

3.33The inquiry evidence also suggests that there is a scope for improving the promotion and communication of the ADG. For example, the Australian Food and Grocery Council (AFGC) recommended:

…a greater focus on promoting the [ADGs] – especially to those people that have poor literacy and would benefit from education programs and skills on nutrition and culinary literacy as a preventative health measure.[42]

3.34Dairy Australia suggested the ADG could be better promoted by:

• Supporting marketing and communications activities to promote the guidelines
• Simplifying the number of key messages and rationalising ADG resources
• Ensuring there are visual aspects to the guidelines to help with interpretation whether this be displaying different foods in each food group or demonstrating relatable portion sizes, such as the palm of one’s hand
• Supporting consumers with the practical application of the guidelines in the form of recipes and digital education tools such as podcasts, to bring the guidelines to life and increase accessibility.[43]

Low carbohydrate diets

3.35Through the course of the inquiry, the Committee received evidence regarding the use of a low-carbohydrate diet for diabetes management. In its submission, Sydney Low Carb Specialists discussed the merits of carbohydrate restriction, and argued that such a diet can have a more profound impact on Type 2 diabetes than pharmacology interventions.[44]

3.36In reflecting on her experience with this type of diet, Ms Jane MacDonald, who lives with Type 1 diabetes, said:

I exercise therapeutic carbohydrate restriction. I do this by eating real whole food, by avoiding ultra-processed food and by minimising carbohydrates and sugars. This method allows me to avoid the two biggest risks of diabetes emergencies: the risk of diabetes ketoacidosis, and of severe hypoglycaemia—as well as avoiding living the ticking time bomb of diabetes, being the No. 1 risk factor for some other health conditions. This way of life is achievable and sustainable, as my continuous 5½ years achievement demonstrates. I have also maintained the 14-kilogram weight loss that occurred as a bonus.[45]

Food labelling

3.37Food labelling can play a significant role in supporting healthy eating habits. Australia and New Zealand have a joint food regulation system, which has jurisdiction for food labelling.[46] Food Standards Australia New Zealand (FSANZ) is an independent statutory agency that as part of its remit develops standards regulating the use of ingredients, processing aids, colourings, additives, vitamins and minerals, composition of some foods and foods developed by new technologies.[47] FSANZ also sets food labelling standards in the Food Standards Code. These standards are subsequently enforced by the Australian states and territories.[48]

3.38The Committee primarily received evidence relating to three components of product food labelling, namely the:

• Nutrition Information Panel
• Glycaemic Index symbol
• Health Star Rating system.
  39. The Nutrition Information Panel (NIP) on food labels provides information about seven core elements: energy, protein, total fat, saturated fat, carbohydrate, sugars, and sodium (a component of salt).[49] Since 2002, a standardised NIP has been required on all packaged foods and beverages (except for alcohol, coffee, tea and water) sold in Australia.
  40. The glycaemic index (GI) is a measure used to determine how much a particular food will affect blood sugar levels. Foods are classified as low, medium or high glycaemic foods. Foods high in refined sugars are digested more quickly and have a high GI, while foods high in protein, fat or fibre tend to have a low GI.[50] The Glycemic Index Foundation, a health promotion charity that administers the GI symbol, submitted that the GI symbol is a powerful tool for consumers to make healthy food choices:

Foods that carry the certified Low GI Symbol must meet stringent nutrient criteria including total available (glycemic) carbohydrate, saturated fat, unsaturated fat, sodium, and in certain foods protein, trans fat, sugars, fibre and/or calcium. In addition, products must have had their glycemic index tested at an accredited laboratory that uses the International Standard.[51]

3.41Finally, the Health Star Rating (HSR) system – a front-of-pack labelling method that rates the overall nutritional profile of packaged food and assigns it a rating from half a star to five stars – is an initiative of the Australian and New Zealand Governments.[52] The Department of Health and Aged Care explained that the system:

…helps Australians compare the nutritional value of similar packaged products. Products are given a health star rating based on their nutritional profile, considering 4 aspects of food associated with risk factors for chronic diseases. These are energy, saturated fat, sodium, and total sugars, along with certain ‘positive’ aspects of a food such as dietary fibre, protein and fruit, vegetable, nut, and legume content.[53]

3.42Questions pertaining to the clarity of the food labelling system were frequently raised during the inquiry. The Central Australian Aboriginal Congress recommended that an easily understandable approach to food labelling, such as a ‘traffic light’ system, be implemented for all packaged and processed foods.[54] Alternatively, warning labels could be added to foods high in saturated fats, refined sugar, salt and energy.[55]

3.43The Committee also heard suggestions that existing food labels could be improved by providing more details. The Glycemic Index Foundation proposed some additions to the NIP, including that more detailed information should be provided about carbohydrates such as the amount of starches, which are used as a substitute in foods when sugars are removed. The organisation also suggested mandating the inclusion of dietary fibre in the NIP, as well as the addition of the GI in the NIP on high carbohydrate foods and beverages.[56]

3.44Multiple calls were made for added sugar to be reflected on food labels.[57] Added sugar is sugar that has been added during the processing of food, as opposed to naturally occurring sugar.[58] The Food for Health Alliance, a partnership between Cancer Council Victoria, VicHealth, and the Global Centre for Preventative Health and Nutrition at Deakin University, emphasised that added sugars contribute to increased weight gain, heart disease, Type 2 diabetes and poor dental health.[59]

3.45The PHAA submitted that currently added sugars ‘may appear under at least 40 different names, making it a challenge for many people to identify foods containing added sugars and to limit consumption as recommended by the ADGs.’[60]

3.46Echoing the need for clear labelling of added sugar, the Food for Health Alliance proposed:

• That added sugar labelling be mandatory and applied across the packaged food supply and
• That a comprehensive definition of added sugar is adopted that includes sugars from processing methods (including hydrolysis, fermentation, heat treatment, extrusion, pulping, juicing).[61]

According to the organisation, 80 per cent of Australians adults agree that the NIP should show added sugar.[62]

3.47It was suggested that visual depictions of the amount of added sugar in the form of teaspoons or sugar cubes on front of pack labelling could be effective.[63] As Professor Brukner told the Committee:

At the moment you read the food, you've got to take your glasses to the supermarket, you read the tiny writing and it's very hard to work out what's in food, whereas if you had a simple front-of-packet labelling that showed the amount of sugar, that would be very effective…[64]

3.48Peak bodies representing the Australian food and beverages industry did not support suggestions to change the sugar labelling methods. Ms Tanya Barden, Chief Executive Officer of the AFGC, explained that the AFGC would not support pictorial front-of-pack labelling of added sugar, but was open to potential changes to the NIP.[65] Mr Geoff Parker, Chief Executive Officer of the Australian Beverages Council, expressed a similar view:

having an additional front-of-pack labelling device […] is going to erode the benefit of HSR and consumers’ understanding of HSR, which is just starting to get traction.[66]

3.49The Department of Health and Aged Care informed the Committee that FSANZ is currently leading the work on nutrition labelling for added sugars.[67]

The Health Star Rating system

3.50Under the HSR system, products receive a score ranging from half a star (least healthy) to five stars (most healthy), in half-star increments. A product’s HSR is determined using the HSR Calculator, which considers the overall content of a food, including positive components that are recommended for consumption under the ADG (such as protein, dietary fibre and fruits, vegetables, nuts and legumes) and negative components that the ADG recommend limiting (e.g. saturated fat, sugars and sodium).[68]

3.51The HSR rates the ‘overall nutritional profile’ of the product, ‘rather than just focusing on a single nutrient.’[69] Importantly, the system compares similar packaged products. HSR is thus ‘meant to provide a comparison within similar product categories only. For example, the system helps choose between one breakfast cereal and another, not between yoghurt and pasta sauce.’[70]

3.52The Committee heard that front-of-pack labelling systems such as the HSR provide two potential benefits, in that they:

• Educate consumers about the health benefits of similar products, supporting individuals to make healthier choices
• Encourage industry reformulation of products to make them healthier.[71]
  53. These benefits notwithstanding, the Committee was informed that there were two main issues with the current HSR system: shortcomings in the HSR algorithm, and the voluntary nature of the system.
  54. In reflecting on the former, Professor Brukner explained that the algorithm that determines how many stars a product received ‘was developed in collaboration with technical and nutrition experts from government (including FSANZ), industry, public health and consumer organisations.’[72] He suggested that industry’s involvement has weakened the utility of the HSR system:

…the vested interests of industry appear to have influenced the outcomes of the algorithm to the point where the health star ratings only serve to further confuse consumers. When a full fat Greek yoghurt gets a 1.5 star rating and a highly processed, sugary food like Up and Go gets 4.5, you can see how it is flawed. The health star rating panel should be free of COI [conflicts of interest], and the criteria for healthy food reflect gold-standard evidence.[73]

Echoing this concern, Dr Muecke AM described the HSR system as ‘a device created by industry for industry.’[74]

3.55PHAA proposed changes to ‘identify and resolve current anomalies where unhealthy products score highly.’[75] Diabetes Australia similarly called for an examination of the HSR algorithm:

One analysis of Australia’s Health Star Rating system found that technical weaknesses, design flaws and governance limitations result in 75% of ultra-processed foods displaying at least 2.5 health stars. The analysis found that the existing Health Star Rating system could be misrepresenting the healthiness of new packaged food products and inadvertently encouraging people to choose foods with little nutritional value.[76]

3.56The Consumers Health Forum of Australia further proposed that the rating algorithm be changed to ‘an objective measure of nutritional value rather than relative value compared to other products in the same “class”.’[77] Rather than the current system which only allows product HSRs to be compared within a similar product category (such comparing two types of breakfast cereal), the system could be changed to allow comparison across products (between for example a type of cereal a type of yogurt).

3.57Dr Dimitri Batras, Board Director and Company Secretary of the Australian Health Promotion Association, also expressed concern that the category-based HSR system could confuse consumers. He commented: ‘If you see three stars on a cereal box, you might assume that's a healthy-ish option and not understand the fact that's within a category.’[78]

3.58In focusing on consumers with diabetes, the Glycemic Index Foundation submitted that since the HSR algorithm ‘only includes total sugars… and it does not include GI or GL [glycemic load]’, it ‘is not suitable for the management of blood glucose levels by people with existing diabetes who need to know the total amount of available carbohydrate and glycemic index or load.’[79] The Glycemic Index Foundation thus argued that the GI symbol is currently the most useful front-of-pack labelling scheme for the prevention or management of diabetes.[80]

3.59Evidence as to the effectiveness of the current HSR system as a tool for informing consumers and supporting healthier choices is mixed.

3.60The Central Australian Aboriginal Congress submitted that interpretive front-of-pack labelling systems like the HSR have been found to ‘contribute to increased consumption of healthy food choices.’[81] The AFGC also stated that ‘Consumers understand, use and generally trust the on-pack labelling – supporting them make food choices more consistent with the advice of the [ADG].’[82]

3.61The Royal Australasian College of Physicians (RACP) outlined that according to some studies, ‘consumers’ ability to select healthier products is heightened when products display an HSR.’ However, RACP also noted that these studies found that ‘recognition of the [HSR] rating system is modest and patchy in some social demographics.’[83]

3.62Against this backdrop, there is scope for stronger public education about the HSR system, to raise awareness and understanding about how to use it correctly.[84]

3.63The Committee also heard substantial evidence pertaining to the fact that the HSR system is voluntary by design, and that it only appears on products ‘at the discretion of food manufacturers and retailers (such as supermarkets).’[85]

3.64The AFGC submitted that ‘the implementation of the HSR System has been a successful public health intervention’ and that the ‘uptake by industry has been strong.’[86] In appearing before the Committee, Ms Barden from the AFGC highlighted the benefits of the voluntary nature of the system, as its uptake is encouraged by mechanisms such as targets set by the government, industry groups, and consumers themselves.[87]

3.65The voluntary nature of the HSR system, however, has been raised in the evidence as problematic. The Australian Dental Association submitted that ‘[m]otivating food and beverage companies to make these changes [displaying HSRs and advisory labels] across their entire product range will continue to be challenging without mandatory systems.’[88]

3.66The George Institute for Global Health further explained the shortcomings of the voluntary approach:

The inconsistent uptake of the HSR means that consumers are not aware of the unhealthiness of some products and there is little incentive for producers to make their products healthier. The voluntary nature of the HSR allows manufacturers of healthier products to use it as a marketing tool, while the nutritional information of unhealthy products remains hidden. To be effective, the HSR was always envisaged as a tool to compare the healthiness of all products.[89]

3.67According to the Australian Chronic Disease Prevention Alliance, analyses conducted in Australia and overseas challenged the merit of industry self-regulation in this area, and demonstrate that ‘regulatory approaches are more cost-effective and have greater health gains than voluntary approaches to improve diets and reduce obesity.’[90]

3.68Monitoring of HSR uptake is performed by FSANZ.[91] First implemented in June 2014, the HSR underwent an independent review in 2019 that assessed if and how well the objectives of the HSR system have been met.[92] The review recommended making the system mandatory if the uptake targets were not achieved under the voluntary model.[93] Ms Goodchild from the Department of Health and Aged Care noted that ‘the Food Ministers’ (all Australian health and agricultural ministers) ‘made an agreement that they would look to mandating the health star rating if we didn't get 70 per cent uptake […].’[94]

3.69The most recent FSANZ review of the HSR update was published in May 2024 and found that, as of November 2023, the HSR was displayed on 32 per cent of intended products in Australia. This was below the target 60 per cent.[95]

3.70The George Institute for Global Health assesses the healthiness of products within the portfolios of Australia’s 20 largest food and beverage manufacturers; the results are published annually in its FoodSwitch: State of the Food Supply Report. The most recent audit found the HSR displayed on 41 per cent of all products. In its submission, the Institute further highlighted that HSR uptake was uneven: ‘The voluntary nature of the HSR allows manufacturers of healthier products to use it as a marketing tool, while the nutritional information of unhealthy products remains hidden.’[96] The RACP similarly noted that ‘certain products that should display an HSR to alert consumers to their harmful dietary contents are less likely to include an HSR rating.’[97]

3.71Ms Barden argued that one of the barriers to higher uptake of the HSR system, and a possible explanation for delayed uptake, was the cost to industry of adding the HSR to food labels:

We've had an economist independently doing some work on this [the cost of changing food labels] a few years ago. Any label change in the industry is in the hundreds of millions of dollars. We've recently had changes around plain English allergen labelling, changes around added sugars that's being floated, changes around the health star and also changes around recycling labelling. When you've got all of these going on separately, businesses will sometimes then wait and be able to do them together so it doesn't cost five lots of hundreds of millions of dollars.[98]

3.72In discussing the current uptake levels, Mr Geoff Parker, Chief Executive Officer of the Australian Beverages Council, told the Committee that the HSR scheme should continue to be voluntary at least through to late 2025.[99]This is when HSR uptake will be monitored against the final target, which is that 70 per cent of intended products carry an HSR.[100]

Healthy Food Partnership

3.73The Healthy Food Partnership is a voluntary, collaborative initiative between government, the public health sector, and the food industry.[101] Its aim is to encourage healthy eating among Australians, promote appropriate portion sizes, and enable food manufacturers to provide healthier choices. The initiative focuses on two key areas: Partnership Reformulation Program and the Industry Guide to Voluntary Serving Size Reduction.

3.74In its submission, AFGC commended the Healthy Food Partnership framework, and noted that product variants which are reformulated in response to the latest nutritional science and public health concerns have long been part of the industry practice.[102]

3.75In addition to reformulation, AFGC concurred that portion and serving guidance has also been important in assisting consumers moderate their intake of energy dense, nutrient poor foods:

Appropriate serving sizes labelled on packs coupled with practical, convenient devises provides portion guidance to consumers which underpins healthy diet selection. Evidence consistently shows that people consume more food and beverage when offered larger sizes than when offered smaller serving sizes.[103]

3.76The Committee heard that positive reformulation also occurs outside of the Healthy Food Partnership. For instance, the Australian Beverages Council drew attention to the Sugar Reduction Pledge, an initiative led by the non-alcoholic beverages industry that aims to reduce sugar across beverages to help address overweight and obesity. The Sugar Reduction Pledge covers about 80 per cent of the volume of non-alcoholic drinks, and has a ‘more ambitious sugar reduction target’ than the Healthy Food Partnership’s Reformulation Program.’[104]

3.77The Australian Beverages Council submitted that ‘mandating the reformulation of existing products as a standalone measure is a blunt and ineffective instrument when it comes to shifting food consumption behaviour.’[105] Instead, it advocated for industry initiatives, including those that are driven by changing consumer preferences, as a means to encourage long-term behaviour change.[106] The AFGC similarly gave preference to collaborative, partnership approaches between industry and government.[107]

3.78The Committee received multiple submissions noting the ineffectiveness of Healthy Foods Partnership as a voluntary scheme and calling for reformulation targets to be mandated.[108]

3.79The Food for Health Alliance cited that according to a report by the George Institute for Global Health, ‘voluntary targets under the Healthy Food Partnership have not been effective in significantly improving the composition of packaged foods,’[109] and that therefore the reformulation targets should be mandated, ‘government led in line with current evidence’.[110] Moreover, the Food for Health Alliance proposed that ‘failure to comply with targets within a set time period must result in government regulation.’[111]

Reconstitution levy for sugar-sweetened beverages

3.80Sugar-sweetened beverages (SSBs) are water-based beverages ‘with added caloric sweeteners, such as sucrose, high-fructose corn syrup or fruit juice concentrate.’[112] They can include soft drinks, sports drinks, fruit drinks, energy drinks and cordials.[113] SSBs do not include alcoholic drinks or artificially-sweetened (diet) drinks.[114] The AMA highlighted that SSBs contain ‘a high number of liquid calories’ but provide ‘almost no nutritional benefit.’[115]

3.81The average 375-millilitre can of soft drink in Australia contains between 8–12 teaspoons of sugar (33–50 grams).[116] This is more than the WHO’s daily recommended amount.[117] The Australian Dental Association noted that some SSBs contained particularly high sugar content, as many as 49 teaspoons of sugar in some instances.[118]

3.82Throughout the inquiry, the Committee heard evidence that these drinks significantly contributed to obesity and obesity-related conditions such as Type 2 diabetes. In reflecting on the link between SSB consumption and weight gain, the Australian Patients Association noted that ‘despite there being many calories in SSBs, people tend not to eat less to compensate for this, and SSBs can actually trigger hunger.’[119]

3.83The RACP identified SSBs ‘as a major source of added sugars in a diet,’ and suggested that ‘reduced consumption of sugar sweetened drinks would potentially decrease obesity and related comorbidities.’[120] Indeed, the Menzies School of Health Research submitted that ‘people who consume sugary drinks regularly – 1 to 2 cans a day or more – have a 26% greater risk of developing type 2 diabetes than people who rarely consume such drinks.’[121]

3.84The Grattan Institute submitted that SSB consumption was linked to weight gain and an increased risk of developing Type 2 diabetes.[122] According to its analysis, excess sugary drink consumption was responsible for an estimated 15 per cent of the diet-attributable diabetes burden in high-income countries.[123] The Grattan Institute submission further highlighted that ‘recent studies have found evidence that sugary drink consumption increases diabetes risk factors [including obesity] in children.’[124]

3.85Throughout the course of the inquiry, the Committee received numerous calls for stronger regulation of SSBs, including through the introduction of a reconstitution levy.[125] The AMA called for the Government action, proposing that:

To effect a change in SSB consumption, both a clear message for consumers that the product is unhealthy, and a tangible deterrent are warranted. A tax can deliver on both counts by creating a price signal that the product is unhealthy, and reducing consumption through higher prices (and therefore lower affordability). Furthermore, an appropriately designed tax can also incentivise manufacturers of SSBs to reformulate their products to contain less free sugar.[126]

3.86The Infant and Toddler Foods Research Alliance similarly asserted that a levy would be a powerful tool for incentivising beverage manufacturers ‘to reformulate to reduce sugar content,’ encourage the ‘provision of cheaper low/no sugar products’ and further encourage ‘consumers to shift to low/no sugar products.’[127] The Menzies School of Health Research and the RACP agreed that such fiscal measures did increase product reconstitution, leading to reduced sugar content.[128]

3.87In December 2022 the World Health Organization (WHO) recommended that countries introduce (or increase existing) SSB levies.[129] Many countries have already implemented a form of levy for SSBs; indeed, the Australian Academy for Health and Medical Sciences highlighted the fact that ‘according to the World Bank, as of February 2023, 106 countries and territories had some type of SSBs taxation in place, covering 52% of the world’s population.’[130]

3.88While there is considerable support for the introduction of a levy on SSBs, the effectiveness of such a measure remains contentious. Appearing at a public hearing, Ms Goodchild from the Department of Health observed that:

Over 100 countries worldwide have implemented a sugar sweetened beverage levy. I think the evidence is lacking as to whether that has impacted overweight or obesity rates. It has definitely taken large-scale amounts of sugar out of beverages. I think there's strong evidence that it has clearly had dental benefits.[131]

3.89In a similar vein, the Mayor of Alice Springs Town Council, Mr Matt Paterson, expressed reservations as to whether these measures would indeed be effective in his community:

My gut tells me it won't work. You're just targeting the most disadvantaged people anyway who are going to use it. If you go into a remote community, it's [the price] already so high for a can of Coke now. Will people still buy it? I think the answer is yes. We've got a floor price on our alcohol in Alice Springs, so it means that a minimum standard drink is a certain price. Some would say that's worked to a certain extent, but we're still having alcohol issues. So I don't know if adding a sugar tax is necessarily going to address all of those or if it's just targeting the most disadvantaged as well. I think it's a very delicate space.[132]

3.90Industry bodies have challenged the link between sugar consumption and the trend in obesity rates, noting that while the level of sugar consumption in Australia has decreased, obesity rates are still on the rise. Citing data from the Australian Health Survey data, the AFGC outlined that:

…the average daily energy (kilojoule) intake has decreased for both men and women between 1995 and 2011-12. The average daily intake of sugars and saturated fat also declined significantly during this time. This suggests that there are factors other than increased energy intake, contributing to high levels of obesity across the nation.[133]

3.91Ms Barden from the AFGC told the Committee that:

If we look at the data, the evidence has shown that sugar consumption has been decreasing… We're also finding in Australia, in the absence of a sugar tax, significant reductions in beverage levels of sugar. Yet there's not a correlation with a reduction in obesity.[134]

3.92The Australian Beverages Council also argued that sugar consumption in Australia is decreasing, providing an analysis of 22 years sales data (1997–2018) for SSBs in Australia that showed a trend in consumer preferences for low and no-sugar beverages. This analysis, according to the Australian Beverages Council, showed a ‘significant 30 per cent decrease in per capita sugar contribution’ of non-alcoholic water-based beverages over the 22 years.[135]

3.93The Australian Beverages Council also challenged positioning of SSBs as a major contributing factor to obesity. In 2016, the organisation commissioned the Commonwealth Scientific and Industrial Research Organisation to undertake secondary analysis of the 2011–12 Australian Health Survey, which found that:

• In adults, there was no clear association between weight status and the proportion consuming sugar-sweetened beverages, or the total consumption of these beverages
• The contribution of beverages to total energy intake was relatively low across the adult population – four per cent of intake.[136]
  94. Rather than focus on a single element like SSBs, the AFGC advocated for a holistic ‘whole diet’ approach, noting that:

An excessive and simplistic focus in the obesity debate, for example, on a particular nutrient – sugars, sodium or saturated fat – has limited chance of success in addressing the issue. It is important to consider the multifactorial nature of health, as opposed to a single initiative or program to address the issue.[137]

3.95The Committee heard that some groups of people consume more SSBs than others. In Australia, consumption of SSBs ‘is highest amongst young people, Aboriginal and Torres Strait Islanders and people from socially disadvantaged groups.’[138] NT Health told the Committee that there was high consumption of SSBs in remote communities, ‘including among babies and children.’[139]

3.96The Grattan Institute further emphasised that the consumption of SSBs in Australia is an issue for multiple reasons because, despite the long-term decrease in consumption:

• ‘…average sugary drink consumption […] has been steady recently’
• ‘…studies in NSW and South Australia found that sugary drink consumption has declined the least for disadvantaged groups… [which is] of particular concern because these groups are at higher risk of obesity and diabetes’
• ‘…the groups at the highest risk of developing diabetes and obesity, including poorer people and Indigenous Australians, drink the most sugary drinks.’[140]
  97. During the inquiry, discussion regarding the potential introduction of reconstitution levy questioned how such a measure might impact Australia’s sugar industry. The AMA, however, argued that the impact on Australian sugar farming would be minimal:

About 80 per cent of Australia’s domestic sugar production is exported. The AMA estimates that only 5.3 per cent of total domestic production goes towards domestic sugar-sweetened beverage manufacture. The estimated change in SSB consumption modelled in this report translates to a 0.64 to 1.01 per cent drop in demand for domestic sugar production.[141]

3.98The AMA also expressed the opinion that ‘Australian surveys have consistently shown majority support for a tax on sugar-sweetened beverages,’[142] and emphasised that a majority of Australians support such a measure, particularly if the proceeds are used to fund obesity prevention initiatives.[143]

3.99The question of a link between the consumption of sugary drinks and access to clean water has also been raised as part of the inquiry. The National Aboriginal Community Controlled Health Organisation (NACCHO) flagged that about 25,000 Aboriginal and Torres Strait Islander people living in remote communities do not have access to safe tap water for drinking.[144] In some of these communities ‘SSBs can be viewed as the safer option to the community’s water supply, and consumption can be high among young children and babies.’[145] The AMA also submitted that it was ‘aware of price anomalies between SSBs and bottled water in remote community stores’ and recognised the fact that SSBs are sometimes the cheaper option.[146]

3.100The Grattan Institute noted that a levy would incentivise beverage manufacturers to reformulate their products with a reduced amount of sugar.[147]In addition, AMA modelling found that for a 20 per cent tax on SSBs, ‘half (49.5%) of the total health gains accrued to the two most disadvantaged SES [socio-economic status] quintiles.’[148] The AMA’s model estimated that over the population’s lifetime, almost $300 million in out-of-pocket health costs would be saved, with the most disadvantaged SES groups incurring the greatest healthcare cost savings.[149]

3.101Based on this modelling, the AMA argued that ‘when viewed holistically, an SSB tax could be considered a progressive measure, since lower SES groups would theoretically experience a disproportionate health benefit in response to the tax, compared to higher SES groups.’[150]

3.102In their submissions, entities such as the AMA, PHAA, and the Grattan Institute discussed options for creating a reconstitution levy.[151] For additional detail on the design of such a measure, the Australian Academy for Health and Medical Sciences noted that the WHO has published a ‘global tax manual for SSBs’ to support countries in implementing these types of policies.[152]

3.103Estimates about the effect of a reconstitution levy depend upon multiple factors, including the design of the measure, what beverages are captured (i.e. the definition of SSBs), the pass-through rate (whether the manufacturers absorb it or pass it onto consumers), the degree of product reformulation, and consumption.

3.104In its submission, PHAA recommended ‘a 20% health levy on sugar sweetened beverage manufacturers, with a tiered approached (based on sugar content).’[153] The Grattan Institute similarly suggested the following model:

• Less than 5 grams of sugar per 100ml: no levy
• Between 5 and 8 grams of sugar per 100ml: 40 cents per litre
• 8 or more grams of sugar per 100ml: 60 cents per litre.[154]

Based on modelling, the Grattan Institute estimated that under its proposed scheme, ‘the price of drinks with the most sugar would increase by about 12 per cent on average.’[155]

3.105The Institute for Health Transformation at Deakin University cited research that suggested a reconstitution levy ‘would be cost-effective and save the Australian Government $1.7bn, costing very little (~$11.8m) to implement, while delivering $1.7bn in total healthcare cost offsets.’[156] The AMA’s most recent modelling indicates that a fiscal measure on SSBs would ‘raise annual government revenue of $814 million to $749 million.’[157]

3.106In support of the inquiry, the Parliamentary Budget Office (PBO) undertook cost modelling of the application of a 20 per cent levy on SSBs. For the purpose of this analysis, SSBs were defined to include all non-alcoholic water-based beverages with added sugar, including soft drinks, cordial, energy drinks, sports drinks, fruit drinks and flavoured mineral waters.[158]

3.107The PBO advised that the introduction of such a measure would be ‘expected to increase the fiscal and underlying cash balances by around $1.4 billion over the 2023–24 Budget forward estimates period […]’.[159]

Marketing of unhealthy foods

3.108Throughout the course of the inquiry the Committee heard concerns that Australians are in their daily lives often and increasingly subjected to factors that contribute to the development of obesity, which scientific literature refers to as an obesogenic environment.[160] In discussing measures that might counter this trend, various submissions and witnesses before the Committee raised the possibility of regulating the marketing of unhealthy foods.

3.109Unhealthy food, which is also termed ‘discretionary food,’ ‘junk food,’ or ‘ultra-processed food,’ refers to items ‘that lack nutrients, vitamins and minerals, and are high in kilojoules (energy), salts, sugars, or fats.’[161]

3.110One of the central themes of the evidence gathered is a concern regarding the prevalence of advertisements promoting unhealthy food, particularly to children, and the potential effects that this advertising can have on health outcomes for children in Australia.[162] For example, the PHAA submitted that unhealthy food and beverages have ‘a negative impact on children’s dietary intake and weight.’[163] Preventing obesity during childhood and adolescence is important, the AMA further explained, as obesity during this period is often associated with other comorbidities, including ‘a greater risk of developing type 2 diabetes.’[164]

3.111The Committee heard that food marketing to children is ‘pervasive and persuasive,’ and ‘ubiquitous in their daily lives – in their homes, schools, communities and gathering places.’[165] Dr Muecke AM also expressed concern at what he described as the food industry’s ‘relentless promotion of unhealthy food and drinks at checkouts and at the end of aisles within their supermarkets.’[166] Furthermore, children are often further exposed to this marketing across various online platforms.[167]

3.112Indeed, the RACP reported that:

Children in Australia see 168 junk food or sugary drink advertisements on the web or mobile devices per week, adding to the 800 promotions they see annually if they watch 80 minutes of television per day.[168]

3.113According to a 2024 report by Deakin University, food companies are marketing unhealthy products online in ways that target children as young as 8 years old. The report suggests that children aged 8 to 13 may be targeted with approximately 13 junk foods advertisements on a typical day they spend online.[169]

3.114The report further estimated that teenagers aged 14 to 17 see an average of 24 junk food advertisements every day. For one teenager in the study this was as high as 70 advertisements over a typical two-hour period spent online. The study also found that many advertisements targeted at children and young people were interactive, prompting children and young people to ‘shop or order now’ for confectionary and unhealthy takeaway foods by directing them to platforms where they could purchase these products.[170]

3.115The RACP informed the Committee that there was emerging evidence indicating a link between unhealthy food marketing and increased energy consumption in children, citing one study which found that Australian children ‘eat more food after watching junk food promotions,’ but without ‘decompensation at later meals.’[171]

3.116In addition, the Food for Health Alliance submitted that ‘exposure to unhealthy food marketing influences the foods that children prefer, the foods they choose and the foods they eat.’[172] The AMA drew the Committee’s attention to a report published in 2023 on food marketing to children by the United Nations Children’s Fund (UNICEF) and the WHO that echoed this point:

We know that food marketing harms children. It negatively affects children’s food preferences, purchase decisions and consumption behaviours, ultimately contributing to childhood obesity and diet-related disease. Food marketing also affects household purchasing decisions and the types of foods that are eaten in the home.[173]

3.117Drawing upon data from the Australian Institute of Health and Welfare (AIHW), Diabetes Australia submitted that children were eating too many discretionary foods containing saturated fat, added salt and added sugars. Discretionary foods, according to AIHW research, ‘comprise almost 40% of Australian children’s energy intake, while less than 5% of Australian children are consuming the amount of fruit and vegetables recommended by the Australian Dietary Guidelines.’[174]

3.118The definition of both healthy and unhealthy food is a subject of ongoing debate, especially in relation to the marketing of unhealthy food to children.[175] Professor Jason Wu, Head of Nutrition Science at the George Institute for Global Health, however, argued that the inability to develop an agreed definition should not be used as an argument to delay regulation in this domain. Referencing how other countries have approached the question of regulation, Professor Wu said:

Different countries have used different definitions to decide what should be allowed to be marketed to children. One commonly used strategy is the nutrient profiling based model—pretty similar to our health star rating, actually. Under the health star rating, we look at the level of different nutrients, and that's how we bring it all together to generate the health star rating. You can use that underlying algorithm to say: 'If a product scores above a certain threshold then it can be marketed, or if it's below then it shouldn't be.' So that is a commonly used approach.[176]

3.119Policies designed to prevent children from being subjected to unhealthy food marketing, the National Retail Association submitted, should follow Australia’s HSR scheme, or the FSANZ Nutrient Profiling Scoring Calculator (a tool designed to help food manufacturers determine whether a food meets the Nutrient Profiling Scoring Criterion).[177] Defining unhealthy food using either of these existing models according to the National Retail Association, would be ‘the logical choices for determining objectively which foods are healthy choices and furthermore, they can be relatively easily updated as our understanding of nutrition science evolves […].’[178]

3.120In recognising the involvement of industry in the development of the HSR scheme, contributors such as Cancer Council Australia called instead for an ‘independent and consistent nutrition criterion to determine which foods are unhealthy and therefore unsuitable to be promoted to children.’[179]

3.121The Department of Health and Aged Care informed the Committee that the Australian Government commissioned a ‘feasibility study to explore the current landscape of marketing and advertising to children and consider options for implementing restrictions in Australia.’[180] Based on the findings of the study, ‘the department will provide recommendations to Government on potential options to restrict unhealthy food marketing to children.’[181]

3.122The Committee received evidence indicating that the mandatory advertising codes that currently exist in Australia, which are under the remit of the Australian Communications and Media Authority (ACMA), ‘only concern what can be shown during children’s specific television programs on commercial television, with no regard to diet specifically.’[182] The RACP commented that ‘the existing codes are not aligned to the changing television viewing patterns of children and the rapid shifts toward internet viewing and subscription streaming platforms.’[183]

3.123Advertising to children is currently managed as part of an industry self-regulation approach in Australia, through the Australian Association of National Advertisers (AANA). Advertising to children is currently covered by two separate Codes:

• Food and Beverages Advertising Code
• Children’s Advertising Code (December 2023).[184]
  124. The National Retail Association explained that the Food and Beverages Advertising Code:

…restricts advertising or marketing of food determined as “discretionary” under the Food Standards Australia and New Zealand (FSANZ) Nutrient Profiling Scoring Criterion (NPSC) from being targeted in marketing toward people under 15 years of age. These marketing communications include broadcast, print, digital and online, social media, point of sale and sponsorships.[185]

3.125The Children’s Advertising Code, the National Retail Association outlined:

…is a general code that governs how products and services are marketed toward children, including factual presentation, use of sexualisation, safety, social values, parental authority, claims, competitions, use of personalities, costs, presentation of alcohol and encouraging unhealthy lifestyle or eating or drinking habits.[186]

3.126The National Retail Association expressed support for the AANA’s self-regulatory approach to advertising to children, noting that:

We believe that restricting advertising targeted to children and general advertising where children represent a significant proportion of the audience provides sufficient protection to children, and further regulation is not required.[187]

3.127Ms Barden from the AFGC noted that the AANA industry self-regulation approach has ‘been in place for a number of years… has commitments from industry and… very high compliance rates around avoiding marketing to children.’[188]

3.128Mr Parker from the Australian Beverages Council highlighted that some industries have made additional commitments beyond the AANA codes. Reiterating the current level of industry self-regulation about advertising to children, he said:

The non-alcoholic beverages industry is steadfastly committed to responsible marketing through our marketing and advertising commitment and our alignment with other industry self-regulatory codes…like the Australian Association of National Advertisers, or AANA, Food and Beverages Advertising Code and their children's advertising code. Our marketing and advertising commitment holds all members to account to ensure that all marketing is obviously accurate and truthful, does not misrepresent health benefits, supports the [ADG], reflects responsible consumption and, most critically, prohibits the marketing of products directly to children—which we define as people under the age of 18—or during children's programming.[189]

3.129Multiple submissions asserted, however, that the current model of industry self-regulation via the AANA is insufficient.[190] The RACP commented that ‘children are bombarded by junk food advertising despite the AANA encouraging advertisers to avoid depiction of material contrary to prevailing community standards on health.’[191]

3.130The Cancer Council of Australia and Diabetes Australia both cited research indicating that voluntary industry codes and initiatives aimed at limiting the marketing of unhealthy food to children are insufficient.[192] Diabetes Australia explained that these ‘lack meaningful incentives to comply or monitoring of compliance.’[193]

3.131Governments around the world are taking steps to restrict the marketing of unhealthy food to children.[194] The Australian Chronic Disease Prevention Alliance noted that ‘at least 40 countries restrict the marketing of unhealthy foods in broadcast and/or digital media, or plan to.’[195] The RACP also highlighted that ‘the WHO and UNICEF have recently urged countries to regulate junk food advertising.’[196]

3.132The Committee heard that there is general support within Australia for restricting the marketing of unhealthy food to children.[197] The RACP highlighted that there was strong support among Australian physicians for such measures. Indeed, the RACP has recently launched the Switch off the Junk campaign, calling for a crackdown on unhealthy food advertising as one measure to address childhood overweight and obesity.[198]

3.133Multiple submissions called upon government to protect children against unhealthy food marketing.[199] The Food for Health Alliance’s Brands Off Our Kids campaign called for government regulation to prevent children from being exposed to unhealthy food marketing. The Alliance’s proposal calls for the regulation to:

• Ensure television, radio and cinema are free from unhealthy food marketing from 6am to 9.30pm
• Prevent processed food companies targeting children
• Ensure that public spaces and events are free from unhealthy food marketing
• Protect children from digital marketing of unhealthy food.[200]
  134. Two key aspects of the Food for Health Alliance’s proposal are that the government regulation should protect all children up until 18 years of age, and the definition of what constitutes marketing should be ‘comprehensive and future-proofed.’[201]
  135. In support of the inquiry, the PBO undertook cost modelling of initiatives that would limit the marketing of ‘unhealthy foods.’ The following seven options were considered:
• Option 1: Marketing unhealthy foods on radio, television, print and social media is banned entirely.
• Option 2: Marketing unhealthy foods on radio only is banned entirely.
• Option 3: Marketing unhealthy foods on television only is banned entirely.
• Option 4: Marketing unhealthy foods in print only is banned entirely.
• Option 5: Marketing unhealthy foods on social media only is banned entirely.
• Option 6: Marketing unhealthy foods on radio and television are banned during prime time hours (e.g. 6pm–9pm).
• Option 7: Marketing of unhealthy foods on social media is banned for children and adolescents only.[202]
  136. For the purpose of this modelling, ‘unhealthy foods’ were defined in accordance with the definition for ‘junk food’ provided by the Australian Government healthdirect website as ‘foods that lack nutrients, vitamins and minerals, and are high in kilojoules (energy), salts, sugars, or fats.’ Examples include but are not limited to:
• Cakes and biscuits
• Fast foods (such as hot chips, burgers and pizzas)
• Chocolate and sweets
• Processed meat (such as bacon)
• Snacks (such as chips)
• Sugary drinks (such as sports, energy and soft drinks)
• Alcoholic drink.[203]
  137. According to the PBO, all examined options would decrease the fiscal and underlying cash balances by between around $1.8 million (Option 4) and $46 million (Option 1) over the 2023–24 Budget forward estimates period.[204]

Access to healthy food

3.138Maintaining a healthy diet requires access to quality food. For some communities in Australia, this continues to present a challenge. As the National Aboriginal Community Controlled Health Organisation (NACCHO) explained:

Food security is a complex issue that comprises multiple factors, including low household income, unemployment, inadequate transport to food stores – particularly those that offer food at a lower cost – and higher food costs in remote areas. Food security is also impacted by poor housing infrastructure, and insecure access to electricity and potable water.[205]

3.139The Australian College of Rural and Remote Medicine also emphasised that ‘Australia’s rural, remote and Aboriginal and Torres Strait Islander communities experience food insecurity in conjunction with a range of other health risk factors… Many people do not have access to affordable, healthy nutritious food.’[206]

3.140The Aboriginal Health Council Western Australia (AHCWA) further explained that:

when food is scarce and incomes are less, people are often more likely to maximise calories per dollar spent and foods rich in fats, refined starches and sugars as they represent the lowest-cost options. The reality for many Aboriginal communities is that eating majority healthy options like lean meats, grains, and fruits and vegetables are more expensive and not readily and prioritised [sic].[207]

3.141In remote areas of Australia, the cost of food and other essentials is more expensive than in other areas. By way of example, the Committee was informed that, on average, food in very remote stores in the Northern Territory (NT) costs 52% more than in Darwin. This is particularly impactful because ‘nearly 60% of Aboriginal and Torres Strait Islander people in the NT live in a household with incomes that are in the lowest 20% nationally.’[208]

3.142According to AHCWA ‘it has been estimated that in some Aboriginal communities, 34 to 80 per cent of the family income is required to purchase healthy diets; this is compared to 30 percent for the lowest income families more generally, and 14 per cent for the average Australian family.’[209]

3.143The Central Australian Aboriginal Congress explained that ‘prices for healthy, fresh foods, particularly fresh fruit, vegetables and dairy foods, are higher in remote areas for a number of reasons, including the cost of freight over long distances, and the high cost of storing perishable food.’[210] Grocery stores in rural and remote areas thus tend to stock longer-life foods and offer fewer options,[211] which further limits access to healthy food. Longer-life frozen fruit and vegetables are also often not suitable alternatives due to lack of access to freezers for storage in some communities.[212]

3.144The Committee also heard about the difficulty of accessing healthy and affordable food for people who live in ‘food deserts in the outskirts of major cities.’[213] The Synod of Victoria and Tasmania, of the Uniting Church of Australia, described food deserts as places ‘where shops don’t sell fresh food and healthy groceries, and only ultra-processed food is available.’[214] It noted that food deserts are typically located in lower-socioeconomic areas, and that being unable to purchase ‘raw ingredients within 15 minutes of their homes by public transport… means it is difficult to source healthy food.’[215]

3.145Dr Muecke AM further emphasised that people from lower socio-economic areas needed support in order to have access to ‘real food at affordable prices, rather than rely on the cheap, addictive, and alluring sugary products that reign supreme in their suburbs.’[216]

3.146Dr Kathryn Williams, Head of the Department of Endocrinology and Clinical Lead of the Family Metabolic Health (Obesity) Service at Nepean Hospital, described how the Penrith Local Government Area (LGA) ‘has a visibly high concentration of fast-food outlets… [with] 220 “non-healthy” food outlets (84% of the total number of outlets) and 42 “healthy” food outlets (16% of the total).’[217] Dr Williams highlighted that the Penrith LGA also had ‘some of the highest rates of obesity in the region,’ and that there was a ‘correlation between a high relative proportion of unhealthy food outlets, and low socio-economic advantage, poor health outcomes and low WalkScores [a measure of the walkability of an area].’[218]

3.147In addition to economic barriers, physical distance to healthy stores can present an additional barrier. Mr Paterson described the challenges some people living outside of Alice Springs face in doing grocery shopping:

…a lot of community are telling us that they will drive 300 kilometres from their remote community into Alice Springs to do their weekly shop. When I say they're driving, they're not driving on bitumen roads, they're driving on very substandard roads. When they come in, there's obviously the cost of petrol but the road also damages their cars. We can start to unravel, as you can imagine, the difficulties to cars and all those sorts of things.[219]

3.148A community member quoted by the Diabetes across the Lifecourse Partnership also highlighted the fact that a lack of transportation options can hinder access to healthy food:

There is no community buses. No. The thing that happens is, a family member will ask another family member who has a car. But then again saying that, there is no fuel station, so they probably have no fuel. They can’t [go] anywhere. They can’t buy fresh food. So what do we do?[220]

3.149An inability to access healthy food is seen as a factor underpinning rising rates of Type 2 diabetes and gestational diabetes.[221] As such, multiple submissions called for a healthy food subsidy,[222] or a healthy food subsidy specifically targeted at remote areas.[223]

3.150The Australian College of Nursing suggested that a healthy food subsidy would be effective because ‘in the longer term, subsidising food saves money spent on health care, ensures a healthier population, and potentially reduces the incidence of type 2 diabetes.’[224] A trial program in the NT found that a 20 percent discount on fruit and vegetables led to increase in consumption, suggesting that such measures could have significant impact.[225]

3.151Some of the specific proposals for a healthy food subsidy related to what amount the discount would need to be to have a significant impact. The Diabetes across the Lifecourse Partnership noted that in very remote stores in the NT, ‘prices are on average 56% higher’ than in Darwin.[226] It noted that a 50 to 60 per cent discount in these remote stores would only reduce the cost of healthy food to Darwin levels, which were higher than prices on the Eastern seaboard. Accordingly, it recommended a 60 per cent price discount, and suggested that ‘a smaller reduction could be considered in non-remote areas.’[227]

3.152Other points of discussion focused on how such a subsidy should be delivered. The Central Australian Aboriginal Congress proposed a direct to consumer, point of sale subsidy.[228] Miwatj Health suggested funding ‘transport subsidies for food supply to remote communities,’ and noted that the Queensland (Qld) Government recently announced a ‘$64 million remote freight subsidy in Far North QLD.’[229]

3.153While most of the evidence focusing on food security discussed subsidies, other types of policies were also proposed, such as regulating shops in remote areas,[230] and implementing a program for the ‘prescribing of healthy foods or meals in the same way that doctors prescribe drugs.’[231]

3.154Food security is a recognised problem for a range of communities across Australia. A recent inquiry into food security in Australia by the House of Representatives Standing Committee on Agriculture made various recommendations relating to this issue, including the development of a National Food Plan, appointment of a Minister for Food and a National Food Council, development of a National Food Supply Chain Map, development of a school curriculum for food and nutrition education, and provision of subsidies for community stores in remote locations so they can provide fresh food in regular quantities and at affordable prices.[232]

3.155The Committee also heard that a remote food security strategy is currently being developed, led by the National Indigenous Australians Agency and the Aboriginal Medical Services Alliance Northern Territory.[233]

Physical activity-related approaches

3.156Physical activity and exercise are important elements in diabetes management.[234] The Australian Sports Commission noted that ‘all diabetes clinical guidelines consider diet and exercise to be the foundation for diabetes management, with even small changes in physical activity levels leading to great reductions of the incidence of type 2 diabetes.’[235]

3.157In appearing before the Committee, Professor Richard Telford AM from the University of Canberra, said that there was evidence to suggest that physical activity was the ‘key independent risk factor in the prevention of type 2 diabetes.’[236] Physical activity – which does not exclusively mean structured exercise, but rather all body movement that uses energy[237] – was equally important for the prevention of gestational diabetes and community obesity.[238]

3.158In Australia, levels of physical activity are frequently measured against physical activity and exercise guidelines produced by the Australian Government. In its submission, the Department of Health and Aged Care explained that these guidelines were:

‘…available for all life-stages, [and] provide guidance on what duration and intensity of physical activity, and what sedentary behaviour, is appropriate for each age group to benefit their overall health and wellbeing.’[239]

3.159In the course of this inquiry, the Committee received a body of evidence suggesting that Australians were not meeting the recommended levels of activity. The Obesity Collective highlighted that:

The majority of children (88% of those aged 5-12) and adolescents (98% of those aged 13-17) are not meeting the physical activity and sedentary behaviour guidelines and over half of adults did not participate in sufficient physical activity.[240]

3.160Diabetes Australia referenced research showing that ‘while rates of leisure-time physical activity have remained relatively stable, physical activity accrued via daily work-related activity, transport activity and home-based activity have all declined.’[241] At the same time, it noted that sedentary activities have increased.[242]

3.161Evidence as to the level of physical activity within particular communities provides additional insights. Diabetes Australia submitted that people living in low socio-economic areas were less likely to meet the national physical activity guidelines than people living in the highest socio-economic areas.[243] Multiple factors can contribute to decreased physical activity, including ‘a lack of time, a lack of opportunities to get physically active and environments that promote inactivity or car-based transport.’[244]

3.162Miwatj Health highlighted that Aboriginal and Torres Strait Islander people, and in particular those living in rural or remote communities, often faced additional barriers to physical activity including a ‘lack of transport, competing work, family or cultural commitments… lack of diversity in sporting programs… pathway/footpath interruptions, fear of dogs, individuals feeling “shame” to participate, climate and limited capacity building opportunities of local people to operate sustainable programs.’[245]

3.163Asserting that increasing physical activity in Australia would necessarily cut across a series of public policy areas, the PHAA proposed multiple key priority action areas, namely: ‘whole-of-school physical activity programmes, improving active transport and land use, healthcare, sport and recreation for all and community-wide programmes.’[246]

3.164There are of course a significant number of existing initiatives within Australia aimed at promoting physical activity, including exercise and sport. The Australian Sports Commission highlighted the Australian Government’s Sporting Schools program, which was provided for free to children and their families. Led by the Australian Sports Commission:

…the program is designed to help schools increase children’s participation in sport and connect them with community sport opportunities. Since it began in 2015, the program has engaged over 15 million children across more than 9,000 schools (86% of all schools in Australia) who are registered with the program, with 57% of schools located in regional or remote areas.[247]

3.165The Committee received evidence regarding current initiatives that focus on physical activity with the aim of addressing obesity, which are supported by governments at all levels.[248] There is a broad consensus, however, that further action is required to encourage and increase physical activity and exercise among the Australian population.[249]

3.166The Institute for Physical Activity and Nutrition recommended that the Australian Government ‘develop a National Physical Activity Action Plan to support the prevention and management of diabetes.’[250] It noted that such a plan should ‘incorporate physical activity into health and social services,’ and highlighted that this was not something currently done well in Australia.[251]

3.167Mr Matthew Carroll AM, Chief Executive Officer and Secretary General of the Australian Olympic Committee, argued that physical education and sport should be a mandatory part of the curriculum in primary and secondary schooling:

We acknowledge primary school physical education and its role in developing the competence required to enjoy sport. Physical activity has declined in the last five decades as the prevalence of obesity has increased. As students progress, secondary school sport must continue to be a mandatory part of the curriculum. With 44 Olympic sports, there are plenty of options—many with very, very low cost. [252]

3.168The AMA echoed that physical education and participatory sports programs should be a ‘core syllabus component’ in both primary and secondary schools, and called on the Australian Government to achieve this in cooperation with state and territory governments.[253] Government supported after school physical activity programs would also be a welcome intervention, particularly for ‘students from low socioeconomic background who often cannot afford... [to] enrol in physical activity programs.’[254]

Committee comment

3.169The Committee believes that greater effort could be expended in delivering population-wide, public health initiatives to prevent the development of both obesity and diabetes in Australia. While there is some debate as to whether public health approaches should focus primarily on diet or physical activity to address diabetes, it is clear that both factors must be addressed.

3.170The Committee is encouraged by evidence showing that improving diet and physical activity can prevent or delay Type 2 diabetes in some patients. Equally positive is the evidence relating to Type 2 diabetes remission, which presents an opportunity for some individuals to significantly improve their health and consequently their overall quality of life.

3.171While the ADG were originally designed for healthy Australians, they no longer serve the needs of the majority of people. In particular, they do not take into account the significant number of Australians living with pre-diabetes, diabetes, or excess weight.

3.172Noting that a review of the ADG is already underway, the Committee encourages the National Health and Medical Research Council to ensure that the updated ADG are designed to counter the growing prevalence of Type 2 diabetes, and include specific dietary guidance for people with pre-diabetes or diabetes.

3.173Bodyweight is the leading modifiable risk factor for Type 2 diabetes, and a key risk factor for gestational diabetes. As such, it is likely that initiatives to reduce bodyweight will, with time, prevent cases of diabetes. The Committee acknowledges the efforts to tackle the rising rate of obesity outlined in the National Obesity Strategy 2022–2023, and believes that the effective implementation of the Strategy must be a priority.

3.174The Committee also believes that the availability and marketing of unhealthy food and drink products should be better regulated. The Committee recognises that a broad public health campaign promoting healthy food is inherently less targeted than advertisements designed for and pitched at very specific audience groups. In particular, the Committee believes that the ability to purchase and make use of social media data to market products to children should be strictly regulated.

3.175The Committee also recognises that too many Australians do not have access to healthy, affordable food. This includes many people living in rural and remote areas, but also many people living in or near cities, particularly in lower socio-economic areas. The Committee acknowledges that the Australian Government is currently developing a remote food security strategy that should address some of these issues.

3.176The Committee notes that the House of Representatives Standing Committee on Agriculture undertook an inquiry into food security in Australia in 2023, and provided a report to Parliament on 7 December 2023 that included multiple recommendations aimed at improving access to affordable healthy food. The Government’s response to this report was due on 7 June 2024.

3.177The Committee recommends that the National Health and Medical Research Council expedites a review of the Australian Dietary Guidelines, and ensures that the revised guidelines include adequate information for Australians living with diabetes.

3.178In their present form, the Australian Dietary Guidelines do not fully respond to the needs of all Australians, many of whom struggle with excess weight and/or live with diabetes. The guidelines should provide adequate information for this cohort to better manage their diet.

3.179The Committee recommends that the Australian Government implements food labelling reforms targeting added sugar to allow consumers to clearly identify the content of added sugar from front-of-pack labelling. This food labelling initiative should be separate from the information regarding added sugar potentially being included in the Nutrition Information Panel.

3.180The Committee acknowledges the fact that food labelling plays a role in encouraging healthy consumer habits. The existing system is not fit for purpose, especially with respect to sugar content in food and beverage.

3.181The Committee recommends that the Australian Government implements a levy on sugar-sweetened beverages, such that the price is modelled on international best practice and the anticipated improvement of health outcomes. The levy should be graduated according to the sugar content.

3.182Despite the decreasing consumption of sugar-sweetened beverages across Australia’s overall population, the Committee notes that some Australians who are particularly at-risk of and impacted by diabetes and overweight and obesity, including those living in lower-socioeconomic areas and Aboriginal and Torres Strait Islander people, still consume high amounts of sugar-sweetened beverages.

3.183From reviewing the evidence, the Committee considers that a reconstitution levy on sugar-sweetened beverages, comparable to fiscal measures pertaining to tobacco, can contribute towards a healthier Australia.

3.184The Committee recommends that the Australian Government considers regulating the marketing and advertising of unhealthy food to children, and that this regulation should:

• Focus on children defined as those aged 16 and under
• Be applied to television, radio, gaming and online
• Use definition of unhealthy food that has been independently developed.
  185. The Committee considers that the current amount of unhealthy food marketing targeting children is inappropriate, and that it contributes towards childhood overweight and obesity, which can have a flow-on effect to diabetes.

3.186The Committee recommends that the Australian Government provides its response to the Australian Food Story: Feeding the Nation and Beyond report and considers a dedicated resource within the Department of Health and Aged Care to support access to healthy food to all Australian communities.

3.187The Committee acknowledges and commends the recent inquiry by the House of Representatives Standing Committee on Agriculture into food security in Australia, which made multiple recommendations that, if implemented, will improve many Australians access to healthy and affordable food.

3.188The Committee recommends that the Australian Government, in consultation and cooperation with state and territory governments, develops a best practice framework to tackle the problem of obesogenic environments, including through better urban planning and the development of physical activity initiatives and supports efforts to increase access to regular exercise in schools and neighbourhoods as a matter of urgency.

3.189The environments we live in play a major role in our lifestyles, including when we live more sedentary lives. Emphasis needs to be placed on making positive lifestyle change through urban and environmental planning, both by altering built environments and increasing physical activity in our communities.

Footnotes

[1]Australian Government, National Preventative Health Strategy 2021-2030, accessed 17 May 2024, www.health.gov.au/resources/publications/national-preventive-health-strategy-2021-2030; National Obesity Strategy 2022–32 (2022), accessed 17 May 2024, www.health.gov.au/resources/publications/national-obesity-strategy-2022-2032.

[2]See, for example: NT Health, Submission 161, p. 3; Australian Medical Association (AMA), Submission 219, p. 1; Health and Wellbeing QLD, Submission 250, p. 2; Doctors for Nutrition, Submission 323, p. 3; Australian College of Nurse Practitioners, Submission 403, p. 7; Coalition for Healthy Remote Stores, Submission 404, p. 2; The Australian Youth Advocacy Network, Submission 448, p. 8; Mr David Clarke, Chief Executive Officer, Australian Patients Association, Committee Hansard, Canberra, 15 September 2023, p. 4.

[3]AMA, Submission 219, p. 1.

[4]Rural Doctors Association of Australia, Submission 407, p. 8.

[5]Alice Springs Hospital Endocrinology Department on behalf of the Department of Medicine, Submission 348, p. 1. See also: NT Health, Submission 161, p. 3; Australian College of Nurse Practitioners, Submission 403, p. 7.

[6]See, for example: Dr Kathryn Williams, Submission 73, p. 8; The Australian Centre for Behavioural Research in Diabetes, Submission 353, p. 11; The George Institute for Global Health, Submission 406, n.p.

[7]The Australian Centre for Behavioural Research in Diabetes, Submission 353, p. 11.

[8]The George Institute for Global Health, Submission 406, n.p.

[9]Professor Steve Robson, President, Australian Medical Association, Committee Hansard, Canberra, 15 September 2023, p. 59.

[10]Ms Tiffany Petre, Director, The Obesity Collective, Committee Hansard, Canberra, 17 November 2023, p. 16.

[11]Cancer Council Australia, Submission 298, p. 3.

[12]Diabetes Australia, Submission 248.1, p. 3.

[13]Department of Health and Aged Care, Submission 152, p. 13.

[14]Federation of Canteens in Schools, Submission 25, p. 1.

[15]Institute for Physical Activity and Nutrition (IPAN), Deakin University, Submission 259, n.p.

[16]IPAN, Deakin University, Submission 259, n.p.

[17]Exercise and Sports Science Australia, Submission 410, p. 5.

[18]Diabetes Australia, Submission 248.1, p. 12.

[19]Australian Government, Australian National Diabetes Strategy 2021–2030, viewed 17 May 2024, www.health.gov.au/resources/publications/australian-national-diabetes-strategy-2021-2030, p. 3; Australasian Society of Lifestyle Medicine, Submission 276, p. 4.

[20]Australian and New Zealand Metabolic and Obesity Surgery Society, Submission 201, p. 1; Diabetes Australia, Submission 248.1, p. 12; Nestle Health Science, Submission 312, p. 1; Australian Diabetes Society, Submission 317.1, p. 6; Professor Stephen Colagiuri, Submission 371, p. 3.

[21]Diabetes WA, Submission 421, pp. 17-18.

[22]Diabetes Australia, Type 2 diabetes, accessed 17 May 2024, www.diabetesaustralia.com.au/about-diabetes/type-2-diabetes/.

[23]Diabetes Australia, Submission 248.1, p. 12.

[24]NSW Health, Submission 349, p. 24; IPAN, Deakin University, Submission 259, n.p.; Australian Diabetes in Pregnancy Society, Submission 318, p. 7.

[25]NSW Health, Submission 349, p. 24.

[26]Butterfly Foundation, Submission 331, p. 9.

[27]Professor Tracey Wade, Associate Professor Deborah Mitchison and Mikayla Hussey, Submission 95, p. 2.

[28]Professor Tracey Wade, Associate Professor Deborah Mitchison and Mikayla Hussey, Submission 95, pp. 2–3.

[29]Dr James Muecke AM, Submission 67, Attachment 2, p. 3.

[30]See, for example: IPAN, Deakin University, Submission 259; Cancer Council Australia, Submission 298, p. 5; Australian Food and Grocery Council (AFGC), Submission 337, p. 5.

[31]Public Health Association of Australia, Submission 220, p. 7.

[32]See, for example: Dr James Muecke AM, Submission 67, Attachment 1, p. 12; IPAN, Deakin University, Submission 259, n.p.

[33]Eat for Health, Australian Dietary Guidelines, accessed 6 June 2024, www.eatforhealth.gov.au/guidelines/guidelines

[34]Eat for Health, Australian Dietary Guidelines, accessed 6 June 2024, www.eatforhealth.gov.au/guidelines/guidelines

[35]National Health and Medical Research Council, Review of the 2013 Australian Dietary Guidelines, accessed 6 June 2024, www.nhmrc.gov.au/health-advice/nutrition/australian-dietary-guidelines-review/about-the-review.

[36]Professor Steve Wesselingh, Chief Executive Officer, National Health and Medical Research Council, Senate Community Affairs Legislation Proof Hansard, Canberra, 5 June 2024, p. 49.

[37]Professor Jonathan Shaw, Deputy Director, Clinical and Population Health, Baker Heart and Diabetes Institute, Committee Hansard, Melbourne, 23 November 2023, p. 37.

[38]Sydney Low Carb Specialists, Submission 84, p. 5.

[39]Professor Peter Brukner, Private capacity, Committee Hansard, Melbourne, 23 November 2024, p. 47.

[40]Diabetes Australia, Submission 248.1, p. 19; Diabetes SA, Submission 395, p. 7.

[41]Dr Alan Barclay, Health and Nutrition Consultant, National Retail Association, Committee Hansard, Brisbane, 20 November 2023, p. 2.

[42]AFGC, Submission 337, p. 11.

[43]Dairy Australia, Submission 309, p. 3.

[44]Sydney Low Carb Specialists, Submission 84, p. 1.

[45]Jane MacDonald, Private capacity, Committee Hansard, Canberra, 22 March 2024, p. 58.

[46]Department of Health and Aged Care, Submission 152, p. 28.

[47]Australian Government Department of Health and Aged Care, Food Standards Australia New Zealand (FSANZ), viewed 21 May 2024, www.health.gov.au/contacts/food-standards-australia-new-zealand-fsanz; Food Standards Australia New Zealand (FSANZ), viewed 21 May 2024, ‘Labelling’, www.foodstandards.gov.au/business/labelling.

[48]Food Standards Australia New Zealand (FSANZ), viewed 21 May 2024, ‘Labelling’, www.foodstandards.gov.au/business/labelling.

[49]The Glycemic Index Foundation, Submission 268, p. 14; Food Standards Australia New Zealand (FSANZ), ‘Nutrition information panels’, accessed 21 May 2024, www.foodstandards.gov.au/consumer/labelling/panels.

[50]Healthline, ‘Glycemic Index: What It Is and How to Use It,’ https://www.healthline.com/health/diabetes/oatmeal#takeaway

[51]The Glycemic Index Foundation, Submission 268, p. 1; Glycemic Index Foundation: https://www.gisymbol.com/about-the-gi-symbol/

[52]Australian Government, Health Star Rating System, accessed 11 June 2024, www.healthstarrating.gov.au/internet/healthstarrating/publishing.nsf/Content/About-health-stars

[53]Department of Health and Aged Care, Submission 152, p. 29.

[54]Central Australian Aboriginal Congress, Submission 226, p. 14.

[55]Australian Patients Association, Submission 218, p. 8; Australian Chronic Disease Prevention Alliance, Submission 414, p. 3.

[56]Glycemic Index Foundation, Submission 268, pp. 14–15.

[57]Dr James Muecke AM, Submission 67, p. 1; Public Health Association of Australia (PHAA), Submission 220, p. 8; Infant and Toddler Foods Research Alliance, Submission 305, p. 2; Institute for Health Transformation, Deakin University, Submission 342, p. 8; Food for Health Alliance, Submission 370, p. 15; Synod of Victoria and Tasmania, Uniting Church in Australia, Submission 396, p. 4; Australian Chronic Disease Prevention Alliance, Submission 414, p. 6.

[58]AMA, Submission 219, Attachment 1, p. 9.

[59]Food for Health Alliance, Submission 370, p. 15.

[60]PHAA, Submission 220, p. 8.

[61]Food for Health Alliance, Submission 370, p. 15

[62]Food for Health Alliance, Submission 370, p. 15.

[63]Professor Brukner, Committee Hansard, Melbourne, 23 November 2023, p. 49; Dr James Muecke, Submission 67, p. 1.

[64]Professor Brukner, Committee Hansard, Melbourne, 23 November 2023, p. 49.

[65]Ms Tanya Barden, Chief Executive Officer, Australian Food and Grocery Council (AFGC), Committee Hansard, Canberra, 16 February 2024, p. 9.

[66]Mr Geoff Parker, Chief Executive Officer, Australian Beverages Council, Committee Hansard, Canberra, 22 March 2024, p. 68.

[67]Department of Health and Aged Care, Submission 152, p. 28.

[68]Glycemic Index Foundation, Submission 268, p. 14.

[69]AFGC, Submission 337, p. 7.

[70]Australian Government, Health Star Rating System - How to use Health Star Ratings, accessed 24 May 2024, www.healthstarrating.gov.au/internet/healthstarrating/publishing.nsf/Content/How-to-use-health-stars.

[71]Diabetes Australia, Submission 248.1, p. 17; PHAA, Submission 220, p. 8.

[72]Professor Peter Brukner, Submission 130, p. 6.

[73]Professor Peter Brukner, Submission 130, p. 6.

[74]Dr James Muecke, Submission 67, p. 1.

[75]PHAA, Submission 220, p. 8.

[76]Diabetes Australia, Submission 248.1, p. 17.

[77]Consumers Health Forum of Australia, Submission 367, p. 5.

[78]Dr Dimitri Batras, Board Director and Company Secretary, Australian Health Promotion Association, Committee Hansard, Canberra, 16 February 2024, p. 18.

[79]Glycemic Index Foundation, Submission 268, p. 14.

[80]Glycemic Index Foundation, Submission 268, p. 14.

[81]Central Australian Aboriginal Congress, Submission 226, p. 15.

[82]AFGC, Submission 337, p. 7.

[83]Royal Australasian College of Physicians (RACP), Submission 174, p. 7.

[84]Public Health Association of Australia, Submission 220, p. 8; Diabetes Australia, Submission 248.1, p. 17; Infant and Toddler Foods Research Alliance, Submission 305, p. 10; Mr David Clarke, Chief Executive Officer, Australian Patients Association, Committee Hansard, Canberra, 15 September 2023, p. 4.

[85]Australian Government, Health Star Rating System - How to use Health Star Ratings, accessed 24 May 2024, www.healthstarrating.gov.au/internet/healthstarrating/publishing.nsf/Content/How-to-use-health-stars.

[86]AFGC, Submission 337, p. 7.

[87]Ms Barden, AFGC, Committee Hansard, Canberra, 16 February 2024, p. 10

[88]Australian Dental Association, Submission 249, p. 7.

[89]The George Institute for Global Health, Submission 406, n.p.

[90]Australian Chronic Disease Prevention Alliance, Submission 414, p. 10.

[91]Ms Tiali Goodchild, Acting First Assistant Secretary, Population Health, Department of Health and Aged Care, Committee Hansard, Canberra, 1 March 2024, p. 19.

[92]Food Standards Australia and New Zealand, Health Star Rating System, accessed 11 June 2024, www.foodstandards.gov.au/consumer/labelling/Health-Star-Rating-System

[93]RACP, Submission 174, p. 7.

[94]Ms Goodchild, Department of Health and Aged Care, Committee Hansard, Canberra, 1 March 2024, p. 19.

[95]Uptake of the Health Star Rating system as at November 2023, A report on progress against the first interim target of the Health Start Rating system, May 2024, p. 2.

[96]The George Institute for Global Health, Submission 406, n.p.

[97]RACP, Submission 174, p. 7.

[98]Ms Barden, AFGC, Committee Hansard, Canberra, 16 February 2024, p. 10.

[99]Mr Parker, Australian Beverages Council, Committee Hansard, Canberra, 22 March 2024, p. 69.

[100]Australian Government, Health Start Rating System, HSR system changes – 2020, accessed 11 June 2024, www.healthstarrating.gov.au/internet/healthstarrating/publishing.nsf/Content/HSR-system-changes2020#:~:text=60%25%20uptake%20across%20intended%20products,products%20by%2014%20November%202025.

[101]Department of Health and Aged Care, About the Healthy Food Partnership, accessed 11 June 2024, www.health.gov.au/our-work/healthy-food-partnership/about-the-healthy-food-partnership; Department of Health and Aged Care, Submission 152, p. 28.

[102]AFGC, Submission 337, p. 8.

[103]AFGC, Submission 337, p. 8.

[104]Australian Beverages Council, Submission 374, p. 8.

[105]Australian Beverages Council, Submission 374, p. 6.

[106]Australian Beverages Council, Submission 374, p. 6.

[107]AFGC, Submission 337, p. 8.

[108]PHAA, Submission 220, p. 10; Infant and Toddler Foods Research Alliance, Submission 305, p. 12; Food for Health Alliance, Submission 370, p. 15; Dietitians Australia, Submission 390, p. 10; Synod of Victoria and Tasmania, Uniting Church in Australia, Submission 396, p. 10; The George Institute for Global Health, Submission 406, n.p.

[109]Food for Health Alliance, Submission 370, p. 17.

[110]Food for Health Alliance, Submission 370, p. 17.

[111]Food for Health Alliance, Submission 370, p. 17. See also Dietitians Australia, Submission 390, p. 10.

[112]NT Health, Submission 161, p. 2.

[113]NT Health, Submission 161, p. 2.

[114]AMA, Submission 219, Attachment 1, p. 4.

[115]AMA, Submission 219, Attachment 1, p. 4.

[116]AMA, Submission 219, Attachment 1, p. 9.

[117]AMA, Submission 219, Attachment 1, p. 9.

[118]Australian Dental Association, Submission 249, p. 7.

[119]Australian Patients Association, Submission 218, p. 6.

[120]RACP, Submission 174, p. 7.

[121]Diabetes across the Lifecourse Partnership, Menzies School of Health Research, Submission 66, p. 7.

[122]Grattan Institute, Submission 471, p. 7.

[123]Grattan Institute, Submission 471, p. 7.

[124]Grattan Institute, Submission 471, p. 7. See also: Australian and New Zealand Obesity Society (ANZOS), Submission 379, p. 8.

[125]See, for example: Diabetes across the Lifecourse Partnership, Menzies School of Health Research, Submission 66, p. 7; NT Health, Submission 161, p. 4; RACP, Submission 174, p. 7; Australian Patients Association, Submission 218, p. 6; AMA, Submission 219, p. 2; PHAA, Submission 220, p. 7; Central Australian Aboriginal Congress, Submission 226, p. 6; Diabetes Australia, Submission 248.1, p. 14; Australian Dental Association, Submission 249, p. 7; Cancer Council Australia, Submission 298, p. 6; Infant and Toddler Foods Research Alliance, Submission 305, p. 2; Australian Diabetes Society, Submission 317.1, p. 15; Australasian Diabetes in Pregnancy Society (ADIPS), Submission 318, p. 8; Institute for Health Transformation, Deakin University, Submission 342, p. 6; Consumers Health Forum of Australia, Submission 367, p. 5; Food for Health Alliance, Submission 370, p. 9; Australian and New Zealand Obesity Society (ANZOS), Submission 379, p. 8; Dietitians Australia, Submission 390, p. 8; Synod of Victoria and Tasmania, Uniting Church in Australia, Submission 396, p. 7; The George Institute for Global Health, Submission 406, n.p.; Australian Chronic Disease Prevention Alliance, Submission 414, p. 5; Aboriginal Health Council Western Australia (AHCWA), Submission 447, p. 9; Miwatj Health, Submission 449, pp. 15–16; Grattan Institute, Submission 471, p. 3; Professor Brukner, Committee Hansard, Melbourne, 23 November 2023, p. 50; Dr Ruwani Peiris, Public Health Registrar, Aboriginal Medical Services Alliance Northern Territory, Committee Hansard, Darwin, 7 March 2024, p. 12.

[126]AMA, Submission 219, Attachment 1, p. 5.

[127]Infant and Toddler Foods Research Alliance, Submission 305, p. 8.

[128]See, for example: Diabetes across the Lifecourse Partnership, Menzies School of Health Research, Submission 66, p. 10; RACP, Submission 174, p. 7.

[129]Australian Academy for Health and Medical Sciences, Submission 224, p. 6.

[130]Australian Academy for Health and Medical Sciences, Submission 224, p. 6.

[131]Ms Goodchild, Department of Health and Aged Care, Committee Hansard, Canberra, 1 March 2024, p. 24.

[132]Mr Matt Paterson, Mayor, Alice Springs Town Council, Committee Hansard, Alice Springs, 6 March 2024, p.5.

[133]AFGC, Submission 337, p. 9.

[134]Ms Barden, AFGC, Committee Hansard, Canberra, 16 February 2024, p. 11.

[135]Australian Beverages Council, Submission 374, p. 4.

[136]Australian Beverages Council, Submission 374, p. 4.

[137]AFGC, Submission 337, p. 10.

[138]Diabetes Australia, Submission 248.1, pp. 14–15.

[139]NT Health, Submission 161, p. 2.

[140]Grattan Institute, Submission 471, pp. 7–8.

[141]AMA, Submission 219, Attachment 1, p. 4.

[142]AMA, Submission 219, Attachment 1, p. 11.

[143]AMA, Submission 219, Attachment 1, p. 11.

[144]National Aboriginal Community Controlled Health Organisation (NACCHO), Submission 244, p. 23.

[145]AMA, Submission 219, Attachment 1, p. 26.

[146]AMA, Submission 219, Attachment 1, p. 26

[147]Grattan Institute, Submission 471, p. 2.

[148]AMA, Submission 219, Attachment 1, p. 22

[149]AMA, Submission 219, Attachment 1, p. 24.

[150]AMA, Submission 219, Attachment 1, p. 24.

[151]See, for example: AMA, Submission 219, Attachment 1, pp. 15–17; PHAA, Submission 220, p. 7; Institute for Health Transformation, Deakin University, Submission 342, n.p.; Grattan Institute, Submission 471, p. 3.

[152]Australian Academy for Health and Medical Sciences, Submission 224, p. 6.

[153]PHAA, Submission 220, p. 7.

[154]Grattan Institute, Submission 471, p. 13.

[155]Grattan Institute, Submission 471, p. 13.

[156]Institute for Health Transformation, Deakin University, Submission 342, p. 6.

[157]AMA, Submission 219, Attachment 1, p. 6.

[158]Parliamentary Budget Office (PBO) costings, Appendix D, p. 1.

[159]Parliamentary Budget Office (PBO) costings, Appendix D, p. 1.

[160]See, for example: RACP, Submission 174, p. 4; Diabetes Australia, Submission 248.1, p. 3; Cancer Council Australia, Submission 298, p. 5; Australia and New Zealand Obesity Society (ANZOS), Submission 379, p. 3; Australian College of Nurse Practitioners, Submission 403, p. 6.

[161]Health Direct, Junk food and your health, accessed 30 May 2024, www.healthdirect.gov.au/junk-food-and-your-health#what-is.

[162]See, for example: Dr James Muecke AM, Submission 67, Attachment 2, pp. 4, 10; RACP, Submission 174, p. 6; AMA, Submission 219, p. 2; PHAA, Submission 220, pp. 6–7; Diabetes Australia, Submission 248.1, p.16; Infant and Toddler Foods Research Alliance, Submission 305, p. 10; Institute for Health Transformation, Deakin University, Submission 342, pp. 6–7; Food for Health Alliance, Submission 370, pp.10–13; Dietitians Australia, Submission 390, pp. 8–10.

[163]PHAA, Submission 220, p. 7.

[164]AMA, Submission 219, p. 2.

[165]AMA, Submission 219, Attachment 3, p. 11.

[166]Dr James Muecke AM, Submission 67, Attachment 2, pp. 4, 10.

[167]AMA, Submission 219, Attachment 3, p. 11.

[168]RACP, Submission 174, p. 6.

[169]K Backholer, #Digital Youth – How children and young people are targeted with harmful product marketing online, Deakin University, Melbourne, 2024, p. 1.

[170]K Backholer, #Digital Youth – How children and young people are targeted with harmful product marketing online, Deakin University, Melbourne, 2024, p. 1.

[171]RACP, Submission 174, p. 6.

[172]Food for Health Alliance, Submission 370, p. 10.

[173]AMA, Submission 219, Attachment 3, p. v.

[174]Diabetes Australia, Submission 248.1, p. 16.

[175]Ms Sally Witchalls, Policy Adviser, AMA, Committee Hansard, Canberra, 15 September 2023, p. 56; Mr David Stout, Director, Policy, National Retail Association, and Dr Barclay, National Retail Association, Committee Hansard, Brisbane, 20 November 2023, p. 9.

[176]Professor Jason Wu, Head, Nutrition Science, The George Institute for Global Health, Committee Hansard, Brisbane, 20 November 2023, p. 18.

[177]National Retail Association, Submission 372, pp. 20.

[178]National Retail Association, Submission 372, pp. 19–20.

[179]Cancer Council Australia, Submission 298, p. 6.

[180]Department of Health and Aged Care, Submission 152, p. 28.

[181]Department of Health and Aged Care, Submission 152, p. 28.

[182]RACP, Submission 174, p. 6.

[183]RACP, Submission 174, p. 6.

[184]National Retail Association, Submission 372, p. 19.

[185]National Retail Association, Submission 372, p. 19.

[186]National Retail Association, Submission 372, p. 19.

[187]National Retail Association, Submission 372, p. 20.

[188]Ms Barden, AFGC, Committee Hansard, Canberra, 16 February 2024, p.12.

[189]Mr Parker, Australian Beverages Council, Committee Hansard, Canberra, 22 March 2024, p. 67.

[190]RACP, Submission 174, p. 6; PHAA, Submission 220, p. 6; Diabetes Australia, Submission 248.1, p. 16; Cancer Council Australia, Submission 298, p. 6.

[191]RACP, Submission 174, p. 6.

[192]Diabetes Australia, Submission 248.1, p. 16; Cancer Council Australia, Submission 298, p. 6.

[193]Diabetes Australia, Submission 248.1, p. 16.

[194]Diabetes Australia, Submission 248.1, p. 16; Australian Chronic Disease Prevention Alliance, Submission 414, p. 3.

[195]Australian Chronic Disease Prevention Alliance, Submission 414, p. 3.

[196]RACP, Submission 174, p. 6.

[197]RACP, Submission 174, p. 6; Diabetes Australia, Submission 248.1, p. 16; Infant and Toddler Foods Research Alliance, Submission 305, p. 10; Australian Diabetes in Pregnancy Society, Submission 318, p. 8.

[198]RACP, Submission 174, p. 6.

[199]See, for example: Dr James Muecke AM, Submission 67, Attachment 2, p. 10; Professor Peter Brukner, Submission 130, p. 7; RACP, Submission 174, p. 6; AMA, Submission 219, p. 2; PHAA, Submission 220, p. 6; Central Australian Aboriginal Congress, Submission 226, p. 14; Diabetes Australia, Submission 248.1, p. 16; Australasian Society of Lifestyle Medicine, Submission 276, p. 10; Cancer Council Australia, Submission 298, p. 6; Infant and Toddler Foods Research Alliance, Submission 305, p. 2; Institute for Health Transformation, Deakin University, Submission 342, p. 6; Consumers Health Forum of Australia, Submission 367, p. 5; Food for Health Alliance, Submission 370, p. 10; Australian and New Zealand Obesity Society (ANZOS), Submission 379, p. 8; Dietitians Australia, Submission 390, p. 8; Synod of Victoria and Tasmania, Uniting Church in Australia, Submission 396, p. 8; Australian Chronic Disease Prevention Alliance, Submission 414, pp. 3–4; Royal Australian College of General Practitioners, Submission 427, p. 10.

[200]Food for Health Alliance, Submission 370, p. 9.

[201]AMA, Submission 219, p. 2.

[202]Parliamentary Budget Office (PBO) costings, Appendix E, p. 1.

[203]Parliamentary Budget Office (PBO) costings, Appendix E, pp. 1–2.

[204]Parliamentary Budget Office (PBO) costings, Appendix E, p. 3.

[205]NACCHO, Submission 244, p. 22.

[206]Australian College of Rural and Remote Medicine, Submission 428, p. 7.

[207]AHCWA, Submission 428, p. 7.

[208]Diabetes across the Lifecourse Partnership, Menzies School of Health Research, Submission 66, p. 10.

[209]AHCWA, Submission 447, p. 5.

[210]Central Australian Aboriginal Congress, Submission 226, p. 7.

[211]Australian College of Nursing, Submission 245, pp. 9–10.

[212]Royal Australian College of General Practitioners, Submission 427, p. 6; AHCWA, Submission 447, p. 5.

[213]Australian College of Nursing, Submission 245, p. 14.

[214]Synod of Victoria and Tasmania, Uniting Church in Australia, Submission 396, p. 6.

[215]Synod of Victoria and Tasmania, Uniting Church in Australia, Submission 396, p. 6.

[216]Dr James Muecke AM, Submission 67, Attachment 2, p. 10.

[217]Dr Kathryn Williams, Submission 73, n.p.

[218]Dr Kathryn Williams, Submission 73, n.p.

[219]Mr Paterson, Alice Springs Town Council, Committee Hansard, Alice Springs, 6 March 2024, p.1.

[220]Diabetes across the Lifecourse Partnership, Menzies School of Health Research, Submission 66, p. 9.

[221]Rural Doctors Association of Australia, Submission 407, pp. 8–9; Victorian Aboriginal Community Controlled Health Organisation, Submission 455, p. 8.

[222]See, for example: AMA, Submission 219, Attachment 1, p. 11; PHAA, Submission 220, p. 8; Australian College of Nursing, Submission 245, p. 11; Consumers Health Forum of Australia, Submission 367, p. 5; Australasian Society of Lifestyle Medicine, Submission 276, p. 10.

[223]See, for example: Diabetes across the Lifecourse Partnership, Menzies School of Health Research, Submission 66, p. 4; Central Australian Aboriginal Congress, Submission 226, p. 7; Endocrine Society of Australia, Submission 401, p. 3; Miwatj Health, Submission 449, p. 4.

[224]Australian College of Nursing, Submission 245, p. 11.

[225]Diabetes across the Lifecourse Partnership, Menzies School of Health Research, Submission 66, p. 8.

[226]Diabetes across the Lifecourse Partnership, Menzies School of Health Research, Submission 66, p. 8.

[227]Diabetes across the Lifecourse Partnership, Menzies School of Health Research, Submission 66, p. 7.

[228]Central Australian Aboriginal Congress, Submission 226, p. 7.

[229]Miwatj Health, Submission 449, p. 4; see also Public Health Association of Australia, Submission 220, p. 8.

[230]Alice Springs Hospital Endocrinology Department on behalf of the Department of Medicine, Submission 348, p. 4.

[231]The George Institute for Global Health, Submission 406, n.p.

[232]House Standing Committee on Agriculture, Australian Food Story: Feeding the Nation and Beyond, November 2023.

[233]NACCHO, Submission 244, p. 23; NT Health, Submission 161, p. 4.

[234]Exercise and Sports Science Australia, Submission 410, p. 2.

[235]Australian Sports Commission, Submission 307, p. 2.

[236]Professor Richard Telford AM, Professorial Fellow, Research Institute for Sport and Exercise, University of Canberra, Committee Hansard, Canberra, 20 March 2024, p. 5.

[237]IPAN, Deakin University, Submission 259, n.p.

[238]IPAN, Deakin University, Submission 259, n.p.; Australasian Diabetes in Pregnancy Society (ADIPS), Submission 318, p. 7; Professor Telford AM, University of Canberra, Committee Hansard, Canberra, 20March 2024, p. 5.

[239]Department of Health and Aged Care, Submission 152, p. 30.

[240]The Obesity Collective, Submission 343, p. 5.

[241]Diabetes Australia, Submission 248.1, p. 18.

[242]Diabetes Australia, Submission 248.1, p. 18.

[243]Diabetes Australia, Submission 248.1, p. 18.

[244]Diabetes Australia, Submission 248.1, p. 18.

[245]Miwatj Health, Submission 449, p. 8.

[246]PHAA, Submission 220, p. 11.

[247]Australian Sports Commission, Submission 307, p. 2.

[248]Department of Health and Aged Care, Submission 152, pp. 29–30; NSW Health, Submission 349, p. 30.

[249]See, for example: AMA, Submission 219, Attachment 1, p. 11; Diabetes Australia, Submission 248.1, pp. 18-19; IPAN, Deakin University, Submission 259, n.p.; AFGC, Submission 337, p. 4; Miwatj Health, Submission 449, p. 8.

[250]IPAN, Deakin University, Submission 259, n.p.

[251]IPAN, Deakin University, Submission 259, n.p.

[252]Mr Lewis Matthew Carroll AM, Chief Executive Officer, Secretary General, Australian Olympic Committee, Committee Hansard, Canberra, 20 March 2024, p. 2.

[253]AMA, Submission 219, p. 3.

[254]Australian Patients Association, Submission 218, p. 11.