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Nutritional quality of Australian breakfast cereals. Are they improving? 1Jimmy Chun-Yu Louie, 2,3Elizabeth K Dunford, 4Karen Z Walker, 1Timothy P Gill 1Cluster for Public Health Nutrition, Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders, The University of Sydney NSW 2006 Australia 2The George Institute for Global Health, Camperdown NSW 2050 Australia 3School of Public Health, The University of Sydney NSW 2006 Australia

Abstract

The nutritional quality of Australian breakfast cereals is not systematically monitored despite the importance of breakfast for general health. We examined whether the nutritional quality of Australian breakfast cereals has improved between 2004 and 2010, and whether any change could be detected after the introduction of Daily Intake Guide (DIG) front-of-pack labelling. Supermarket surveys were conducted in 2004 and 2010 using the same methodology to collect information from the nutrition information panels of Australian breakfast cereals and the nutrient content of cereals was compared by year. Breakfast cereals with and without DIG labelling in 2010 were also compared. Nutritional quality was assessed using UK Traffic Light criteria. No significant difference was detected in nutritional composition of breakfast cereals between 2004 and 2010. There was no notable improvement in nutritional composition of breakfast cereals marketed as the same product in both years. Overall there has been little improvement in the nutritional quality of Australian breakfast cereals in the 6 year period. A large proportion of Australian breakfast cereals were considered high sugar. In conclusion, the introduction of DIG labelling does not appear to have promoted product reformulation, and breakfast cereals carrying DIG labels were not consistently healthier. Keywords: breakfast cereals, nutritional quality, traffic light labelling, DIG labelling, Australia Appetite. 2012; 59(2):464-70. DOI:10.1016/j.appet.2012.06.010

Introduction

Australians eat breakfast more than five days a week, around 50% of the time they choose to eat breakfast cereals (Williams 2002). Consumption of breakfast cereals is associated with improved overall diet quality (Albertson et al 2008, Gibson and Gunn 2011, Nicklas et al 1998a, Williams 2007, Wilson et al 2006), and improved mental and physical performance (Nicklas et al 1998b, Rampersaud et al 2005). This may be because they are a good source of whole grains and commonly eaten with milk. Whole grains are rich in dietary fibre and both grains and milk will improve micronutrient intake (Coudray 2011, Drewnowski 2011, Vissers et al 2011, Williamson 2010). Breakfast cereals are often now also fortified with vitamins such as folate and thiamine (Berner et al 2001, Hannon et al 2007).

Regular consumption of breakfast cereals has also been associated with lower body weight (Albertson et al 2003, Deshmukh-Taskar et al 2010, Kafatos et al 2005, Kosti et al 2008, Panagiotakos et al 2008, Song et al 2005, Williams et al 2009). For example, in a large national survey, American children and adolescents who regularly consumed breakfast cereals had lower body mass index-for-age z-scores, lower waist circumference and lower prevalence of obesity than children and adolescents who skipped breakfast (Deshmukh-Taskar et al 2010). On the other hand, the high sugar and sodium content of many breakfast cereals is often criticized (CHOICE 2010, Which? 2006), particularly for those targeted at children (Harris et al 2009, Pestano et al 2011, Schwartz et al 2008).

Food reformulation to reduce the intake of negative nutrients (i.e. nutrients that are harmful to health when consumed in excess) is a potentially important public health strategy. For

example, one study found that the Australian Heart Foundation Tick program had prompted an average reduction of 40% in sodium in Australia breakfast cereals. This would translate to a reduction in the salt intake of Australians approximating to 235 tonnes per year (Williams et al 2003). Because breakfast cereals are a popular breakfast choice (Albertson et al 2003, Grieger and Cobiac 2012, Rangan et al 2011, Williams 2002), there is considerable potential to enhance nutrition through reformulation. However, strong incentives may be required to encourage food manufacturers to reformulate their products, as the process can require considerable research and development investments. It has been suggested that one way to drive a change towards reformulation in through the introduction of front-of-pack labelling (FOPL). Consumers are becoming more health conscious (Food Standards Australia New Zealand 2007), and if they have access to clear FOPL their understanding of the nutritional quality of the food products may improve and their purchase of less healthy products may decline (Grunert and Wills 2007, Ni Mhurchu et al 2011). This in turn could encourage product reformulation to boost sales.

In November 2006 the Australian Food and Grocery Council introduced a Daily Intake Guide (DIG) FOPL scheme aiming to assist consumers in making healthier food choices (Australian Food and Grocery Council 2010b). Display of a DIG is voluntary and food manufacturers can choose from a wide variety of labelling options including; an energy only DIG label, an energy plus vitamin / mineral DIG, a simple DIG providing information only on energy, fat, saturated fat, sugars and sodium content, a full DIG label containing information on energy, protein, total fat, saturated fat, total carbohydrates, sugars and sodium, or a full DIG label plus additional DIG for micronutrients (Australian Food and Grocery Council 2011). At

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present over 4,600 food products sold in Australia carry DIG labelling (Australian Food and Grocery Council 2012), where a simple DIG or a full DIG plus additional DIG for micronutrients was commonly displayed on Australian breakfast cereals. Similar systems have also been introduced and adopted by manufacturers and retailers in Europe and US (Confederation of the Food and Drink Industries in the EU 2011).

An alternate FOPL system, the Colour-Coded Traffic Light Labelling, has been developed by the Food Standards Agency in the UK in 2007 (Food Standards Agency 2007). This system categorises the 4 key negative nutrients most associated with public health issues (fat, saturated fat, sugars and salt) as high, medium or low compared to a set of agreed criteria based on the Guideline Daily Amount (GDA) on a per 100 g basis (Department of Health 1991, European Union 2006). These nutrients are then each given a ‘red’, ‘amber’ or ‘green’ rating. Public health groups have been advocating for the introduction of the Colour-Coded Traffic Light Labelling, which has been demonstrated to most consistently help consumers identify healthier products (Hawley et al 2012, Kelly et al 2009, Louie et al 2008). The system has recently been considered for introduction to Australia (Blewett et al 2011).

Despite the adoption of DIG and similar systems by manufacturers and retailers around the world (Australian Food and Grocery Council 2010a, Confederation of the Food and Drink Industries in the EU 2011), there is limited assessment of the impact of FOPL on the reformulation of breakfast cereals or other foods. In addition, there has been no systematic monitoring of the nutritional quality of Australian breakfast cereals. Therefore the primary objective of this project was to investigate whether the nutritional quality of Australian breakfast cereals has improved from 2004 to 2010, and whether the introduction of DIG labelling resulted in any detectable nutritional change.

Materials and methods

Data collection

A systematic supermarket survey of all breakfast cereals offered for sale was conducted in 2010 to collect data from the nutrition information panel (NIP) on packages of Australian breakfast cereals and compared to data previously collected in the same manner in 2004. Methods of collection for the 2004 data have been reported previously (Woods and Walker 2007). In brief, between August and September 2004, a surveyor systematically collected nutrition information from all packaged breakfast cereals (n = 164), including those shelved in the health food section, presented for sale in a large chain supermarket in metropolitan Melbourne, Australia. Data were recorded on standardised entry sheets, which included information on brand name, product title, suggested serving size, and per 100 g content of energy, protein, total fat, saturated fat, total available carbohydrates, sugars, dietary fibre and sodium. It should be noted that ‘suggested serving size’ is that recommended by the manufacturer, and do not necessarily reflect the actual amount eaten by the consumers. Details of the ingredients list were not recorded as this was not the primary aim of the study.

Data for breakfast cereals available in 2010 (n = 234) were collected between October and November 2010 from supermarkets from the two major chains in metropolitan New South Wales using similar methodology. In addition to the variables collected in 2004, the presence of DIG labelling on the package was also recorded.

This study was deemed exempt from ethics approval by the University of Sydney Human Research Ethics Committee as it involved no direct human contact.

Nutrient Green (Low) Amber (Medium) Red (High)

Total fat ≤ 3.0 g / 100 g > 3.0 to ≤ 20.0 g / 100 g > 20.0 g / 100 g or > 21.0 g / portiona

Saturated fat ≤ 1.5 g / 100 g > 1.5 to ≤ 5.0 g / 100 g > 5.0 g / 100 g or > 6.0 g / portiona

Sugars# ≤ 5.0 g / 100 g > 5.0 to ≤ 12.5 g / 100 g > 12.5 g / 100 g or > 15.0 g / portiona

Salt (NaCl) ≤ 0.3 g / 100 g > 0.3 g to ≤ 1.5 g / 100 g > 1.5 g / 100 g or > 2.4 g / portiona

Table 1 - Criteria used in the Colour-coded Traffic Light System for classifying nutrients in solid foods as green, amber or red

# The sugars colour code is determined as follows: The lower limit of amber is determined using total sugars

The upper limit of amber is determined using non-milk extrinsic sugars, i.e. added sugars If the food item falls in the amber category and is high in fruit or milk sugars, a statement on the packaging to highlight the presence of natural sugars (e.g.

contains naturally occurring sugars) is required aper portion criteria were used to ensure foods contributing more than 30% of the recommended upper intake for total fat, saturated fat, sugar and 40% of salt be labelled red Source: Food Standards Agency (UK) (2007)

Biscuit & Bites

Brans Bubbles, flakes and

puffs

Cereals for kids

Muesli Oats Total

n 22 7 63 16 59 30 197

Suggested serving size (g) 36.5 ± 1.5* 42.1 ± 1.5 37.8 ± 1.1** 30.9 ± 0.8*** 49.7 ± 0.9### 36.6 ± 1.4* 40.6 ± 0.7

Nutrients per 100 g

Energy (kJ) 1505.5 ± 11.6**

1410.0 ± 31.4*** 1557.7 ± 9.9 1574.0 ± 19.0

1640.1 ± 20.8### 1591.8 ± 10.2 1577.8 ± 8.4

Protein (g) 10.8 ± 0.4 13.1 ± 0.9## 9.9 ± 0.5 6.3 ± 0.4*** 10.3 ± 0.3 10.8 ± 0.4 10.1 ± 0.2

Total fat (g) 2.0 ± 0.3*** 4.4 ± 1.1 3.2 ± 0.3*** 1.9 ± 0.4*** 10.8 ± 0.6### 7.7 ± 0.3# 5.9 ± 0.3

Saturated fat (g) 0.7 ± 0.2** 0.8 ± 0.3 0.6 ± 0.1*** 0.7 ± 0.2* 2.4 ± 0.2### 1.5 ± 0.1 1.3 ± 0.1

Carbohydrate (g) 68.0 ± 1.0 47.4 ± 3.7*** 71.2 ± 1.1### 80.6 ± 1.6### 58.9 ± 1.0*** 61.8 ± 1.0* 65.7 ± 0.7

Sugars (g) 9.7 ± 1.9*** 14.5 ± 3.0 19.2 ± 1.0# 27.3 ± 2.1### 18.2 ± 0.8 8.7 ± 2.2*** 16.7 ± 0.7

Fibre (g) 11.8 ± 0.8# 27.0 ± 3.5### 8.3 ± 0.7* 4.4 ± 0.8*** 9.4 ± 0.3 9.2 ± 0.4 9.5 ± 0.4

Sodium (mg) 248.3 ± 30.7 286.1 ± 51.5* 303.2 ± 25.6###

367.2 ± 56.6### 67.9 ± 12.2*** 24.4 ± 10.3*** 188.7 ± 14.0

Table 2 – Comparison of serving size and nutrient content per 100 g for different categories of breakfast cereals surveyed in 2010

Values are expressed as mean ± SEM. Lower than the rest of the cereal categories, * p < 0.05; ** p < 0.01, *** p < 0.001. Higher than the rest of the cereal categories. # p < 0.05; ## p < 0.01, ### p < 0.001. All tests were conducted using one-way ANOVA.

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Accuracy of nutrition information panels

The accuracy of nutrition information collected from the NIPs was assessed by comparing the stated energy content on the label with energy content calculate from the stated macronutrient content. NIPs with stated energy which fell between 95% - 105% of calculated energy were considered to be plausible.

Assessment of nutritional quality

Assessment of micronutrient content of the breakfast cereals was not possible in this study because micronutrients are not required to be presented on the Australian NIP (Food Standards Australia New Zealand 2009). We therefore focussed on the content of negative nutrients, namely: total fat, saturated fat, sugar and sodium. The content of these nutrients were classified as ‘low’, ‘medium’ or ‘high’ based on the Traffic Light Labelling criteria developed by the UK Food Standards Agency (FSA) (Food Standards Agency 2007), where cut-offs of these nutrients on a per 100 g basis (Table 1) were applied. These criteria were chosen as this system has recently been considered for introduction to Australia (Blewett et al 2011).

It was not possible however to accurately differentiate between natural sugars (e.g. sugars in dried fruits) and added sugars as required by the FSA criterion as this information is lacking in an Australian NIP (Food Standards Australia New Zealand 2009). To estimate the added sugar content of the breakfast cereals included in this study, a sub-study of 30 Australian breakfast cereals containing dried fruit manufactured by major breakfast cereal companies in 2011 was conducted, where their ingredient lists were recorded and analysed. In Australia it is a requirement to list the proportion of total product weight for ‘characterising’ ingredients in the ingredients list, and for these cereals, the characterising ingredients are their dried fruit content. The proportion of sugars from fruits were estimated (Supplemental Table 1, available from http://www.awash.org.au/documents/BCSUPP.doc), and the mean proportion for each category was applied to breakfast cereals with dried fruit in the corresponding category in the present study to estimate their natural sugars content. Their added sugar content is then calculated as total sugars minus natural sugars. Presence of dried fruits in breakfast cereals marketed in 2004 was determined based on the name of the cereal (e.g. Sultana & Bran) and the professional knowledge of one author (JCYL), who is a dietitian. For breakfast cereals marketed in 2010 additional information on dried fruit content were sought from the company websites. Overall, 50.0% and

50.8% of breakfast cereals marketed in 2004 and 2010 respectively were deemed to contain dried fruit.

Statistical analyses

Breakfast cereals with incomplete serving size or nutrition data (n = 12 in 2004 and n = 10 in 2010), or inaccurate NIP (n = 28 in 2004 and n = 27 in 2010) were excluded from the analysis. To allow direct comparison, breakfast cereals were categorized into one of the following categories as described by Woods & Walker (Woods and Walker 2007) - ‘Biscuit & bites’ (e.g. whole wheat biscuits), ‘Brans’ (e.g. bran flakes), ‘Bubbles, flakes and puffs’ (e.g. puffed rice, corn flakes), ‘Cereals for kids’ (e.g. cereals with promotional character on package), ‘Muesli’ (e.g. bircher muesli, Swiss muesli) and ‘Oats’ (e.g. rolled oats, quick oats). All data were analysed using IBM SPSS Statistics, version 19.0 (IBM Australia, St Leonards NSW, Australia). Nutrient data were aggregated as the mean ± SEM. One way ANOVA was used to compare the nutrient quality or the change in nutrient quality of different categories of breakfast cereals, whether surveyed at the same or at different time points, and whether with or without a DIG label. For the analysis of breakfast cereals marketed in 2010 (Table 2), the mean values of a given cereal category were compared with the mean values of the total remaining cereal categories by one-way ANOVA. A paired sample t-test was used to test for change in suggested serving size and nutritional content for those breakfast cereals which were marketed under the same name in 2004 and 2010 (Table 3), while Pearson χ2 was used to test for differences in the percentage of cereals in different traffic light categories. To account for the effect of multiple comparisons, a Bonferroni correction was applied and only a p < 0.001 was considered statistically significant.

Results

A total of 325 breakfast cereals products with complete data and plausible NIP were included in this analysis (n = 128 from 26 brands in 2004; n = 197 from 33 brands in 2010). The nutritional composition of Australian breakfast cereals available in 2010 is summarized in Table 2. Although containing lower total fat, ‘cereals for kids’ had significantly higher carbohydrate and sugar content, as well as lower protein and fibre content than other categories of breakfast cereals. ‘Bubbles, flakes and puffs’ and ‘cereal for kids’ were found to have significantly higher sodium content than the rest of the cereals, while ‘muesli’ and ‘oats’ had the lowest sodium content. ‘Brans’ had the highest fibre content among the cereals, and they also provide the most protein per 100g (marginally significant; p < 0.01), while ‘muesli’

All breakfast cereals Cereals with DIG Cereals without DIG

2004 2010 2004 2010 2004 2010

n 67 40 27

Suggested serving size (g) 37.5 ± 1.2 38.3 ± 1.1 35.3 ± 1.3 36.9 ± 1.1 40.7 ± 2.3 40.5 ± 2.0

Nutrients per 100 g

Energy (kJ) 1532.7 ± 18.9 1552.3 ± 14.9 1561.8 ± 17.0 1568.5 ± 13.2 1489.5 ± 38.6 1528.2 ± 31.0

Protein (g) 9.4 ± 0.4 9.7 ± 0.4* 9.8 ± 0.5 9.9 ± 0.5 8.8 ± 0.5 9.3 ± 0.6*

Total fat (g) 4.6 ± 0.5 4.4 ± 0.5 4.1 ± 0.5 4.2 ± 0.6 5.3 ± 0.9 4.8 ± 0.9

Saturated fat (g) 1.3 ± 0.2 1.0 ± 0.1 1.3 ± 0.4 1.0 ± 0.1 1.4 ± 0.3 1.0 ± 0.2

Carbohydrate (g) 66.9 ± 1.5 67.8 ± 1.4 69.1 ± 1.8 69.1 ± 1.7 63.5 ± 2.6 66.0 ± 2.4†

Sugars (g) 16.0 ± 1.4 16.2 ± 1.4 18.1 ± 2.0 18.0 ± 2.0 13.0 ± 1.6 13.4 ± 1.7

Fibre (g) 9.8 ± 1.2 9.3 ± 0.8 10.3 ± 1.8 8.8 ± 1.0 9.0 ± 1.1 10.0 ± 1.3

Sodium (mg) 209.0 ± 29.7 210.3 ± 28.6 243.1 ± 36.7 246.7 ± 38.8 153.1 ± 44.8 161.9 ± 44.7

Table 3 – Comparison of serving size and nutrient content per 100 g for different breakfast cereals marketed under the same name in 2004 and 2010, stratified by year of data collection

Values are expressed as mean ± SEM. DIG – daily intake guide * denotes p < 0.05 when compared to breakfast cereals in 2004, tested by paired sample t-test. † denotes significantly higher increase (p < 0.05) in mean carbohydrate content than breakfast cereals with DIG, tested by one-way ANOVA.

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had the highest mean suggested serving size, energy, total fat and saturated fat.

Overall breakfast cereals displaying DIG labelling had a smaller serving size than those with no DIG labelling (mean ± SEM serving size: 43.0 ± 1.1 g vs 38.4 ± 0.8 g; p < 0.001). However, breakfast cereals displaying DIG labelling had significantly higher sugar content than those with no DIG label (mean ± SEM sugar per 100g: 14.3 ± 0.9 g vs 19.0 ± 1.0 g; p < 0.001), mainly driven by ‘bubbles, flakes & puffs’. ‘Cereals for kids’ with DIG labelling had a marginally significantly higher total energy content (mean ± SEM energy per 100 g: 1509.3 ± 37.4 kJ vs 1612.8 ± 6.8 kJ; p < 0.01). When assessed using the UK FSA Traffic Light criteria (Figure 1), a significantly higher proportion of breakfast cereals with DIG labelling had ‘high’ sugar content.

Out of the 67 breakfast cereals available both in 2004 and 2010 as the same product, 60 had changed their formulations (21 out of 27 without DIG; 39 out of 40 with DIG).

When stratified by categories, there had been more than two-fold increase in fibre content amongst ‘cereals for kids’ although it is only of marginal statistical significance (mean ± SEM fibre per 100g: 1.7 ± 0.3 g vs 4.4 ± 0.8 g; p = 0.026). Overall breakfast cereals in 2010 had a marginally higher energy density than those in 2004 (mean ± SEM energy per 100 g: 1536.2 ± 15.1 kJ vs 1577.8 ± 8.4 kJ; p < 0.01). Despite some improvements in the proportion considered ‘low’ sodium among ‘cereals for kids’ (Figure 2), overall the nutritional profiles of breakfast cereals available in 2010 showed little improvement, or in some cases, had deteriorated compared to 2004.

Breakfast cereals marketed in 2004 and 2010 as the same product were found not to differ in nutrient content, except for a marginally higher protein content (Table 3). Further stratification by the presence of DIG labelling showed the increase was mainly driven by breakfast cereals not carrying DIG labels.

Discussion

This study documented the change in nutritional quality of Australian breakfast cereals over a six year period. Overall, we found little improvement in the nutritional quality of Australian breakfast cereals, and there is no indication that the introduction of DIG labelling has promoted product reformulation by the food industry.

Despite ongoing lobbying from public health groups (CHOICE 2010, Harris et al 2009, The Parents Jury 2009, Which? 2006), as well as the self-regulated commitment of the breakfast cereals industry to improve the nutritional composition of their products (Nestle Australia 2011, Williams et al 2003), we found very limited improvement has occurred since 2004. There has been some laudable reduction in sodium in ‘cereals for kids’, but overall the proportion of breakfast cereals considered ‘low’ sugar and/or sodium had actually decreased from 2004 to 2010. In fact more than 40% of Australian breakfast cereals in 2010 were ‘high’ in sugar. While we have applied category specific proportion factors to estimate the natural sugar content of the breakfast cereals, it is only a rough estimation and hence this may have resulted in a small amount of misclassification, although it is an improvement from using only ‘total sugars’ as the assessment criterion. Of note is that none of the ‘high’ sugar

Figure 1 – Proportion of breakfast cereals categories meeting ‘low’, ‘moderate’ and ‘high’ benchmarks for total fat, saturated fat, sugars and sodium for breakfast cereals marketed in 2010 only, stratified by the presence of DIG FOPL. ‘Other cereals’ include all cereals except ‘Cereals for kids’.

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‘cereals for kids’ contained any naturally occurring fructose, avoiding such limitation to the classification methodology in this case. The slight increase in the proportion of breakfast cereals considered to have a ‘medium’ sodium content, with a concurrent decrease in those considered ‘low’ in sodium, also demonstrates that little progress had been made in reducing the overall sodium content in Australian breakfast cereals, highlighting the importance of continuous monitoring of the nutritional content of the food supply.

It has been argued that breakfast cereals are significant contributors to daily micronutrient intake (Gibson 2003, Williamson 2010), and hence the benefits of breakfast cereal consumption outweigh the potential harm caused by their high sugar and sodium content (Clark and Crockett 2008, Nicklas 2008). While we acknowledge that some healthy breakfast cereals products are available in the market, it is concerning to see that overall the nutritional quality of Australian breakfast cereals appears no better than in 2004.

It has been suggested that the addition of sugar and sodium increases palatability of otherwise bland, low sugar breakfast cereals, especially among children (Clark and Crockett 2008, Thompson et al 2008). A recent study however found that children will consume low sugar breakfast cereals when offered (Harris et al 2011). Even with the addition of table sugar to increase the palatability of low sugar breakfast cereals, the total sugar consumed was significantly less than that contained in high sugar breakfast cereals (Harris et al 2011), implying the high sugar content in ‘cereals for kids’ is unnecessary. It was also found in the same study that high sugar breakfast cereals promote excess consumption. Children randomized to consume high sugar breakfast cereals ate approximately double the amount of the cereals compared to those randomized to the low sugar group. In addition to their high sugar and sodium

contents, in the present study we also found ‘cereals for kids’ had lower protein and fibre content than other cereals (despite a marginally statistically significant increase in fibre from 2004), making them less healthy choices.

There was no indication that the introduction of DIG labelling has encouraged product reformulation by food manufacturers. In 2010, breakfast cereals carrying DIG labelling had significantly higher sugar content. Indeed the analysis of breakfast cereals marketed in 2004 and 2010 as the same product and carrying DIG labelling in 2010 demonstrated that no significant change in nutritional quality had occurred over this six year period. This finding does not support the contention that the introduction of FOPL based on the DIG labelling format will encourage product reformulation (Grunert and Wills 2007, Ni Mhurchu et al 2011).

It may be that DIG labelling provides fewer incentives to the manufacturers than other more interpretive systems to reformulate products as the nutritional quality of the food product is less apparent to the consumer and less likely to affect purchase decisions. Also the DIG is based on serving size which can allow distortions, e.g. a smaller serving size will lower the amount of saturated fat shown on the DIG label. In addition, it has been argued in the U.S. that the introduction of ‘Nutrition Keys’ (Grocery Manufacturers Association 2011), a system similar to the DIG labelling, by the industry was a strategy to pre-empt the introduction of an alternative system such as colour-coded traffic light labelling (Brownell and Koplan 2011), which will better highlight negative nutrients to consumers. (Malam et al 2009). In the UK, the introduction of colour-coded traffic light labelling prompted product reformulation among manufacturers and retailers who adopted the system (Faculty of Public Health et al 2008, J Sainsbury plc 2011, Lobstein et al 2007).

Figure 2 – Proportion of breakfast cereals categories meeting ‘low’, ‘moderate’ and ‘high’ benchmarks for total fat, saturated fat, sugars and sodium, stratified by year of data collection. ‘Other cereals’ include all cereals except ‘Cereals for kids’.

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A FOPL may also be considered successful if it changes consumers purchasing behaviour towards healthier options. However, the sales of children’s breakfast cereals between 2006 – 2010 remained relatively stable (Euromonitor International 2010), suggesting the DIG labelling may not have affected purchasing behaviour. Fiscal strategies such as taxation of less healthy options may provide more incentive for change in purchasing behaviours, as it effectively increases their retail price which may deter regular consumption of these less healthy breakfast cereals (Bond et al 2010, Steenhuis et al 2011). However, since the poor spend a larger proportion of their income on food, a tax on less healthy breakfast cereals may be regressive, i.e. having less effect on individuals with higher income levels and disadvantaging the poor. It would therefore be important to ensure breakfast cereals that are taxed do not provide nutrients difficult to obtain from other affordable food sources. Clearly there are affordable and healthier alternatives (e.g. whole wheat biscuits) to high sugar low fibre breakfast cereals (e.g. cocoa puffed rice). It has been proposed that allocation of the revenue collected from such taxes to subsidize healthy food choices could help reduce the burden to the poor (Steenhuis et al 2011).

A limitation of this study is that data depends on the accuracy of the NIP. While we have excluded breakfast cereals with an implausible NIP, i.e. energy content calculated based on stated macronutrient contents fell outside 95% - 105% of stated energy content, we cannot ensure the accuracy of macronutrient contents stated on the NIP. One study (Fabiansson 2006) has reported good agreement between the NIP and nutrient content defined by laboratory analysis. Moreover, data from 2004 suggest that only around 10 – 20% of Australian breakfast cereals carried an implausible NIP (Woods and Walker 2007), and similar results were found in the 2010 survey undertaken. Another limitation was the difference in the location of data collection (metropolitan Melbourne versus metropolitan Sydney) in the two supermarket surveys. Yet as Australia has the most concentrated supermarket sector in the world, with only two major chains providing approximately 80% of total market share (National Association of Retail Grocers of Australia 2010), the difference between product availability in the two capital cities can be considered minimal. Nevertheless, some minor brands sold only by small retail outlets would have been missed in both surveys. With the major breakfast cereal brands having > 85% of the market share (Euromonitor International 2010), however, such omission would have negligible effects at a population consumption level.

In conclusion, overall there has been little improvement in the nutritional quality of Australian breakfast cereals from 2004 to 2010. The majority of Australian breakfast cereals available in 2010 were ‘high’ in sugar content, although the dried fruit content of some breakfast cereals contributed to this classification. The increased proportion of ‘cereals for kids’ considered ‘high’ sugar from 2004 is of concern. The introduction of DIG labelling does not appear to have promoted product reformulation by industry. A higher proportion of breakfast cereals carrying DIG labelling in 2010 were ‘high’ in sugar.

Acknowledgement

EKD is a Research Officer for the Australian Division of World Action on Salt & Health. All other authors declare they have no competing interest.

All authors were involved in the conception of the study. KZW provided nutrition information for breakfast cereals from 2004, and EKD collected the 2010 data. EKD and KZW categorized

the breakfast cereals. JCYL analysed the results. All authors were involved in interpretation of the results and made significant contributions to the discussion. JCYL drafted the manuscript. All authors were involved in the subsequent edits of the manuscript, and have read and approved the final manuscript.

Funding source: This study was funded by the internal revenue of The George Institute for Global Health, and the Sydney University Nutrition Research Foundation. EKD is supported by a Sydney Medical School Foundation Postgraduate Scholarship.

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