Whole grain diets, health star ratings and opportunities for health related promotion of grains

Take home messages

• The Global Burden Disease Study indicates whole grain is key to health and studies suggest a 20% reduction in key diseases such as coronary heart disease, Type 2 diabetes mellitus and total mortality with each 16g of whole grain.
• Most Australians consume only about 23g of the 48g Daily Intake Target (DTI) for whole grain (and consume more refined grain).
• Whole grain has always been the focus of dietary guidelines, but it is not included in the algorithm for the Health Star Rating (HSR) system found on food packaging.
• Food trends offer some opportunity to the industry to promote grain foods – particularly claims based on plant protein, gut health and quality carbohydrates/ whole grain.
• Whole grains themselves are rarely more expensive than refined food choices, however, certain segments of the market do produce premium products.
• Nutrition campaigns that better support Dietary Guidelines like the previous “2 Fruit & 5 Veg” may be needed to assist with the confusion that surrounds the value of grain foods in the Australian Diet and the positive effect on overall health.

Background

Globally, poor diet is a significant, and largely preventable risk factor for mortality and morbidity; accounting for 10.9 million deaths, and 255 million Disability Adjusted Life Years (DALYs) in 2017.

The Global Burden Disease Study is a comprehensive study which uses observational epidemiological data examining trends since 1990. Among dietary risks, low intake of whole grain foods has been noted as the second leading risk for mortality (behind sodium), and the leading risk factor for DALYs, leading to 82.5 million DALYs (Collaborators GRF, 2017).

Meta-analyses and systematic reviews of all-cause and cause-specific mortality support whole grain diets playing a role in prevention of disease (Aune et al., 2016; Zong et al., 2016; Zhang et al., 2018). Analyses of randomised clinical trials provide further evidence which supports, that when consumed, whole grains lead to a reduction in low density lipoprotein (LDL) cholesterol, total cholesterol and percentage body fat compared to diets without them. Additional analyses has identified improvements in postprandial glucose levels and glucose homeostasis resulting from whole grain diets (Hollaender et al., 2015; Marventano et al., 2017; Pol et al., 2013). These findings are contrary to recent low carbohydrate diet trends and suggest that diet quality and quality grain foods are important factors for human health (Pollard et al., 2017.) – Whole grain diets are gaining popularity globally as consumers realise the importance of quality carbohydrates (including whole grains) in a balanced diet.

According to the 2011-12 National Nutrition and Physical Activity Survey (NNPAS), grain foods (both whole, and refined grains) such as breads, cereals, pasta, rice, and noodles were the leading contributors of seven key nutrients in the Australian diets; including dietary fibre, folate, thiamin, iron, magnesium, iodine, and carbohydrates (Statistics ABo, 2014). However, consumption of whole grains in Australia is low, with NNPAS data identifying only one third (34%) of grain foods consumed were whole grain (Statistics ABo, 2016), equating to 22.7g on average, less than half of the 48g Daily Target Intake (DTI) (Galea et al., 2017).

Refined grain core foods like white bread, white pasta and white rice are chosen by the greater proportion of Australians. In addition, approximately 35% of total energy (for adults) is from discretionary foods, the leading groups being cakes, muffins, scones, cake-type desserts, pastries and biscuits. These foods are predominantly made from refined grains and contain higher levels of sugar, fat and saturated fat.

Food Standards Australia New Zealand (FSANZ) define whole grains as ‘the intact grain or the dehulled, ground, milled, cracked or flaked grain where the constituents—endosperm, germ and bran—are present in such proportions that represent the typical ratio of those fractions occurring in the whole cereal, and includes wholemeal’ (Code ANZFS, 2015). The Grains Legumes Nutrition Council (GLNC) is responsible for the regulation of whole grains in food marketed in Australia, and in 2013 established a voluntary Code of Practice for its inclusion in food claims. GLNS also conduct regular and rolling audits of grain and legume foods and ingredients to ensure compliancy across the board for all whole grain claims.

The recommendation to include mainly whole grains in diets (as opposed to refined grain foods), has consistently featured in Australian Dietary Guidelines (ADGs) since their inception in 1979 (Health DoCSa, 2018). Many countries, such as the USA, Canada, Denmark, France, Germany, Mexico, Spain, and Singapore, amongst others, also promote whole grain consumption within their respective dietary guidelines (Council OWG, 2018). Yet, whole grain does not feature in current front of pack (FOP) labelling or the Health Star Rating (HSR) system.

The HSR system assigns a star rating between 0.5 to 5 stars based on an algorithm which determines the level of certain ‘positive’ aspects of food such as fruit and vegetable content and in some cases dietary fibre and protein along with aspects of food which increase risk factors for chronic disease such as sodium, saturated fat and sugars, and assigns a star. However, whole grain content is not included in the evaluation.

Higher scores indicate healthier products within food categories, so comparisons can be made by consumers.

The aim of the study was to examine how effectively the current HSR system differentiates between refined and whole grain foods. However, as food selection is complex and influenced by multiple factors including food trends and media messages, these will also be discussed.

Method

Packaging information from grain products from four major supermarkets (Woolworths, Coles, Aldi, IGA), in the Sydney Metropolitan area representing more than 80% of total market share (Morgan, 2018), with the addition of a bakery franchise (Bakers DelightTM, Camberwell, Victoria) were collected. The nutrition and on-pack data was collected and analysed; including ingredient lists, nutrition and health claims including HSR and Nutrition Information Panels. Products were excluded from the analysis if dietary fibre per 100g, percentage of whole grain ingredients, and/or a HSR did not feature on-pack.

Food selected for analysis included all types of bread (in loaf, roll, sandwich alternative, and flatbread forms), dry and microwaveable rice (including plain and flavoured), white and wholemeal pasta (dried), all types of noodles (dry and cooked in both plain and flavoured), white and wholemeal flour (plain and self-raising), and breakfast cereals (ready-to-eat, muesli, granola, clusters, hot cereals plain and flavoured).

Products contain grains were then categorised into either whole grain (WG) or refined grain (RG), based on eligibility for registration with GLNC’s Code of Practice for whole grain claims (greater than 8g whole grain per manufacturer serve). The mean and standard deviation for fibre (per 100g) and whole grain (per 100g). The mean and range of HSR was determined for the RG and WG product within each Food subcategory.

Results and discussion

Data from 1,261 products was collected, including 359 bread, 205 pasta, 151 rice, 55 noodle, 50 flour, and 441 breakfast cereal (BFC) products in the respective food categories. After excluding products not reporting dietary fibre, percentage whole grain, and/or displaying a HSR on-pack, 441 products remained, of which more than two thirds contained WG (68%).

Overall, the mean HSR for WG products was 4.3, half a star greater than the mean HSR for RG at 3.8. Within WG and RG classified Food subcategories, there was 0.4 difference within breads, 0.3 difference within rice, 0.4 difference within flour, and 0.7 within BFC; the latter recording the greatest discrepancy of all subcategories.

While some consumer research around the influence of HSR on consumer choice has been undertaken, the multifactorial nature of food choice means results are confounded by other influencing factors such as price, environment and ethics, and rational for choices are inconsistently applied by consumers. The threshold at which consumers select foods with a certain number of stars, and the differentiation between two products with only 0.5-1-star difference has not been adequately studied. It is likely the level of difference between the WG and RG foods examined here would not be sufficient to compel consumers to swap to whole grain.

Plant-based diets and flexitarian eating styles which are growing in popularity, support the inclusion of quality grain foods consumption. Additionally, a decline in the number of consumers choosing gluten-free diets, alongside an increase in vegan and vegetarian dietary patterns are helping to increase the potential size of the whole grain market.

Conclusion

Whole grain is a key dietary component linked with protection against chronic disease and it is promoted globally for inclusion as part of a healthy diet, yet most Australians in their diet fall short of the recommended amount. FOP labelling systems such as the HSR may pose a simple strategy for encouraging healthier food choice, including the promotion of WG over RG foods, and while the current system includes dietary fibre in its algorithm, it does not directly reward foods for whole grain, a key point of consideration in the present five-year review. HSR’s ability to distinguish between foods of differing dietary fibre content as a proxy measure for proportion of whole grains in foods may present opportunities to exploit growing markets as a simple tool for marketing whole grain.

Useful resources

Grains and Legumes Nutrition Council 

References

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Aune D, Keum N, Giovannucci E, et al. Whole grain consumption and risk of cardiovascular disease, cancer, and all cause and cause specific mortality: systematic review and dose-response meta-analysis of prospective studies. Br Med J. 2016;353:i2716 DOI: 2710.1136/bmj.i2716.

Zong G, Gao A, Hu FB, Sun Q. Whole Grain Intake and Mortality From All Causes, Cardiovascular Disease, and Cancer: A Meta-Analysis of Prospective Cohort Studies. Circulation. 2016;133(24):2370-2380 DOI:2310.1161/circulationaha.2115.021101.

ZhangB., Zhao Q., Guo W., Bao W., Wang X. Association of whole grain intake with all-cause, cardiovascular, and cancer mortality: a systematic review and dose-response meta-analysis from prospective cohort studies. Eur J Clin Nutr. 2018;72:57-65 DOI:10.1038/ejcn.2017.1149;.

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Marventano S, Vetrani C, Vitale M, Godos J, Riccardi G, Grosso G. Whole Grain Intake and Glycaemic Control in Healthy Subjects: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Nutrients. 2017;9(7):769 DOI.  710.3390/nu9070769.

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Pollard CM, Pulker CE, Meng X, et al. Consumer attitudes and misperceptions associated with trends in self-reported cereal foods consumption: cross-sectional study of Western Australian adults, 1995 to 2012. BMC public health. 2017;17(1):DOI. 10.1186/s12889-12017-14511-12885.

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Contact details

Sara Grafenauer
s.grafenauer@glnc.org.au