*4.4. Implications and Recommendations*

This research highlights the need for policies, guidelines, and targets to improve the healthiness of fast food and provision of nutrition information as these do not currently exist in NZ. The Government needs to ensure the Food Industry Taskforce acts on the taskforce recommendations, and provide leadership by setting guidance for serving sizes, maximum targets for sodium content that are specific and measurable, and requiring fast-food outlets to provide nutrition information. A systematic review [14] found no standardized assessment methods or metrics to evaluate transnational chain restaurants' practices to improve the healthiness of menu items. Public health experts recommend a robust, independent regulatory system with targets set by government and regular monitoring [34].

The wide range of serving sizes within food categories in fast-food outlets makes it difficult to compare products, apply benchmarks, and for consumers to choose healthier op-

tions and appropriate serving sizes. For example, in this study the serving size ranged from 43–298 g for pizzas and from 79–513 g for fries. Advice should include maximum energy values for combos, given that some were very high in energy. A scoping review found some expert-recommended targets for restaurants to improve products, but no internationally accepted standard for serving sizes [14]. In the US, some organisations provide targets for serving sizes for healthy meals such as the Healthy Restaurant Meal Standards [35] and the Heart-Check certification [36]. The Australian Healthy Food Partnership had a portion size working group (now disbanded) [37] to develop recommended portion sizes, including for fast food, and published targets for some nutrients and limited fast-food categories [38]. The UK has calorie reduction guidance for the eating out of home sector [39].

The substantial amount of sodium in the fast-food supply and the increasing consumption of takeaways in NZ warrants reformulation of fast foods to lower sodium and monitoring of the sodium content of fast-food products [40]. Excess sodium intake is a major preventable risk factor for hypertension [41], a leading cause of heart disease and stroke in NZ [1]. Few countries have targets for out-of-home foods. The UK sodium reduction targets are government-led, though voluntary but are regularly monitored [23]. WHO have recently published global sodium benchmarks but only a small number are applicable to fast food [42]. In addition, warning labels should be placed on those products and combos that exceed sodium targets. In 2015 New York City passed a sodium warning label rule, requiring chain restaurants to add a salt shaker icon beside menu items or combos containing more than 2300 mg of sodium [43].

Consumers have a right to know what is in their food and menu nutrition labeling is a strategy to provide this and can also encourage reformulation. Research in the U.S. suggests that the 2010 national menu labeling law may have influenced chain restaurants to reduce the energy content of newly introduced items [44–46]. Menu labeling is under consideration by Food Standards Australia NZ, with a consultation conducted in 2021 on a range of options for labeling the energy content of foods on the menu, including voluntary and mandatory options [47]. Menu labeling, particularly for energy content, is mandatory for fast-food chains in some countries such as Australia (5 jurisdictions) [47], Canada [48] and the U.S. [49] and will be mandatory for large businesses in the UK from 2022 [50].

Other areas that could improve the healthiness of fast-food menu offers include reformulation to reduce saturated fat and sugar content across menu items, healthier items (such as ASBs) to be the default option in combos and deals, introduction of healthier menu items, and marketing and pricing strategies to encourage purchasing of healthier items.
