We developed the NOURISHING framework to highlight where governments need to take action to promote healthy diets and reduce overweight and obesity.
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The evidence suggests people who want to eat well use nutrient lists to choose healthier options. Interpretative labels help them when they find the labels hard to understand. Nutrition labels also create incentives for food manufacturers to reformulate their products, so helping populations more broadly by increasing the availability of food of higher nutritional value.
Clear standards are also needed on the use of nutrient and health claims. Evidence shows these claims alter the perception people have of these products – making it essential that they do not mislead.
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*Most other countries follow Guideline CAC/GL 2-1985 from the Codex Alimentarius Commission in requiring nutrition labels only when a nutrition or health claim is made and/or on food with special dietary uses
Producers and retailers are required by law to provide a list of the nutrient content of pre-packaged food products (with limited exceptions), even in the absence of a nutrition or health claim. The rules define which nutrients must be listed and on what basis (eg per 100g/per serving).
Huang L et al. (2014) A systematic review of the prevalence of nutrition labels and completeness of nutrient declarations on pre-packaged foods in China. Journal of Public Health 37(4), 649-658
EU Regulation 1169/2011 on the Provision of Food Information to Consumers, passed in 2011, requires a list of the nutrient content of most pre-packaged food to be provided on the back of the pack from 13 December 2016. This Regulation is also applicable in Iceland, Norway and Liechtenstein as members of the European Economic Area. In Switzerland, nutrient content labelling is only mandatory for products bearing nutrient or health claims or sold to the EU (but most manufacturers already label nutrient content on their food products voluntarily).
In Malaysia, a nutrient list detailing energy, protein, carbohydrates and fat per 100g/100ml and per serving must be provided on select categories of packaged food, including bread, confectionery, dairy products, canned food, fruit juices, salad dressings and mayonnaise; ready-to-drink beverages must also include total sugars. A nutrient list is also mandatory for any product bearing a nutrition claim, products with added vitamins and minerals, and special purpose food for infants and young children. Details are provided in the Malaysian Guide to Nutrition Labelling and Claims (2010), which reflects labelling legislation from 2003 (as incorporated into the Food Act of 1983 and Food Regulations of 1985) and subsequent amendments.
In South Korea, a nutrient list must be provided on select categories of pre-packaged food, including cookies/candies/popsicles, breads and dumplings, cocoa products, jams, oils, noodles and pasta, drinks and beverages, and food of special use. The Foods Labelling Standards were first enacted in 1996, and the Labelling Standard for Health Functional Food in 2004; both Standards have been revised several times since then. Based on the 1st Master Plan on Reducing Sugar Intake 2016–20 and the 2016 White Paper by the Ministry of Food and Drug Safety, further categories will be required to bear nutrient lists with a three-stage implementation between 2017 and 2022 (including cereals, ready-to-eat products and ready-to-cook products in 2017; dressings and sauces in 2018–19; Korean-style boiled grain-/meat-/fish-based food and processed food based on fruit or vegetable purees/pastes in 2020–22).
Nutrient lists on pre-packaged food must, by law, include the trans fat content of the food. The rules generally define how the trans fat content must be listed, and on what basis (eg per 100g/100ml or per serving). If the trans fat content falls below a certain threshold, it may be listed as 0g (eg less than 0.5g per serving, or less than 0.3g per 100g of food product). Chile requires mandatory trans fat labelling only once the total fat content per serving exceeds 3g.
Doell D et al. (2012) Updated estimate of trans fat intake by the US population. Food Additives and Contaminants 29(6), 861-874
Van Camp et al. (2012) Changes in fat contents of US snack foods in response to mandatory trans fat labelling. Public Health Nutrition 15(6), 1130-1137
Lee JH et al. (2010) Trans Fatty Acids Content and Fatty Acid Profiles in Selected Food Products from Korea between 2005 and 2008. Journal of Food Science 75(7), C647-C652
Ricciuto L et al. (2008) A comparison of the fat composition and prices of margarines between 2002 and 2006, when new Canadian labelling regulations came into effect. Public Health Nutrition 12(8), 1270-1275
Friesen R, Innis SM (2006) Trans Fatty Acids in Human Milk in Canada Declined with the Introduction of Trans Fat Food Labeling. The Journal of Nutrition 136(10), 2558-2561
In 2014, the governments of Australia and New Zealand started to implement a Health Star Rating (HSR) system as a voluntary scheme for industry adoption. It is a joint Australian, state and territory governments and New Zealand government initiative developed in collaboration with industry, public health and consumer groups. The HSR system takes into account four aspects of a food associated with increasing risk for chronic diseases; energy, saturated fat, sodium and total sugars content along with certain "positive" aspects of a food such as its content of fruit, vegetables, nuts and legumes, and, in some instances, dietary fibre and protein. Star ratings range from ½ star (least healthy) to 5 stars (most healthy). Implementation is overseen by the Australia and New Zealand Ministerial Forum on Food Regulation, the Front-of-Pack Labelling Steering Committee, the Trans-Tasman Health Star Rating Advisory Committee, the New Zealand Health Star Rating Advisory Group and a Technical Advisory Group. The Technical Advisory Group is currently evaluating progress as well as conducting a formal review of the HSR system, including an assessment of the underlying algorithm. Recommendations for the HSR system’s improvement will be presented in 2019.
Hamlin, R & McNeill, L (2016) Does the Australasian “Health Star Rating” Front of Pack Nutritional Label System Work? Nutrients, 8(6), 327
The Choices logo, a voluntary, industry-initiated scheme, is widely used in Belgium, Czech Republic, Netherlands and Poland. The logo identifies healthier options in each food group. Products must meet nutritional criteria set by an independent scientific committee. In the Netherlands, the Choices logo was introduced in 2006, and is now actively supported by the Dutch government. It received EU approval for use in 2013. In Belgium, the logo was introduced in 2007, in the Czech Republic in 2011, and in Poland in 2008.
Vyth, EL et al. (2010) Actual use of a front-of-pack nutrition logo in the supermarket: consumers’ motives in food choice. Public health nutrition, 13(11), 1882-1889
Vyth, EL et al. (2009) A front-of-pack nutrition logo: a quantitative and qualitative process evaluation in the Netherlands. Journal of health communication, 14(7), 631-645
The Ministry of Health of Brunei Darussalam introduced a Healthier Choice Symbol in February 2017. Products bearing the logo indicate that the products meet a set of nutrient criteria, which were adapted from Singapore’s Healthier Choice Symbol Nutrient Guidelines. Nutrient criteria exist for >60 sub-categories of foods and beverages. Food and beverages manufacturers wishing to use the symbol must acquire a food analysis report from an accredited food testing laboratory to submit with their application, which is reviewed by the Healthier Choice Committee. Approved products are permitted to use the Ministry of Health’s Healthier Choice Logo and specific nutrition claims (eg. “lower in saturated fat”, “higher in calcium").
In 2012, the Chilean government approved a Law of Nutritional Composition of Food and Advertising (Ley 20.606). In June 2015, the Chilean authority approved the regulatory norms required for the law’s implementation (Diario Oficial No 41.193) which came into effect on 27 June 2016. The regulatory norms define limits for calories (275 calories/100g or 70 calories/100ml), saturated fat (4g/100g or 3g/100ml), sugar (10g/100g or 5g/100ml) and sodium (400mg/100g or 100mg/100ml) content considered “high” in food and beverages. All food and beverages that exceed these limits are required to have a front-of-package black and white warning message inside a stop sign that reads “HIGH IN” followed by CALORIES, SATURATED FAT, CALORIES, SUGAR or SODIUM, as well as “Ministry of Health”. A warning message will be added to products per category that exceeds the limit (eg a product high in fat and sugar will have two stop signs). The regulatory norms provide specifications for the size, font and placement of the warning message on products. The limits for calories, saturated fat, sugar and sodium will be implemented using an incremental approach, reaching the defined limits by 1 July 2018 (see "O – Offer healthy food and set standards in public institutions and other specific settings" and “R – Restrict food advertising and other forms of commercial promotion” for details of the law's school food and advertising restrictions).
The Swedish government set nutritional criteria for the use of the Keyhole logo established in Sweden in 1989 and launched as a common Nordic label on 17 June 2009 in Sweden, Denmark and Norway. The Lithuanian Ministry of Health signed the agreement to join the Keyhole programme in 2013 and approved criteria for products to bear the logo in 2014. In Iceland, the programme entered into force in November 2013. The aim of the Keyhole logo is to help consumers choose products that contain less fat, salt and sugar. Use of the logo is voluntary, but products must conform to the nutrition criteria, which are identical among participant countries of the programme. New, stricter requirements came into force on 1 March 2015, with a transition period until 1 September 2016 for products adhering to the old requirements. Under the new requirements, Keyhole products will need to contain less salt, sugar and saturated fat, and more whole grains. For the first time, criteria were introduced for maximum salt content in meat and fish products.
A regulation of the Ministry of Public Health of Ecuador published in November 2013 (No. 4522, El Reglamento de Etiquetado de Alimentos Procesados) requires packaged food to carry a “traffic light” label in which the levels of fats, sugar and salt are indicated by red (high), orange (medium) or green (low). Full compliance with the regulation was required by 29 August 2014.
Added February 2018: Freire WB, Waters WF, Rivas-Mariño G, Nguyen T, & Rivas P (2017) A qualitative study of consumer perceptions and use of traffic light food labelling in Ecuador. Public health nutrition, 20(5), 805-813
EU Regulation 1169/2011 on the Provision of Food Information to Consumers, passed in 2011, permits EU Member States to develop voluntary guidelines for front of pack nutrition information, to be used in addition to the mandatory nutrition information on the back of pack. Information on energy value, fat, saturated fat, sugar and salt content is permitted. Different styles of presentation (eg % Guideline Daily Allowances or traffic lights) are permitted. This Regulation is also applicable in Iceland, Norway and Liechtenstein as members of the European Economic Area and Switzerland based on its bilateral agreements with the EU.
National legislation regarding the compulsory use of warning labels on high-salt food in Finland has been in place since 1993. The legislation is applied to all the food categories that make a substantial contribution to the salt intake of the Finnish population. Food that is high in salt is required to carry a "high salt content" warning if the salt content is more than 1.1% in bread, 2% in sausages, 2.2% in cold meat cuts, 2% in fish products, 1.4% in cheese, 1.2% in ready to eat meals, and 1.4% in breakfast cereals or crisp bread. These limits were last updated in December 2016 and since then also apply to unpackaged cheese, sausages, and other meat products, where the information must be communicated in writing at the retail outlet in a readily accessible manner close to the unpacked food.
A heart symbol system was introduced in 2000 by the Finnish Heart Foundation and the Finnish Diabetes Foundation. The heart symbol indicates that a product is a better choice regarding sodium and salt content compared with another product in the same food category. The heart symbol system is acknowledged by the Finnish national authorities, and the National Nutrition Council recommends consumers to use products bearing the heart symbol.
On 26 January 2016, the French Ministry of Health introduced Article 5 of the Health Act that recommended introducing a system of nutrition labelling. The Directorate-General for Health requested Public Health France to design the nutrition labelling and the decision to recommend the NutriScore system was informed by research that trialled four different types of nutrition labels in 80 supermarkets in September 2016. The NutriScore system was chosen as the most consumer-friendly. The NutriScore label uses a nutrient-profiling system, based on the UK Food Standards Agency model. It classifies food and drinks according to five categories of nutritional quality, indicated via a colour scale ranging from dark green to dark red. Each colour is also associated with a letter from A (dark green) to E (dark red) to make the labelling more accessible and understandable to consumers. The score takes into account for every 100 grams of produce whether the contents of the product include nutrients and food that should be favoured (positive nutrients including fibre, protein, fruit and vegetables) or nutrients that should be limited (negative nutrients including energy, saturated fatty acids, sugars, salt). The amount of nutrients per 100 grams contained in the product is scored using a points system (0–40 for negative nutrients and 0–15 for positive nutrients that should be favoured). The nutritional score of the product is calculated by subtracting the negative nutrient points from the positive nutrient points. All processed food is included, except aromatic herbs, teas, coffees and yeasts, and all beverages, except alcoholic beverages.
Added February 2018: The European Commission approved the use of the NutriScore label and on 31 October 2017 the French government signed a decree outlining that the NutriScore label would be used in France. The label is voluntary and to date six major retailers and manufacturers have already entered into a Charter of Commitment to use the labelling on their products.
On 20 April 2017, the Minister of Health of Malaysia launched the Healthier Choice Logo in collaboration with food and beverages industries in Malaysia. The objectives of the Healthier Choice Logo are to: help consumers quickly identify healthier products within the same food category; assist consumers in making informed food choices through authentication of the logo displayed on the food products; educate the public on the use of approved products within a healthy and balanced eating pattern; and encourage and promote good practices among food industries in producing “healthier choice” products. Implementation of the Healthier Choice Logo is voluntary. Products bearing the logo indicate they meet a set of nutrient criteria, which exist for 42 sub-categories of foods and beverages. As of 15 May 2017, 48 products from various food and beverage companies have the Healthier Choice Logo.
The Nigerian Heart Foundation developed the voluntary Heart Check front-of-pack labelling programme in collaboration with the National Agency for Food and Drug Administration and Control (NAFDAC). Products must meet nutritional criteria, set by the Nigerian Heart Foundation and approved by NAFDAC, on added sugar, sodium, fat as well as dietary fibre; oils and related products must meet criteria on trans fat and cholesterol. The Nigerian Heart Foundation grants permission to use the Heart Check logo on packaged food following a joint approval by NAFDAC and Nigerian Heart Foundation. The logo is in use since 2005; the criteria were last amended in January 2016.
The government of Singapore introduced a Healthier Choice symbol in 1998 with defined nutrition criteria. Food manufacturers and retailers can voluntarily use the label on front-of-pack for products that meet the nutritional criteria. In 2003, the use of the symbol was extended to food service operators such as hawkers and restaurants. Food service operators can display the symbol next to dishes meeting the criteria. There is also a Healthy Snack symbol for products that are individually packed in small portions and meet specific nutrition guidelines. A refreshed Healthier Choice symbol, based on revised nutrient guidelines, was launched in September 2015 and existing products with the current symbol will have to be depleted by 1 January 2018. Products carrying the current symbol will need to re-apply to carry the revised symbol. Currently there are nutrition guidelines covering >60 food categories.
In 1993, the Slovenian Heart Foundation initiated the Little Heart logo (formerly Protects Health label), a stylised heart that can be used on pre-packed food and menus in public canteens that meet the requirements of the European Commission’s Regulation No. 1924/2006 on Nutrition and Health Claims made on Foods. Underneath the heart symbol, the specific nutritional properties are listed that the product meets (eg low fat content, rich in fibre) and which make it a healthier choice compared with other food products in the same category. The initiative is supported by the Slovenian Ministry of Health and the Ministry of Agriculture, Forestry and Food.
The South Korean Special Act on Safety Control of Children's Dietary Life recommends colour-coded labelling for use on the front of pre-packaged children's "favourite food" including cookies/candies/popsicles, breads, chocolates, dairy products, sausage (fish or meat based), some beverages, instant noodles and fast food (seaweed rolls, hamburgers, sandwiches). Guidance for the front-of-pack colour-coded labelling was issued by Public Notice (2011), and outlines three permitted designs using green, amber and red to identify whether products contain low, medium or high levels of total sugars, fat, saturated fat, and sodium.
Added February 2018: On 1 May 2016, a traffic light labelling system for beverages was implemented in Sri Lanka after the government introduced a regulation under Section 32 of the Food Act, No. 26 of 1980. The regulation states that drinks that contain more than 11g of sugar per 100ml of drink should have a red label, drinks that contain 2–11g per 100ml should have an amber label and drinks containing less than 2g per 100ml should have a green label. The regulations have been enforced with raids carried out on retailers by Ministry of Health officers, and legal action is threatened for those who do not comply with the regulation under Section 32, as above.
A Notification to the Ministry of Public Health (2007) issued by the Thai Food and Drug Administration requires five categories of snack food to carry a Guideline Daily Allowance (GDA) label. The label includes text aimed to help consumers understand the GDA and requires a warning label that reads "Should consume in small amounts and exercise for better health”.
In August 2016, the voluntary Healthier Choices logo was launched in Thailand, a front-of-pack labelling scheme to help consumers identify healthier food choices (Notification of the Ministry of Public Health No. 373, B.E.2559 2016, Re: The Display of Nutrition Symbol on Food Label, 12 February 2016). The logo was developed in collaboration between the National Food Commission, the Ministry of Health's Food and Drug Administration, the Health Promotion Foundation and Mahidol University. The Healthier Choices logo is owned by the Thai Food and Drug Administration, and its use is managed by the Nutrition Promotion Foundation of Mahidol University. The logo can be applied to beverages, sauces and condiments, dairy products, ready-to-eat meals, instant food and snacks; it is intended to eventually cover all food products. To be eligible for the logo, fish sauce must not contain more than 6g of sodium per 100ml, and soy sauce not more than 5g sodium per 100ml. Beverages must not contain more than 6g of sugar per 100ml if they are sold in single-serving containers; in beverages sold in containers that exceed 150% of a single serving, sugar must not exceed 18g per container. All other food must not exceed 500kcal and has to reach at least 20 points out of an achievable 40 points on the required nutrient content. The point system contains minimum and maximum levels of total fat, saturated fat, total sugar, protein, sodium, calcium fibre and iron in six categories, ranging from 0 (worst) to 5 (best).
In 2015, the Health Authority Abu Dhabi (HAAD) introduced the voluntary Weqaya food programme which allows food producers to use the Weqaya logo on products which satisfy the criteria set out in the Specification for using the Weqaya food programme (ADS 13/2015). The logo consists of a heart shape in which the word ‘Weqaya’ is written, meaning ‘prevention’ in Arabic. The specifications require that products must adhere to maximum levels of calories, total fat, saturated and trans fat, sodium, added, total and naturally occurring sugars, and cholesterol. In addition, they may not be deep fried or contain artificial sweeteners and flavours. Flour, rice and grain-based products must contain minimum amounts of whole grains and fibre to be permitted to bear the logo. The only beverages allowed under the programme are unsweetened 100% vegetable juices, and unsweetened low fat milk and other fermented dairy products.
In 2013, the UK government published national guidance for a voluntary Front of Pack Nutrition Labelling Scheme for pre-packaged products. The guidelines are for colour-coded labels which use green, amber and red to identify whether products contain low, medium or high levels of energy, fat, saturated fat, salt and sugar.
Through the English government’s voluntary pledge programme, the Responsibility Deal, 23 companies have made voluntary commitments ("pledges") to adopt the government’s recommended Front of Pack Nutrition Labelling Scheme (last company signed up in February 2014). This pledge was created in June 2013 and continues to exist even though the Responsibility Deal, while not officially terminated, has not seen any activity since elections in May 2015 replaced the 2010–15 coalition government.
Knai C et al. (2015) Has a public-private partnership resulted in action on healthier diets in England? An analysis of the Public Health Responsibility Deal food pledges. Food Policy 54, 1-10
The Food Safety Act 2009 in Fiji and the Pure Food (Food Control) Regulations 2009 in the Solomon Islands require on-shelf labelling for canned luncheon meat, canned meat containing other food that has more than 20% fat, and for all minced meats and sausages sold unpackaged. The label should read "This brand of canned luncheon meat/canned meat with (name of the other food) is high in fat. For a healthy diet eat less". It is reported to not be widely implemented.
Legislation in the Australian Capital Territory (amendments to Food Regulation 2002 in effect since February 2012) and the states of New South Wales (Food Regulation 2010, in effect since February 2011), South Australia (amendments to Food Regulation 2002 in effect since February 2012) and Queensland (amendments to Food Act 2006, passed in March 2016, enforceable from March 2017) require restaurant chains (eg fast food chains, ice cream bars) with ≥20 outlets in the state (or seven in the case of ACT), or 50 or more across Australia, to display the kilojoule content of food products on their menu boards. The display must be clear and legible. Average adult daily energy intake of 8,700kJ must also be prominently featured. Other chains/food outlets are allowed to provide this information on a voluntary basis, but must follow the provisions of the legislation.
Wellard L et al. (2015) The availability and accessibility of nutrition information in fast food outlets in five states post-menu labelling legislation in New South Wales. Australian and New Zealand Journal of Public Health 39(6):546-549
New South Wales Food Authority (2013) Evaluation of Kilojoule Menu Labelling. Newington. NSW: NSW Food Authority.
In 2010, the Nutrition Section of the Ministry of Health of Bahrain developed voluntary menu labelling recommendations for fast food chain restaurants. Nutrients are mostly displayed per portion and include calories, fat, protein, carbohydrates, salt and sugar. Menu labelling may be done in a variety of ways such as on panels at ordering counters and checkouts or on food tray sheets. The main fast food chains operating in Bahrain have implemented the menu labelling recommendations (such as Burger King, McDonald’s, Diary Queen, Kentucky Fried Chicken, Subway and Jasmi’s).
In effect since 1 January 2017, Ontario’s Healthy Menu Choices Act, 2015 (passed in May 2015 as part of the Making Healthier Choices Act, 2015 (Bill 45) and accompanied by Ontario Regulation 50/16) requires food service premises that are part of a chain of 20 or more food service premises in Ontario (as well as certain cafeteria-style food service premises) to display calories for “standard food items” on menus, labels and display tags. Regulated food service premises include restaurants, quick-service restaurants, convenience stores, grocery stores, movie theatres, public-facing cafeterias, food trucks and others. “Standard food items” are restaurant-type food or drink items (eg ready-to-eat items) that are sold or offered for sale in servings that are standardised for portion and content. Menus include paper menus, menu boards, electronic menus, drive-through menus, online menus or menu applications, advertisements and promotional flyers. Food service premises must also display information on daily caloric requirements. Ontario’s 36 public health units are responsible for implementation of the Act. The Ministry of Health and Long-Term Care developed an implementation guide, fact sheets and a frequently asked questions document to facilitate and streamline implementation.
Based on the voluntary 2008 Guidelines of Advertisement and Nutrition Labelling for Fast Food Restaurants, Malaysian fast food restaurants are encouraged to display nutrient information on energy, carbohydrates, protein, fat and sodium for food and total sugar for beverages. Restaurants are free to decide how they display this information (eg on-pack labelling, brochures, posters in the outlet). Implementation of the Guidelines is not monitored but the Ministry of Health periodically engages with the fast food industry to urge companies to implement the Guidelines.
Since 2010, the South Korean Special Act on Safety Control of Children’s Dietary Life has required all chain restaurants with 100 or more establishments to display nutrient information on menus including energy, total sugars, protein, saturated fat and sodium on menus.
Since July 2015, convenience store chains, drink vendor chains and fast food chains have to label the sugar and caffeine content of prepared-when-ordered drinks (eg coffee- and tea-based drinks, fruit and vegetable juices) according to a regulation based on the Act Governing Food Safety and Sanitation. The amount of sugar added to drinks (specified in sugar cubes) and its calorie content have to be displayed on drink menus and/or notice boards in a prescribed minimum font. In addition, different colours have to be used to signal the level of caffeine contained in coffee drinks. It is reported that many stores are not compliant with these labelling requirements due to lack of resources.
In England, as part of the government’s Responsibility Deal, 45 out-of-home businesses have committed to provide calorie information on menus and display boards, including some leading companies (last company signed up in December 2013). Although voluntary, the label must follow a standard government model. The Out of Home Calorie Labelling pledge was implemented in September 2011 and continues to exist even though the Responsibility Deal, while not officially terminated, has not seen any activity since elections in May 2015 replaced the 2010–15 coalition government.
Section 4205 of the US Patient Protection and Affordable Care Act (2010) created a new clause 403(q)(5)(H) in the Federal Food, Drug, and Cosmetics Act (1938) which requires that all chain restaurants with 20 or more establishments display energy information on standard menu items. The implementing regulations were published by the Food and Drug Administration on 1 December 2014. Implementation, delayed several times, is now set for 7 May 2018. Two states (California, Vermont), seven counties (eg King County, WA and Albany County, NY) and two municipalities (New York City, Philadelphia) have already implemented regulations requiring chain restaurants (often chains with more than a given number of outlets) to display calorie information on menus and display boards. These regulations will be pre-empted by the national law once implemented; local governments will still be able to enact menu labelling regulations for establishments not covered by national law (eg food trucks or restaurants not part of a chain which have not self-certified to voluntarily comply with the calorie labelling requirements). The regulations also require vending machine operators of more than 20 vending machines to post calories for food where the on-pack label is not visible to consumers. Implementation for vending machine operators is required by 26 July 2018.
In 2008, New York City was the first jurisdiction to require calorie labelling in chain restaurants. The calorie labelling rule within the NYC Health Code was updated in 2015, with enforcement as of 22 May 2017. All covered food service establishments must now include two new nutrition statements on menus and menu boards (“2,000 calories a day is used for general nutrition advice, but calorie needs vary” and “Additional nutritional information available upon request”), have comprehensive nutrition information on-site and provide it to anyone who requests it, and provide calorie information for multiple-serving standard menu items, combination meals with choices, self-service food, food on display, menu items with a choice of toppings and temporary menu items. This rule affects any establishment that requires a Health Department permit and is part of a chain with ≥15 locations in the US. The updated rule also covers chain food retail establishments that offer restaurant-type food.
Elbel B et al. (2013) Calorie Labeling, Fast Food Purchasing and Restaurant Visits. Obesity (Silver Spring) 21(11): 2172-2179
Krieger JW et al. (2013) Menu Labeling Regulations and Calories Purchased at Chain Restaurants. American Journal of Preventive Medicine 44(6), 595-604
Dumanovsky et al. (2011) Changes in energy content of lunchtime purchases from fast food restaurants after introduction of calorie labelling: cross sectional customer surveys. BMJ 343:d4464
Finkelstein et al. (2011) Mandatory Menu Labeling in One Fast-Food Chain in King County, Washington. American Journal of Preventive Medicine 40(2), 122-127
Elbel B et al. (2009) Calorie Labeling And Food Choices: A First Look At The Effects On Low-Income People In New York City. Health Affairs 28(6), 1110-1121
In January 2016, the parliament of Latvia approved the Law on the handling of energy drinks, implemented on 1 June 2016. Retailers are required to display all energy drinks separately from other food items, and display a note at the point of sale stating "High caffeine content. Not recommended for children and pregnant and breastfeeding women''. The Law also contains marketing restrictions (see “R – Restrict food advertising and other commercial promotion”).
Following an amendment to Article 81 of the New York City Health Code (addition of section 81.49), chain restaurants are required to put a warning label on menus and menu boards, in the form of a salt-shaker symbol (salt shaker inside a triangle), when dishes contain 2,300mg of sodium or more. It came into effect on 1 December 2015 and applies to food service establishments with 15 or more locations nationwide. In addition, a warning statement is required to be posted conspicuously at the point of purchase: “Warning: [salt shaker symbol] indicates that the sodium (salt) content of this item is higher than the total daily recommended limit (2300 mg). High sodium intake can increase blood pressure and risk of heart disease and stroke.” As of May 2017, nine out of ten NYC chain restaurants were in compliance.
Nutrition, Health and Related Claims Standard 1.2.7 (2013) introduces rules on the use of nutrition content claims (ie levels of fat for a low-fat claim) in Australia and New Zealand. Industry were given until January 2016 to comply with the Standard. Although nutrition content claims need to meet certain criteria set out in the Standard, there are no generalised nutritional criteria that restrict their use on "unhealthy" food.
A 2012 Central American Technical Regulation (67.01.60:10) establishes rules on the use of specified nutrient content claims (ie levels of fat for a low-fat claim). Claims are not permitted on products that may promote or sanction excessive consumption of these nutrients or undermine good dietary practice. Although nutrition content claims need to meet certain criteria set out in the Regulation, there are no generalised nutritional criteria that restrict their use on "unhealthy" food.
Regulation 1924/2006 establishes EU-wide rules on the use of specified nutrient content and comparative claims (ie levels of fat for a low-fat claim). As of January 2010, only nutrition claims as listed in the Regulation’s annex are permitted. In theory, these nutrition claims may only be used on food defined as "healthy" by a nutrient profile. This nutrient profiling restriction was due to be implemented in 2010 but no model has yet been established. Therefore, permitted nutrition claims can be used as long as the conditions for use of the claim as set out in the annex are met. Once nutrient profiles are established, nutrition claims may only be used on food products deemed "healthy", though two notable exceptions will apply: nutrition claims referring to the reduction of fat, saturated fats, trans fats, sugars and salt/sodium will be allowed without reference to a profile for the specific nutrient, provided the claims comply with the conditions of the Regulation; and a nutrition claim may be used even if a single nutrient exceeds the nutrient profile as long as a statement in relation to this nutrient appears on the label in close proximity to, on the same side and with the same prominence, as the claim (the statement must read: 'High [name of nutrient] content'). This Regulation is also applicable in Iceland, Norway and Liechtenstein as members of the European Economic Area; Switzerland amended its foodstuff law based on its bilateral agreements with the EU to include permitted EU nutrient claims.
The Indonesian Regulation HK.03.1.23.11.11.09909 (2011) on The Control of Claims on Processed Food Labelling and Advertisements establishes rules on the use of specified nutrient content claims (ie levels of fat for a low-fat claim). The Regulation applies to any food product or beverage that has been processed. Generally, any nutrition or health claim may only be used on processed food or beverages if they do not exceed a certain level of fat and natrium per serving (13g total fat, 4g saturated fat, 60mg cholesterol and 480mg natrium). The Regulation sets out certain exceptions from this rule, detailed in its annexes, whereby products exceeding these limits may still contain certain nutrient or health claims ("low in [name of nutrient]" and "free from [name of nutrient]" claims; claims related to fibre, phytosterol and fitostanol; certain disease risk reduction claims).
The Malaysian Guide to Nutrition Labelling and Claims (as at December 2010) establishes rules on the use of nutrient content claims (ie levels of fat for a low-fat claim) and nutrient comparative claims (eg comparison between an old and new product formulation). The Guide also contains a list of permitted nutrient function claims (ie a claim about the physiological role of a nutrient), including the minimum required amount and additional conditions to be fulfilled (eg the source of the nutrient). Disease risk reduction claims are prohibited. Although nutrition content claims need to meet certain criteria set out in the Guide, there are no generalised nutritional criteria that restrict their use on "unhealthy" food. Labelling legislation was overhauled in 2003 and all new legislation was incorporated into the existing Food Act of 1983 and Food Regulations of 1985. The Malaysian Guide to Nutrition Labelling and Claims (as at December 2010) contains the legislation as of 2003 as well as all amendments up to December 2010.
Regulation NOM-051-SCFI/SSA1 (2010) sets rules for the use of nutrition content claims. It prohibits the use of false and misleading claims on labels, especially those that relate to dietary guidance, eating habits and nutritional properties of food. No disease risk reduction claims are allowed. Although nutrition content claims need to meet certain criteria set out in the Regulation, there are no generalised nutritional criteria that restrict their use on "unhealthy" food.
Section 15(1) of the Foodstuffs, Cosmetics, and Disinfectants Act (by means of regulation of 2010, effective from March 2012) defines the nutrient content claims permitted in South Africa and establishes rules for their use (eg levels of fat permitted in a food product bearing a low fat claim). Nutrient content claims must be substantiated by nutritional information, and the use of terms such as "health", "healthy", "wholesome" or "nutritious" is not allowed. Although nutrition content claims need to meet certain criteria set out in the regulation, there are no generalised nutritional criteria which restrict their use on "unhealthy" food.
The rules on the use of nutrient claims were established in July 2000 under Section 4 of the South Korean Food Sanitation Act (food labelling). The law regulates which claims are permitted, defines the conditions that must be met for the claim, and governs the language that may be used.
In the US, nutrient content claims are generally limited to an FDA-authorised list of nutrients (Food Labeling Guide 1994, as last revised in January 2013). Packages containing a nutrient content claim must include a disclosure statement if a serving of food contains more than 13g of fat, 4g of saturated fat, 60mg of cholesterol or 480mg of sodium. Sugar and whole grain content are not considered.
The Australian Nutrition, Health and Related Claims Standard 1.2.7 (2013) includes rules for the use of general level (ie nutrient function) and high level (ie disease risk reduction) health claims on food labels and in advertisements. Industry were given until January 2016 to comply with the Standard. High level health claims must be pre-approved and listed. General level health claims can either be pre-approved and listed in the Standard or self-substantiated according to requirements of the Standard. Both types of health claims are only permitted on food that meet nutritional criteria, as defined by the nutrient profiling scoring criterion set out in the Standard.
A 2012 Central American Technical Regulation (67.01.60:10) permits and regulates the use of nutrient function and disease risk reduction claims. Claims must be substantiated through information demonstrating the nutritional composition of the food, and the relationship between the claimed function of the food product and the beneficial effect on diet and health. The Ministry of Health has responsibility to approve the use of claims on food containing high levels of nutrients that can increase risk of illness or health problems. Claims are not permitted on products that may promote or sanction excessive consumption of these nutrients or undermine good dietary practice. There are no generalised nutritional criteria that restrict their use on "unhealthy" food.
Regulation 1924/2006 (applicable as of July 2007) establishes EU-wide rules on the use of health claims (claims on nutrient function, disease risk reduction and children’s health). Companies may only use health claims that are substantiated and authorised by the European Commission and Member States (various regulations authorising health claims to date). The European Food Safety Authority is responsible for verifying the scientific substantiation of claims; it has done so for claims currently in use and continues to do so for claims that are proposed and applied for by companies that want to use health claims in the EU. In theory, health claims may only be used on food defined as "healthy" by a nutrient profile. This nutrient profiling restriction was due to be implemented in 2010 but no model has yet been established. Therefore, permitted health claims can be used as long as the conditions for use of the claim as set out in the respective regulations are met. Once nutrient profiles are established, health claims may only be used on food products deemed "healthy". This Regulation is also applicable in Iceland, Norway and Liechtenstein as members of the European Economic Area. Switzerland amended its foodstuff law based on its bilateral agreements with the EU to include permitted EU health claims.
The Indonesian Regulation HK.03.1.23.11.11.09909 (2011) on The Control of Claims on Processed Food Labelling and Advertisements permits a limited number of listed nutrient function and disease risk reduction claims. The Regulation applies to any food product or beverage that has been processed. Generally, any nutrition or health claim may only be used on processed food or beverages if they do not exceed a certain level of fat and natrium per serving (13g total fat, 4g saturated fat, 60mg cholesterol and 480mg natrium). The Regulation sets out certain exceptions from this rule, detailed in its annexes, whereby products exceeding these limits may still contain certain nutrient or health claims ("low in [name of nutrient]" and "free from [name of nutrient]" claims; claims related to fibre, phytosterol and fitostanol; certain disease risk reduction claims).
The rules for the use of health claims are set out in the South Korean Health Functional Food Code, based on Article 17 of Section 3 (Standards, Specifications, Labelling and Advertisements) of the Health Functional Food Act 2004 (which has been amended several times). The Act allows for claims to be expressed in both words and diagrams. The Code lists the wording for allowed claims, sets out standards for manufacturing to be observed for each nutrient, and how much the actual nutrient content of the product may deviate from the labelled content (in percentage, ie beta-carotene must be within 80–150% of the labelled amount). The Code includes the recommended daily intake amount, generally expressed as a range between the minimum to maximum amount. If intake of a nutrient may cause negative health effects, a warning label has to be applied.
The use of disease risk reduction claims is permitted in the US. They are governed by specific rules in the Nutrition Labeling and Education Act (1990) and the Food and Drug Administration Modernization Act (1997). There are three categories of claims permitted:
Health claims are generally not permitted if a food contains more than 13g of fat, 4g of saturated fat, 60mg of cholesterol, or 480mg of sodium. Sugar and whole grain content are not considered.
Companies may make nutrient function claims without notifying FDA, but such claims must be truthful and not misleading. Dietary guidance statements (eg, "Doctors recommend 3 servings of whole grains per day") are also permitted without FDA pre-approval but must be truthful and not misleading.
We know from the evidence that making fruit and vegetables available in schools increases consumption. There is also evidence that food standards to restrict availability have the effect of reducing consumption of the restricted food.
For these actions to be effective for all children, they need to be sustained over time and accompanied by complementary behaviour change communication techniques, such as "modelling", school gardens, and communication to all stakeholders involved in the provision and consumption of school food. Worksites and healthcare also present strong potential for improved eating among adults.
Crunch&Sip® is a vegetable and fruit programme in Australia promoting the consumption of fruit, vegetables and water during class time ("Crunch&Sip time"). It involves students bringing in fruit, vegetables and water from home. It was launched in 2005 in Western Australia, and is currently funded by Healthway (a government agency that funds activities related to the promotion of good health, with a particular focus on young people) as part of the Australian government’s Go for 2&5® fruit and vegetable campaign, and coordinated by the Cancer Council Western Australia. It has since been extended to New South Wales (through the Healthy Kids Association) and South Australia (through the South Australian Dental Service). Funding is currently provided by each of the state governments. Schools participating in Crunch&Sip® are required to ensure that at least 80% of classes and 70% of students participate in the daily fruit and vegetable break. Schools need to endorse a supportive school policy and are encouraged to implement a parent communication strategy and develop curriculum material.
Nathan N, Wolfenden L, Butler M et al. (2011) Vegetable and fruit breaks in Australian primary schools: prevalence, attitudes, barriers and implementation strategies. Health Education Research 26, 722-731
Wise M, Jolley G, Johns J (2011). Crunch and Sip Evaluation Report.
School fruit and vegetable programmes operate at the province level in British Columbia, Manitoba and Northern Ontario:
− British Columbia’s School Fruit & Vegetable Nutritional Program, launched in 2005 and administered by the British Columbia Agriculture in the Classroom Foundation, provides fresh local fruit or vegetable snacks to schools every other week, 13 times in the school year. In 2013, the programme expanded to deliver milk to students in kindergarten to grade two. It is administered by the British Columbia Agriculture in the Classroom Foundation, and funded by the British Columbia Ministry of Health in partnership with the Ministries of Agriculture and Education.
− Ontario’s Ministry of Health and Long-Term Care launched the Northern Fruit and Vegetable Program (NFVP) in Northern Ontario in 2006, in cooperation with the Ontario Fruit and Vegetable Growers’ Association and the Ontario Ministry of Agriculture, Food and Rural Affairs. Elementary and intermediate school-aged children receive fruit and vegetable snacks at no cost, in combination with healthy eating and physical activity education, twice per week from January to June. NFVP is currently delivered in three regions of Northern Ontario, in partnership with the local health units, school boards, and elementary and intermediate schools.
− Manitoba’s Vegetable & Fruit Snack Program, launched in 2008, is funded by the Province of Manitoba and the Public Health Agency of Canada; the number of times pupils receive fruit and vegetable snacks per week depends on each school’s way of implementation.
Updated February 2018: The EU School Fruit Scheme, launched in the 2009-2010 school year, merged with the EU School Milk Scheme on 1 August 2017 into one legal framework based on the Regulation on the new School Fruit, Vegetables and Milk Scheme (Regulation EU No 2016/791). The scheme is funded through the EU’s common agricultural policy and supports the distribution of fruit, vegetables and milk and milk products to schools across the EU as part of a wider programme of education about European agriculture and the benefits of healthy eating. It provides financing to Member States based on the number of school children and level of development of the country. The implementation of the programmes is at the discretion of national or regional governments, but to receive funding, they must distribute fruit, vegetables and milk products in schools and implement educational measures, such as farm and market visits, educational material distributed to teachers and interactive games on education and nutrition, and regularly monitor and evaluate implementation. Foods containing added sugars, salt, fat, sweeteners or artificial flavor enhances are exempt from the scheme: as an exception, limited quantities of added sugar, salt and fat are allowed if they are approved by the Member States' health/nutrition authorities. The Member States determine the frequency and duration of the distribution of the food.
European Commission, Directorate-General for Agriculture and Rural Development. Evaluation of the European School Fruit Scheme Final Report. Brussels, 2012
European Court of Auditors. Are the school milk and school fruit schemes effective? Special Report No. 10. Luxemburg, 2011
In 2007, the Norwegian government introduced legislation requiring schools to offer one free piece of fruit or vegetables, five days a week to pupils in grades 1–10. This was repealed in autumn 2014. In its place, a subsidised programme that requires parents to subscribe has been expanded to all primary schools.
Øvrum A, Bere E (2013) Evaluating free school fruit: results from a natural experiment in Norway with representative data. Public Health Nutrition 17(6), 1224-1231
The School Fruit and Vegetable Scheme has operated in England since 2004. Children aged four to six who attend a fully state-funded infant, primary or special school are entitled to receive a free piece of fruit or vegetable each school day.
In Scotland, the Free Fruit in Schools initiative provides one portion of fruit three times a week during term time to all Key Stage 1 and 2 pupils (primary school). It is implemented at the discretion of local authorities.
Fogarty AW et al. (2007) Does participation in a population-based dietary intervention scheme have a lasting impact on fruit intake in young children? International Journal of Epidemiology 36(5), 1080-1085
Wells L, Nelson M (2005) The National School Fruit Scheme produces short-term but not longer-term increases in fruit consumption in primary school children. British Journal of Nutrition 93(4), 537-542
The Fresh Fruit and Vegetable Program, piloted in the US from 2002 onwards and implemeted nationwide in 2008 (based on the 2008 Farm Bill), makes funds available to elementary schools with at least 50% of students eligible for free or reduced price meals. Participating schools receive $50–75 per child per year and are free to decide what fruit and vegetables to purchase.
Lin Y-C, Fly AD (2016) USDA Fresh Fruit and Vegetable Program Is More Effective in Town and Rural Schools Than Those in More Populated Communities. Journal of School Health 86(11), 769-777
Bartlett S et al. (2013) Evaluation of the Fresh Fruit and Vegetable Program (FFVP): Final Evaluation Report. US Department of Agriculture, Food and Nutrition Service, Alexandria, VA
There are no national mandatory standards in Australia (see below for details of national voluntary guidelines). However, six states and territories have implemented mandatory standards, which are either based on the national voluntary guidelines or nutrient and food criteria defined by the state: Australian Capital Territory (2015), New South Wales (2011), Northern Territory (2009), Queensland (2007), South Australia (2008), and Western Australia (2014). All of these states and territories identify "red category" food, which is either completely banned in schools or heavily restricted (eg offered no more than one or two times per term). The ACT Public School Food and Drink Policy is mandatory for government primary and secondary schools, but not for independent or catholic schools.
Queensland’s Smart Choices school nutrition standards separate food and drinks into green, amber and red categories based on their energy, saturated fat, sugar, sodium and fibre content. Smart Choices ensures that “red” food and drinks are eliminated across the whole school environment.
In February 2014, the Australian Capital Territory (ACT) announced the phasing out of sugary drinks for sale in school canteens by the end of 2014. The 2015 ACT School Food and Drink Policy prohibits the sale of sugary drinks in ACT public school canteens. ACT is working to ensure water is the easiest choice available, including the installation of two water refill stations in each public school.
The Ministry of Health of Bahrain has developed a mandatory list of permitted, prohibited and conditionally allowed food for public elementary and secondary schools. According to the 2016–17 Food Canteen List, only unsweetened 100% fruit juice, water, milk and milk drinks are permitted; fruit drinks and nectar, soft and energy drinks are prohibited. Permitted food includes fresh fruit and vegetables, while conditionally allowed food products have to comply with criteria such as not using trans fat, using low-fat cheese instead of cream cheese for sandwiches and limiting portion size. Banned food includes processed meat, potato chips, mayonnaise, puff pastries, sweets and candies (but not chocolate which is a conditionally allowed food).
In 1997, Bermuda implemented the mandatory Healthy Schools Nutrition Policy which contains school food standards including the provision of fruit and vegetables in food service/cafeteria menus and all school events that provide food, limits on the use of food high in salt and sugar, provision of low-fat dairy products, leaner meats, whole grains, fruits and vegetables, the use of lower-fat cooking methods, the consumption of whole fruit and vegetables as preferable to the sole consumption of fruit and vegetable juices and school lunches are required to be consistent with the recommendations of Bermuda’s Daily Dietary Guidelines EatWell Plate.
The Food Service Providers Contract, implemented in 2009 to strengthen the compliance of cafeteria, hot lunch and breakfast vendors in schools, mandates that food provided in schools must be consistent with the Healthy School Nutrition Policy. To monitor compliance, a form exists in which anyone at any school can rate various aspects of a meal provided by a food service provider (eg appropriateness of portion sizes, inclusion of four of five food groups, etc).
The Ministry of Education also has a policy in which only fruit, yoghurt, cheese, crackers and vegetables can be eaten at morning recess.
Resolution no. 38 (16 July 2009) promulgated by the Brazilian Ministry of Education sets food- and nutrition-based standards for the food available in the national school meal programme (Law 11.947/2009 – Regulamento del Programa Nacional de Alimentação Escolar). Article 17 prohibits drinks of low nutritional value (eg soda), canned meats, confectionary, and processed food with a sodium and/or saturated fat content higher than a specified threshold.
School “canteens” – kiosks and stores where food can be purchased for takeaway inside public schools – are covered by voluntary guidelines (see "Voluntary guidelines for food availabe in schools”).
In Bulgaria, the reduction of salt, fat and sugar content in food served in all canteens in schools, kindergartens and childcare centres was mandated by ordinances in 2009, 2011, and 2013 respectively. In addition, there are restrictions in place for certain unhealthful food and drinks in vending machines. The corresponding recipe books used by school caterers for school children and children aged 0–3 years were updated in 2012 and 2013, respectively, to reflect the ordinances’ requirements. The recipe book for kindergarten pupils is under revision. Compliance with the ordinances is monitored by the Regional Health Inspectorates who may fine offenders.
In 2012, the Chilean government approved a Law of Nutritional Composition of Food and Advertising (Ley 20.606). In June 2015, the Chilean authority approved the regulatory norms required for the law’s implementation (Diario Oficial No 41.193), which came into effect on 27 June 2016. The regulatory norms define limits for calories, saturated fat, sugar and sodium content considered “high” in food and beverages. The law prohibits the sale of these "high in" food items and beverages in schools (see “N – Nutrition label standards and regulations on the use of claims and implied claims on food” and “R – Restrict food advertising and other forms of commercial promotion” for the regulatory norms on labelling regulations and marketing restrictions to children).
Executive Decree No. 36910-MEP-S (2012) of the Costa Rican Ministries of Health and Education sets restrictions on products sold to students in elementary and high schools, including food with high levels of fats, sugars and salt such as chips, cookies, candy and carbonated sodas. Schools are only permitted to sell food and beverages that meet specific nutritional criteria. The restrictions were upheld by the Constitutional Court in 2012 following a challenge by the Costa Rican Food Industry Association.
In 2008, the Estonian Ministry of Social Affairs adopted updated regulations on nutrition requirements applicable to food served in school and pre-school canteens. These requirements contain upper limits for salt, sugar and fat content, and restrict (deep) fried products, sweet treats and soft drinks.
The Ministry of Education’s Food and Nutrition Policy requires all school canteen operators to comply with Fiji’s School Canteen Guidelines, developed by the National Food and Nutrition Centre in 2005 and revised in 2013. The guidelines outline how to prepare and provide healthy “everyday” food with recipes and nutrition guidelines. They are enforced by the Ministry of Education.
In 2017, the Finnish National Nutrition Council updated their nutrition recommendations for school meals replacing the recommendations from 2008. The updated recommendations are based on Health from food – Finnish nutrition guidelines (2014) and Eating together – food recommendations for families with children (2016). The recommendations provide a basic plate model for individual energy expenditure. Food and nutrient recommendations for salt, fibre, fat, starch, and fat content are outlined for all of the components of the basic plate model. The recommendations state that drinks available at school meals should include fat-free milk/milk drinks and buttermilk, fortified with vitamin D. Other liquid dairy products and fermented milk products should be fat-free or low-fat products with a maximum fat content of 1%. Cheese products with a fat content of at most 17% and a maximum salt content of 1.2% should be selected. Fresh water should be available as the primary beverage at meals and must be available as the primary beverage to everybody during the whole school day. No soft drinks, energy drinks or any other acidified beverages or beverages with added sugar are served at school.
The Finnish Act on Early Childhood Education and Care, Section 2b (8.5.2015/580), Section 6 (8.5.2015/280) and Basic Education Act, Section 31(13.6.2003/477) outline that school-age children shall be provided with healthy and necessary nutrition that fulfills their nutritional needs and provided a meal free of charge on every school day. Children at kindergarten/childcare are entitled to a meal each day and low-income populations are provided with a free meal.
In 2009, legislation required products entitled to EU subsidies under the School Milk Scheme to meet nutritional criteria, including maximum levels of salt content. The criteria are set jointly by the Finnish National Nutrition Council and KELA, the Social Insurance Institution of Finland. In August 2017, the legislation was amended so that only fat-free milk and fat-free sour cream are subsidised, and cheese was removed from the subsidy.
Decree No. 2011-1227 of 30 September 2011 (arising from Law No. 2010-874 of 27 July 2010 on the modernisation of agriculture and fisheries) regulates the nutritional quality of school meals in France, including the diversity and composition of meals, provision of water, portion sizes and restrictions on salt and sauces outside of prepared dishes. School canteen managers are required to keep record of menus for the previous three months at all times, including detailed information on food purchased from suppliers, and are required to identify clearly on menus seasonal ingredients in the composition of the meal. This follows from Interministerial Circular No. 2001-118 of 25 June 2001 which made recommendations on consuming a balanced diet in schools.
Two German states have enshrined the voluntary guidelines on quality standards for school meals by the German Nutrition Society (DGE) in law: Berlin implemented the Law for quality improvements of school lunch meals in 2014 in all-day primary schools. The Law sets the DGE quality standards as a minimum requirement which schools have to adhere to, in addition to setting up a lunch meal committee that regularly conducts quality controls and supports the selection of appropriate food suppliers.
The state of Saarland requires all-day primary and secondary schools to provide school meals that are in line with DGE quality standards (Article 8 of the Regulation of all-day primary and secondary schools).
The DGE guidelines recommend that schools provide water and unsweetened herbal or fruit teas, and prohibit drinks that are high in sugar including juices and energy drinks. The guidelines contain a 20-day plan suggesting serving whole grains on at least four days and potato products a maximum of four days; salad, vegetables or legumes each day; fruit at least eight times; dairy products (ideally low-fat) at least eight times; fish at least four times and meat a maximum of eight times; rapeseed oil is the only permitted oil.
Since 2012, food and beverages subject to the public health product tax (see “U – Use economic tools to address food affordability and purchase incentives” for details on the tax) may not be sold on school premises or at events organised for school children, including out-of-school events based on the Ministerial Decree 20/2012 (VIII. 31.) on the Operation of Public Education Institutions and the Use of Names of Public Education Institutions. Section 130(2) of the Decree requires the head of the educational institution to consult the school health service prior to entering into agreements with vending machine operators or food vending businesses. The school health service verifies whether the products to be sold meet the nutritional guidelines set by the National Institute of Pharmacy and Nutrition. Products that do not comply with the guidelines’ “healthy eating” requirements or that have a negative impact on the students’ attention or behaviour, such as those containing artificial colours found in sugary snacks and drinks, are prohibited.
In 2008, the Iranian Ministry of Education and Ministry of Health developed the Guideline for healthy diet and school buffets. In 2013, the nutrition part of the Guideline was updated. The Guideline contains a list of healthy and unhealthy food, established by an expert committee based on their content of sugar, salt, fat, and harmful additives. It also includes guidance on proper food preparation and catering as well as maintenance of the physical environment in which food is prepared (kitchen, storage).
The Jordanian Ministry of Health has set food standards regulating which food may be sold to students in school canteens as part of the National School Health Strategy (2013–17), which was prepared in coordination with a multi-sectorial committee and approved in 2012.
The Ministries of Health and Education of Kuwait introduced a ban of fizzy drinks, crisps and chocolates on school premises to reduce the intake of fat and sugar by pupils, and to increase their milk consumption; they also introduced fruit and vegetables in the breakfasts offered by tuck shops in schools. The ban is monitored by the Ministry of Education but compliance is not reported to be high.
In 2006, the Latvian government implemented legislation that prohibited the sale/availability of soft drinks, drinks with added colours, sweeteners, preservatives and caffeine on all school premises.
In 2012, the government set salt levels for all food served in educational institutions. Levels may not exceed 1.25g of salt per 100g of food product; fish products may contain up to 1.5g of salt per 100g of product. The standards also apply in hospitals and long-term social care institutions (see below).
In November 2011, the Lithuanian Ministry of Health approved Order V-964, which set catering standards for pre-schools, secondary schools and children’s social care institutions. Food and nutrient-based standards exist for lunches (eg obligatory vegetable and fruit offering, “oil-boiled” foodstuffs, sweets and savoury pastry are prohibited), drinking water must be provided and soft drinks are prohibited.
In September 2014, the Macedonian Ministry of Education’s Rulebook on nutrition standards and meals in primary schools was implemented, setting limits on permissible salt, sugar and fat levels of food served in primary schools. Kindergartens and holiday camps are subject to the Ministry of Labour and Social Policy’s Rulebook on standards and norms for services provided by institutions caring for children, implemented in January 2014. It contains intake requirements on calories, carbohydrates, protein, fats, vitamins and minerals based on WHO recommendations. The nutrition standards for kindergartens are widely implemented. The implementation of the elementary school nutrition standards is reported to move at a slower pace, mostly because elementary schools use external catering services which take longer to adjust to the nutrient limits.
In September 2016, the Macedonian Ministry of Education implemented the Rulebook on nutrition standards and meals for the students living in student dormitories. The nutrition standards, based on population-based nutrition guidelines of the Ministry of Health and Institute of Public Health, outline specific nutrient levels (for calories, carbohydrates, protein, fats, sugars, vitamins, minerals) which apply to meals served in all university student dormitories in both public and private dormitories in Macedonia. The nutrition standards include recommended foods and dishes for individual meals and recommended frequency of certain food categories.
The Guide for Healthy School Canteen Management (2012), developed by the Ministry of Education and mandatory for public schools, categorises food items into those which may be sold, those which are not encouraged to be sold and those whose sale is prohibited in school canteens. Prohibited food includes sweets, preserved food, extruded snacks containing artificial flavours and colourings (which are snacks mainly based on corn flour or a combination of flours undergoing extrusion and then coating with a combination of vegetable oil and seasoning), and food and beverages containing alcohol. The list of prohibited food is under review (2016), in particular with respect to carbonated drinks.
In 2009, a regulation was passed in Mauritius banning soft drinks, including diet soft drinks, and unhealthy snacks from canteens of pre-elementary, elementary and secondary schools.
In August 2010, the Mexican Ministries of Education and Health issued a set of mandatory food and beverage guidelines for elementary schools for roll-out in 2011–14. They were developed under the framework of the National Agreement for Healthy Nutrition. The guidelines promote the daily intake in schools of healthy food, such as fruit, vegetables and water; ban sodas; limit the availability of other soft drinks, whole milk, salty and sweet snacks, and desserts that comply with nutritional criteria to a maximum of two days per week; and prohibit completely products that do not comply with the nutritional criteria. The Guidelines were updated in 2014. The revised Guidelines extend the standards to secondary schools, include recommendations for food brought into schools from home, and increase the stringency of some of the nutrient criteria.
In March 2015, Health Directive No. 063 Promotion of Healthy Kiosks and School Canteens was adopted in Peru. The Health Directive establishes recommendations for food provided in school kiosks and canteens, including the amount of energy to be supplied in lunches. School kiosks and canteens are evaluated twice a year at the regional level using a scorecard provided within the Health Directive. School kiosks and canteens that meet the indicators of the evaluation are graded as healthy and given a green pennant.
In 2014, the Ministry of Health amended the Polish Act on Food and Nutrition Safety from 2006 (Journal of Laws, item 1225; amended by Act of 28 November 2014 amending the Act on Food and Nutrition Safety, Journal of Laws, item 1256) to include rules for sale, advertising and promotion of food (based on a list of food categories) and nutrition standards for canteens in pre-schools, primary and secondary schools. It outlines nutrition standards for food and beverages intended for sale: ≤0.12g sodium/100g/ml of product, ≤10g sugar/100g/ml (except breakfast cereals ≤15g sugar/100g), and ≤10g fat/100g of product. The regulation also includes food category-specific restrictions. The amendments came into effect on 1 September 2015.
Legislation introduced in Romania in 2008 sets maximum amounts for sugar, fat and salt in food sold in schools and pre-schools (Ministerial Order 1563/2008); the maximum levels amount to 15g sugar, 20g fat and 1.5g salt or 0.6g sodium per 100g of a food product. Soft drinks are prohibited and drinking water must be accessible.
All school meals must follow dietary guidelines as set out by Slovenia’s Law on School Nutrition (2010, amended in 2013). The Act is complemented by dietary guidelines (including a list of food that is not recommended), recipe books, cross-curriculum nutrition education and food procurement standards available to all schools.
Gregorič M et al. (2015) School nutrition guidelines: overview of the implementation and evaluation. Public Health Nutrition 18(9), 1582-1592
The Swedish Education Act came into force 1 July 2011 requiring school meals to be nutritious and free of charge.
The National Food Agency was commissioned to work with the Swedish National Agency of Education by the Ministry of Education and Research to develop school food guidelines. The Good School Meals guidelines, published in 2007 and revised in 2013, are for primary schools, secondary schools and youth recreation centres. The guidelines include age-specific reference values for energy and nutritional content in school lunches and portion sizes, and drinks are limited to water and milk. Ice cream, pastries and sweets are not provided by the school. The quality of school meals is monitored and assessed by an online tool (SkolmatSverige), and used by over three-quarters of schools in Sweden.
In May 2017, the Trinidad and Tobago Ministry of Health introduced a ban on the sale or serving of sugar-sweetened drinks at all government and government-assisted schools. Banned sweetened drinks include soft drinks, juice drinks, flavoured water, sports/energy drinks, tea and coffee, and milk-based drinks with added sugars and artificial sweeteners. Only water, 100% juice, low-fat milk and blended vegetable or fruit drinks can be sold at schools. The changes were introduced in a phased approach and all cafeterias and canteens needed to be in full compliance by September 2017.
The School Canteen Guidelines for the Emirate of Abu Dhabi (2011–12) are set and revised by a joint committee of representatives from the Abu Dhabi Education Council, the Abu Dhabi Health Authority and the Abu Dhabi Food Control Authority. The Guidelines set out the requirements vendors must meet to obtain a licence to operate in public and private school canteens. Parents may provide their children with their own packed meals as long as they are in line with the canteen guidelines. The Guidelines include calorie requirements for each grade, sample menus, a list of permissible and banned food by category, and nutrient-based standards (eg limits on total fat and sugar content; minimum amounts of macro and micro nutrients). The standards restrict the serving of many energy-dense food, soft drinks and fruit punch, as well as trans fats, mono-sodium glutamate (MSG), preservatives, colours and artificial flavours, caffeine and hot and spicy sauces.
England, Scotland, Northern Ireland and Wales have mandatory nutritional standards for all food served in schools, including breakfasts, snacks, lunches and tuck shops. These standards apply to all state schools and restrict food high in fat, salt and sugar, as well as low-quality reformed or reconstituted food. The standards are as follows:
− England: School Food Regulations 2014 (No. 1603), applicable to school lunches and food provided to students on school premises, came into force 1 January 2015 replacing the School Food Standards of 2007.
− Scotland: Nutritional Requirements for Food and Drink in Schools Regulations 2008, applicable to any food served in schools were introduced in primary schools in August 2008 and in secondary schools in August 2009.
− Northern Ireland: Nutritional Standards for School Lunches 2007, and Nutritional Standards for Other Food and Drinks in Schools 2008.
− Wales: Healthy Eating in Schools (Nutritional Standards and Requirements) Regulations 2013 (No. 1984 (W.194)
Spence S et al. (2014) Did School Food and Nutrient-Based Standards in England Impact on 11-12Y Olds Nutrient Intake at Lunchtime and in Total Diet? Repeat Cross-Sectional Study. PLoS ONE 9(11): e112648
Adamson A et al. (2013) School food standards in the UK: implementation and evaluation. Public Health Nutrition 16(6), 968-981
Spence S et al. (2013) The Impact of Food and Nutrient-Based Standards on Primary School Children’s Lunch and Total Dietary Intake: A Natural Experimental Evaluation of Government Policy in England. PLoS ONE 8(10): e78298
The US Healthy, Hunger-Free Kids Act (HHFKA) of 2010 sets nutrition standards in the National School Lunch and School Breakfast Programs which were implemented in July 2014 based on an interim final rule published in June 2013. A final rule on nutrition standards for all food sold in schools as required by the HHFKA was published in July 2016, introducing minor changes based on comments received on the interim final rule. The standards for total fat are retained as “interim” in the final rule and may be amended in the future. The Act also establishes guidelines for "competitive food" in the Smart Snacks in School Program. Standards include limits on the amount of fat, saturated fat, salt and added sugars permitted in food. Beverages are also restricted to water, low-fat or non-fat milk. Calorie-free carbonated beverages are permitted in high schools.
There are also many state-level rules in place. Some states, including California and Colorado, have restrictions specific to trans fats. For example, in 2008, California adopted Senate Bill No. 1498 which prohibited, as of 1 July 2009, elementary, middle and high schools from making artificial trans fats available through vending machines or school food service establishments during school hours and up to 1/2 hour before and after school hours. In Colorado, Senate Bill 12-086 (2012) prohibits a public school or institute charter school from making available to a student a food item that contains any amount of industrially produced trans fat.
States also have a range of different rules on "à la carte lines" (ie food options that supplement the school lunch programme choices and stores inside schools). For example, Arizona, Rhode Island and Florida have bans on "à la carte lines" in elementary schools. 17 other states have strict restrictions (eg specific lists of restricted food or nutritional criteria) that apply at "à la carte lines" in elementary schools. 15 states have strict restrictions on food available at "à la carte lines" in middle schools, while 11 states apply strict restrictions at high school level.
Arizona, District of Colombia, Florida and Texas have complete bans on school stores in elementary schools, and 13 states have strict restrictions on the food available in stores in elementary schools. 11 states have strict restrictions on the food available in school stores in middle schools, while eight states apply restrictions at high school level.
For more details see State Laws for School Snack Foods and Beverages.
Johnson, DB et al. (2016) Effect of the Healthy Hunger-Free Kids Act on the Nutritional Quality of Meals Selected by Students and School Lunch Participation Rates. JAMA Pediatr 170(1):e153918
Minaya S, Rainville AJ (2016) How Nutritious Are Children’s Packed School Lunches? A Comparison of Lunches Brought From Home and School Lunches. Journal of Child Nutrition and Management 40(2)
In September 2013, the government of Uruguay adopted Law No. 19.140 on healthy eating in schools. It mandated the Ministry of Health to develop standards for food available in canteens and kiosks in schools, prohibited advertising for these same food items, and restricted the availability of salt shakers. The school food standards were elaborated in March 2014 in two further documents: Regulatory Decree 60/014 and the National Plan of Health Promoting Schools. The standards aimed to promote food with “natural nutritional value” with a “minimum degree of processing" and to limit the intake of free sugars, saturated fat, trans fat and sodium. Limits are set per 100g of food, 100ml of drink and also per 50g portion. Prohibited food includes sugary beverages and energy drinks, confectionery, salty snacks, cakes and chocolate. The school food standards and restrictions on advertising began to be implemented in public schools in 2015 and are being monitored for compliance.
Vanuatu’s Sweet Drink Policy, introduced in October 2014 as part of the Vanuatu Health Promoting School Program and in the context of regulation order No. 44 of 2005 on health and safety requirements in schools, came into effect on the first day of Term 1, 2015. The policy bans the sale, consumption and advertising of sugary drinks and instead promotes water, plain milk and fresh coconut water.
In 2010, the South Korean Special Act on the Safety Management of Children’s Dietary Life incorporated provisions to improve the nutritional quality of school meals and sets nutrition and food-based standards for other food on sale in schools. Additionally, this Act establishes Green Food Zones, banning the sale of fast food and soda within 200 metres of schools. In 2016, Green Food Zones existed at over 10,000 schools. The provisions were implemented in 2009–10.
In 2011, Australia introduced the voluntary school food guidelines "National Healthy School Canteens: guidelines for healthy food and drinks supplied in school canteens” (NHSCGs). The guidelines, updated in 2013, are based on the Australian Guide to Healthy Eating and the 2013 Australian Dietary Guidelines. The guidelines include three components: a national food categorisation system for school canteens, training materials for canteen staff and an evaluation toolkit. The food categorisation system uses a traffic light system to distinguish food categories that should be promoted and those that should be limited based on their nutritional value: red (not recommended), amber (select carefully) and green (always available). The guidelines provide examples of food within each category and additional nutrient criteria to assist the categorisation of food, mainly in the amber category. Food in the green category should be actively promoted. Food in the red category, such as sugar- and artificially sweetened drinks, food high in sugar, fat and/or salt and food containing excessive energy, should not be sold in school canteens. Implementation of the guidelines is at the discretion of each state or territory government.
The Australian Capital Territory (ACT), Northern Territory (NT) and Tasmania have implemented the national guidelines in full (ACT Public School Food and Drink Policy 2015, NT Canteen, Nutrition and Healthy Eating Guidelines 2013 and Tasmania School Canteen Handbook – a whole school approach to healthy eating 2014) while other states and territories have incorporated components of the guidelines within their own system:
New South Wales (NSW) has taken a different approach. The “NSW Healthy School Canteen Strategy 2017” is based on the Australian Dietary Guidelines and classifies food and drinks as either "everyday" (healthy) or "occasional" (less healthy). The strategy also uses the Health Star Rating (see "N – Nutrition label standards and regulations on the use of claims and implied claims on food") to guide users in selecting healthier versions of "occasional" packaged foods.
Dick M et al. (2012) Evaluation of implementation of a healthy food and drink supply strategy throughout the whole school environment in Queensland state schools, Australia. European Journal of Clinical Nutrition 66, 1124-1129
The Unser Schulbuffet (Our School Buffet) programme, launched in 2012, is overseen by the Austrian Ministry of Health. The programme provides guidelines for school canteens to follow, including restrictions on certain food including fried products, sweet treats, crisps and savoury snacks, which also apply to vending machines. The guidelines are food-based and informed by the Austrian Food Pyramid. Beyond providing guidelines on nutritional aspects, the guidelines contain advice on the presentation and promotion of healthy options.
Flanders (2008) and Wallonia (2013) both have voluntary guidelines with food-based standards for food available in schools, including restrictions on (deep) fried food, sweet treats and soft drinks.
Mandatory standards are in place for the national school meal programme in Brazil (see "Mandatory standards for food available in schools, including restrictions on unhealthy food"). For “school canteens” – kiosks and stores where food can be purchased for takeaway inside public schools – there are voluntary guidelines. The Healthy Schools Canteens Manual, published by the Ministry of Health in 2010, contains voluntary guidelines for the operators of school canteens on how to promote healthy eating in canteens. In 2012, a self-learning course was made available to support canteen managers implement the manual, as part of the Cooperation Agreement signed by the Ministry of Health and the Private Schools National Federation. The Agreement sets out to plan, implement and evaluate strategies that promote health in private schools at a national level (particularly in the areas of healthy eating and the prevention of obesity related non-communicable diseases). A website monitors actions taken by schools and promotes learning between them.
In 2013, the Federal, Provincial and Territorial Group on Nutrition (FPTGN), a working group consisting of representatives from all Canadian provinces and territories, released a Guidance Document for the development of Nutrient Criteria for Foods and Beverages in Schools. The Guidance contains nutritional guidelines on food served in schools, classing food products into four groups – vegetables and fruit, grain products, milk and alternatives, meat and alternatives – and two categories – Choose Most Often and Choose Sometimes. The Guidelines suggest maximum levels for fat, sugar and salt, with the reference quantities being largely based on Health Canada’s Canada Food Guide. The Guidance is not mandatory, but is intended to guide the provinces and territories in their development of new and revision of existing school nutrition policies, and to support the food industry in developing and reformulating products sold in and to schools.
The German Nutrition Society (DGE) has set voluntary guidelines on quality standards for school meals in Germany. The guidelines recommend that schools provide water and unsweetened herbal or fruit teas and prohibit drinks that are high in sugar including juices and energy drinks. The guidelines contain a 20-day plan suggesting serving whole grains on at least four days and potato products a maximum of four days; salad, vegetables or legumes each day; fruit at least eight times; dairy products (ideally low-fat) at least eight times; fish at least four times and meat a maximum of eight times; rapeseed oil is the only permitted oil.
Many local school authorities (Schulträger) contractually require food suppliers to adhere to DGE quality standards.
Two German states, Berlin and Saarland, have enshrined the voluntary guidelines in law (see above under Mandatory standards for food available in schools, including restrictions on unhealthy food).
In 2006, the government's Centre for Health Protection in Hong Kong issued guidelines for tuck shop operators in primary schools, as well as parents and school personnel, to guide the types of food and drink items to be allowed and promoted in the school environment for the benefit of children's health. They were revised to include secondary schools in 2010.
In Malta, public schools have to comply with a list of permissible and prohibited food and beverages based on the 2014 Healthy Lifestyle (Reducing Obesity) Act and Food and Beverage Standards for food consumed in schools (set by the Education Division of the Ministry of Education, Youth and Employment in 2007 and amended in 2015). The standards include nutrient-based guidelines for food and drink providers with limits for fats, sugar and salt per 100g or ml. The standards are mandatory in public schools and voluntary in most private schools, with public schools monitored for compliance.
In 2008, the Polish National Institute of Food and Nutrition issued School Food Guidelines that are recommended by the Ministry of Health. The guidelines set out nutrient-based standards for food served in schools.
In 2011, the Health Promotion Board of Singapore, in collaboration with the Ministry of Education, launched the Healthy Meals in Schools Programme (HMSP), which was formerly the Model School Tuckshop Programme, launched in 2003. The programme enhances the availability of healthier food and beverage choices in schools through an integrated programme that involves teachers, canteen vendors and students. Canteen vendors from participating schools are expected to follow food service guidelines which aim to reduce the amount of saturated fat, sugar, and salt in school meals and make available whole grains, fruit and vegetables as part of a balanced meal. The Health Promotion Board supports schools by organising culinary and nutrition training for canteen vendors (see “G – Give nutrition education and skills"), and engages nutritionists and dietitians to assess participating schools to ensure compliance to the HMSP criteria. Educational resources are also provided as part of the programme to encourage students to eat a healthy diet. Revised food service guidelines came into effect on 1 January 2016.
The South African Department of Basic Education, in cooperation with the Provincial Education Departments, runs the voluntary National School Nutrition Programme (NSNP), which evolved out of the Primary School Nutrition Programme introduced in 1994. The Programme provides one daily meal which is based on the South African Food Based Dietary Guidelines (2012). Fresh fruit and vegetables should be served every day and soya no more than twice a week. As part of the school nutrition programme, voluntary Guidelines for Tuck Shop Operators (2014) were developed which advise to only sell healthy food (eg fresh fruit, nuts, fish, brown bread sandwiches) and beverages in containers not exceeding 250ml (eg plain water, 100% fruit juice, unsweetened milk). Schools are encouraged to set up vegetable gardens to teach children to grow food and use the harvested produce for school meals. NSNP is implemented in the neediest public schools, and most schools use the opportunity offered to them.
In 2011, the Spanish Parliament approved a Law on Nutrition and Food Safety (Ley 17/2011) that prevents kindergartens and schools from selling food and beverages high in saturated fat, trans fat, salt and sugar. To determine food and drinks allowed in schools, including products available in vending machines, regional authorities can use recommended nutritional criteria outlined in the 2010 Consensus document on food in education centres.
In 2008, the Thai Department of Health, in collaboration with the Ministry of Education’s Office of the Basic Education Commission (OBEC), announced a voluntary ban of soda and sugary packaged snacks in elementary and secondary schools under OBEC. It has been implemented by the majority of schools under OBEC.
The voluntary Thai School Lunch Programme was implemented in 1999, recommending schools to provide meals and snacks in line with the nutrient standards of the Thai Recommended Daily Intake (RDI) (last amended 2003). Three RDIs exist for different age groups: 3–5 years (1,200kcal), 6–12 years (1,550kcal) and 13–18 years (2,000kcal). School meals and snacks should make up 40% of the RDI, and recommend a distribution ratio of 55–60% carbohydrates, 10–15% protein and 25–30% fat. In addition, the RDIs set maximum levels of protein, fat, total carbohydrate and cholesterol, and contain recommended levels of vitamins (A, B1, B2, C), folate and calcium. The guidelines are intended to prevent both undernutrition and overweight/obesity. In 2013, the budget per lunch per pupil was increased from 13 Thai Baht (ca. $0.4) to 20 Thai Baht (ca. $0.6) to increase the quality of school lunches. Due to a lack of monitoring and evaluation capacity of the ministries in charge of the programme (Ministry of Education, Ministry of Public Health, Ministry of Interior), it is unclear how widely the RDIs are implemented.
In February 2014, the Australian Capital Territory (ACT) government announced the removal of vending machines from ACT public schools. The 2015 Australia Capital Territory’s Public School Food and Drink Policy prohibits food and drink vending machines on public school premises.
In 2006, Bermuda implemented the Healthy Schools Vending Machine and Cafeteria Policy which bans sodas and snacks from vending machines on school premises. Only plain, unsweetened water and/or 100% fruit juice is permitted.
Based on the French Public Health Act of 2004 (Law No. 2004-806, Article 30), vending machines containing drinks and snacks are not allowed in schools since 1 September 2005. Fruit and bottled water must be made available.
In 2010, Slovenia adopted a ban on vending machines on school premises (since incorporated into the 2013 School Nutrition Law). It was introduced to reduce consumption of unhealthy food, but also to decrease possible marketing space on the exterior of vending machines.
Arkansas, the District of Columbia, Florida, Indiana and Texas have had bans on vending machines in elementary schools since 2008–09.
13 states have restrictions (either lists specifying restricted food or nutritional criteria) on the content of vending machines in middle schools. Nine states have restrictions that apply in high schools (for more details see State Laws for School Snack Food and Beverages).
Since 2008, Healthy Schools in Bermuda has partnered with a charity that provides healthy breakfasts to at-risk school-age children. The milk served in this programme must be low in fat.
For more information about Healthy School see “Mandatory standards for food available in schools, including restrictions on unhealthy food” (above).
In order to support efforts of the Mexican government to reduce obesity, Liconsa, the government-owned company that purchases and distributes subsidised milk to low-income households, switched two-thirds of its milk supply to low-fat milk in 2013.
In January 2015, the US Healthy Food Banking Wellness Policy was adopted and put into effect by the Community Action Partnership of San Bernardino County (CAPSBC). The policy aims to increase the amount of healthy, nutritious and locally grown food obtained and provided by the CAPSBC Food Bank, which provides emergency food to agencies throughout the county. The Healthy Food Banking Wellness Policy provides guidelines to help with the procurement of healthful food, including fruits and vegetables (fresh or canned with no sugar added), whole grains, low-fat, unsweetened dairy products, protein (lean meats, eggs, nuts, seeds, pulses), healthy beverages (water, 100% juice and low-fat, unsweetened milk or milk substitutes) and where possible, locally produced food. The policy has resulted in a significant increase in the amount of produce procured.
Governments in all Australian states and territories implement mandatory (ACT, WA, SA and NT) or voluntary government endorsed guidelines (NSW, Qld, Vic and Tas) to assist healthier food and drink choices in health facilities (and public sector workplaces in Tas and the ACT). Queensland Health was the first to adopt these guidelines in health facilities in 2007. In all jurisdictions, the guidelines are based on the National Health and Medical Research Council’s Australian Dietary Guidelines and Guide to Healthy Eating. Most use a traffic light system to distinguish foods that should be promoted, and those that should be limited based on their nutritional value: red (limit), amber (choose carefully) and green (best choices). NSW classifies food and drinks as either "everyday" (healthy) or "occasional" (unhealthy). To varying degrees, the guidelines in each jurisdiction cover: the types of products available for sale through retail outlets and vending machines; product advertising and promotion; use of products for fundraising, rewards, incentives, prizes and giveaways; catering for meetings and events; and sponsorships. The most comprehensive guidelines make explicit that:
The Murrumbidgee Local Health District in New South Wales passed an internal directive in April 2016 banning the sale of sugary drinks at their health facilities by December 2016. The majority of the sites had implemented the ban by September 2016. Sugary drinks include any drink with sugar added during processing with the exception of diet soft drinks, diet energy drinks, 99–100% fruit juices and flavoured milk drinks.
Since November 2015, the Western District Health Service (WDHS) in Victoria prohibits the sale of sugary drinks, including fruit juices, in cafeterias and vending machines from its hospitals and health centres on a voluntary basis; all their campuses have implemented the ban. The only permitted beverages are water and low-fat flavoured milk in containers not exceeding 300ml. In June 2016, 12 other health services in South-Western Victoria agreed to implement such a sugary drinks ban over a two-year period.
Miller J et al. (2014) Implementation of A Better Choice Healthy Food and Drink Supply Strategy for staff and visitors in government-owned health facilities in Queensland, Australia. Public Health Nutrition 18(9): 1602-1609
Queensland Health. A Better Choice – Healthy Food and Drink Supply Strategy for Queensland Health Facilities: Evaluation Report. Brisbane, 2010
In 2008, the Government Vending Machine Policy was implemented in government offices and facilities in Bermuda to ensure access to healthy snacks and beverages for staff. The policy requires that all food and beverages in vending machines on government premises meet specific criteria based on levels of total fat, saturated fat, trans fat, sodium and sugar. The criteria exclude nuts and 100% fruit juices.
In July 2016, the Brazilian Ministry of Health implemented procurement guidelines for any food served or sold for purchase in the Ministry and its entities (Ordinance No. 1.274 of 7 July 2016). The guidelines are based on the Food Guide for the Brazilian population. At least one seasonal fruit has to be offered, and sugar-sweetened juice, soft drinks or sweets cannot be sold or served. Ultraprocessed food may only be used in exceptional cases if it is used in meals which are prepared from mostly unprocessed or minimally processed food. Ultraprocessed food is defined by the Ordinance as food which is mainly produced from substances extracted from whole food and/or food components derived from materials synthesised from organic matter, and which contain ≥1mg of sodium per 1kcal, ≥10% of total energy from free sugars, ≥30% of total energy from total fat, ≥10% of total energy from saturated fat and ≥1% of total energy from trans fat (in alignment with PAHO’s Nutrient Profile Model). The Ordinance also mandates sufficient chairs and tables are provided for employees to eat their food.
The Finnish government Decree 564/2003 on supporting meals at universities requires meals to meet specific nutritional criteria in order to qualify for government subsidies. Nutrition recommendations were first published in 2003, revised in 2008 and updated in 2011. The Finnish National Nutrition Council and KELA, the Social Insurance Institution of Finland, jointly set the updated recommendations. They include compulsory meal components, nutritional criteria for all meal components (total fat, saturated fat, salt, fibre), consumer advice and guidance for healthy choices, rotation of menus, number of meals that have to meet the criteria for nutritional quality and criteria adherence guidelines. The updated nutrition recommendations came into effect on 1 January 2013.
The German Nutrition Society (DGE) developed various voluntary guidelines on quality standards for meals in specific settings as part of IN FORM - Germany’s initiative to promote healthy diets and more exercise. Core elements of the DGE quality standards are criteria for optimal food choices, the frequency of serving various food groups, and menu planning and preparation to optimise the nutrient content of the offered food. In all settings, rapeseed oil is the standard cooking oil, and water as well as unsweetened herbal or fruit teas are the recommended beverages.
For nurseries (age 0–6) (2009, revised in 2014), the guidelines prohibit drinks that are high in sugar, including juice and soft drinks as well as energy drinks. They contain a 20-day lunch plan suggesting serving whole grains on at least four days and potato products a maximum of four days; salad, vegetables or legumes each day; fruit at least eight times; dairy products (ideally low-fat) at least eight times; fish at least four times and meat at a maximum of eight times. To date, around one-third of all nurseries act in accordance with the DGE standard.
For canteens in the workplace, the guidelines (2008, revised in 2014) contain a five-day lunch plan suggesting serving whole grains at least once and potato products not more than once; salad, vegetables or legumes each day; fruit at least twice; dairy products (ideally low-fat) at least twice; fish at least once and meat at a maximum of two days.
For meals in hospitals (2011, revised in 2014), rehabilitation centres (2011, revised in 2014) and care homes for elderly (2009, revised in 2014), the guidelines contain a seven-day meal plan for three meals and according to requirements two additional snacks per day suggesting serving whole grains at least 14 times and potato products a maximum of two times; salad, vegetables or legumes three times each day; fruit two times each day; dairy products (ideally low-fat) at least two times a day; fish at least twice a week and meat at a maximum of three times a week.
For meals on wheels (2010, revised in 2014), a service providing meals for persons aged 65+ living in their own homes, the guidelines contain a seven-day lunch plan suggesting serving whole grains at least once and potato products no more than once; salad, vegetables or legumes each day; fruit three times; dairy products (ideally low-fat) at least three times; fish at least once a week and meat at a maximum of three times a week. The guidelines do not include recommendations for beverages, as they do not form part of the standard meal service (but will be provided upon request).
On 17 November 2011, the Guam government enacted Policy in Favor of Healthy Food and Beverage Products in all Vending Machines Located within Government Facilities (22420.1) by amending various sections of the Guam Code. The Act stipulated that by January 2012 at least 50% of all foods and beverages offered in government-contracted vending machines within government institutions need to adhere to the new guidelines. The guidelines were then amended on 27 November 2013. The guidelines outline that at a minimum all vending machine food must display calorie, fat, sugar and sodium content labelling. At least 50% of beverages offered must contain one, or a combination of, water, coffee or tea, non-fat or reduced-fat milk, 100% fruit/vegetable juice, fruit-based drinks containing 100% fruit juice, other non-calorific beverages and sports drinks with less than, or equal to, 100 calories. 50% of the food offered must not contain more than 250 calories; 35% of the calories from fat; not more of 10% of the calories from saturated fat; any trans fat (hydrogenated oils or partially hydrogenated oils); more than 35% of the total weight from sugar or sweeteners; and more than 360mg of sodium. At least one item must have less than 140mg of sodium and a food option that contains at least 2 grams of fibre must be present. The Act also states that the government will inspect vending machines for compliance with the guidelines.
In 2012, the Latvian government set salt levels for all food served in hospitals and long-term social care institutions. Levels may not exceed 1.25g of salt per 100g of food product; fish products may contain up to 1.5g of salt per 100g of product. The standards also apply to educational institutions (see above).
In 2010, the Malaysian Ministry of Health developed the voluntary Guidelines on Healthy Menu Provision During Meetings. All government departments are encouraged to implement these Guidelines to provide healthy meeting catering, including the provision of plain water, low-fat milk and unsweetened hot beverages (though sugar remains available separately), serving fruit and vegetables, and calorie labelling.
From 2008 onwards, the Healthy Cafeteria Initiative encouraged the promotion of healthier food options in cafeterias operated in government health facilities. In 2012, a circular by the Director General of Health made the requirements of the Initiative mandatory. In order to receive Healthy Cafeteria recognition, cafeterias need to display the energy content of food items, information on the Recommended Daily Nutrient Intake and a poster or food replica of one food serving containing less than 500 calories. They also have to provide smaller portion sizes for any food items/dishes exceeding 500 calories, sell at least one type of fresh fruit, plain water, and low-sugar drinks. They are not allowed to sell junk and processed food, sweets, premixed drinks, carbonated drinks and alcohol, as well as pickles preserved in salt, sugar and vinegar. The premises have to be smoke-free. In addition, cafeteria operators have to complete the Healthy Catering training (see "G – Give nutrition education and skills" for more information). As of December 2016, 98% of cafeterias in government health facilities have obtained Healthy Cafeteria status.
Since 2012, the Clean, Safe, Healthy Initiative (BeSS) promotes clean, safe and healthy food in food outlets. In order to obtain BeSS recognition, food outlets have to fulfil some of the same criteria as the Healthy Cafeteria Initiative: plain water as default option, low-sugar drinks upon request; at least one type of fresh fruit sold; condiments to be served separately; display of information on dietary intake recommendations and posters/replicas of food items containing less than 500kcal; smaller serving sizes for food containing more than 500kcal promoted; calorie labelling for a minimum of 10 food items, and calorie information displayed for sugar, sugar syrups, creamer and condensed milk. Operators can voluntarily attend the Healthy Catering training. 1,520 food outlets have received BeSS recognition by October 2016.
Local public health service units oversee the WorkWell programme, launched in New Zealand in 2011. WorkWell helps businesses improve their employees’ health by supporting the improvement of the working environment and organisational systems. It includes a focus on healthy eating by providing companies with the WorkWell for Healthy Eating Toolkit. The Toolkit contains a step-by-step approach, including how to write a healthy eating policy for the company and ideas to change the food environment at the workplace (eg providing drinking water and low-fat milk, changing the caterer to a healthier option). Other tools provided are Guidelines for workplace vending machines, Guidelines for snack boxes, Food ideas for work meetings and Drinking water guidelines.
The National Workplace Health Promotion Programme, launched in Singapore in 2000, is run by the Health Promotion Board. Both private and public institutions are encouraged to improve the workplace environment by providing tools and grants. Grants are awarded to help companies start and sustain health promotion programmes. Tools include a sample Healthy Workplace Nutrition Policy, a sample Healthy Workplace Catering Policy, and a detailed Essential Guide to Workplace Health, setting out ways to transform the workplace into a health-supporting work environment by providing a guide on how to improve the nutritional environment in the work place (for example training for canteen providers, engaging a nutritionist).
Since 2012, restaurants and food stores in public hospitals are encouraged to comply with the Department of Health’s Healthy Food Menu policy, which includes the Healthy Menu and the Fatless Belly Menu. The Healthy Menu requires the dish to be cooked using vegetable oil and providing protein (in the form of meat, nuts, or eggs), carbohydrates (rice or noodles), various vegetables and fresh fruit. To comply with the Fatless Belly Menu, the dish should not exceed 400kcal, 15g of fat, 2g of sugar and 600mg of sodium, and it should consist of 50% vegetables, 25% low-fat meat and 25% rice or a starchy carbohydrate.
In 2000, the Ministry of Public Health, in collaboration with the Ministry of Education, introduced the voluntary Childcare Centre Standard. Childcare centres are encouraged to comply with nutrition guidelines for children aged 1–3 years and 4–5 years (last updated 2013); the latest survey, conducted in 2014, showed that 61.4% of childcare centres across Thailand met the Standard. The Standard prohibits sugar-sweetened beverages, meat high in fat, the use of salty seasonings (such as fish and soy sauce) and sugar in dishes, and snacks high in sugar and salt, including a ban to bring such snacks to the centres. They include recommendations on portion size for underweight, normal and overweight children as well as the frequency of food groups and meals. In addition, childcare centres have to comply with the Thai Recommended Daily Intake (RDI) (last amended 2003) for 3–5 year olds which are based on 1,200kcal/day and recommend a distribution ratio of 55–60% carbohydrates, 10–15% protein and 25–30% fat. The RDI sets maximum levels of protein, fat, total carbohydrate, and cholesterol, and contains recommended levels of vitamins (A, B1, B2, C), folate and calcium. The Standard and RDI are intended to prevent both undernutrition and overweight/obesity.
Vending machines dispensing crisps, chocolate and sugary drinks are prohibited in National Health Service hospitals in Wales. The Welsh government issued a guidance defining what is allowed and not allowed, and has liaised with major vending providers to find ways to introduce healthier food and drink options (Health Promoting Hospital Vending Directions and Guide 2008). In 2008, the Scottish government issued guidelines to chief executives of the National Health Service on the provision of competitively priced fruit and vegetables in hospital settings and the removal of all soft drinks with a sugar content >0.5g per 100ml from vending machines (unsweetened fruit and vegetable juices are exempt). The 2012 update of the guidelines relaxed this requirement to 70% of drinks having to comply with the sugar limit of 0.5g per 100ml (but some hospital boards choose to retain the complete removal of sugary drinks), and mandated that vending machines must contain prominently positioned water, unsweetened fruit juice and/or low-fat milk. In addition, the guidelines require that at least 30% of snacks/confectioneries and 70% of refrigerated food in hospital vending machines meet the specified criteria of “healthier choices” which set limits on the permissible content of fat, saturated fat, sugar and salt/sodium.
New York City’s Food Standards (enacted with Executive Order 122 of 2008, revised in 2014) set nutritional standards for all food purchased or served by city agencies, which applies to prisons, hospitals and senior care centres. The Standards include: maximum and minimum levels of nutrients per serving; standards on specific food items (eg only no-fat or 1% milk); portion size requirements; the requirement that water be offered with food; a prohibition on the deep-frying of food; and daily calorie and nutrient targets, including population-specific guidelines (eg children, seniors). As of 2015, 11 city agencies are subject to the NYC Food Standards, serving and selling almost 250 million meals a year. The Food Policy Coordinator has the responsibility of ensuring adherence with the Food Standards. Self-reported compliance with the standards is 96%. New York City’s Health Code also contains regulations on sweetened beverages and 100% fruit juices served in children’s camps and children’s day care centres. In camps, beverages containing caffeine, artificial sweeteners and non-nutritive sweeteners are banned, and maximum calorie levels and serving portions set. In day care centres, drinks with added artificial and natural sweeteners are banned, and children may only be served a maximum of 4 ounces (118ml) of 100% juice per day; children younger than two do not receive juice.
Based on Executive Order 509 (2009), the Massachusetts State Agency Food Standards set standards per category for all food purchased by state agencies and their contractors. The Standards include targets for nutrient requirements, including guidelines for specific populations (ie children, elderly). The Standards contain a ban on trans fat and deep-frying, and maximum levels of sodium in food and calorie levels of beverages. They are applicable to food served to agencies’ clients and patients (ie hospitals, prisons, childcare services); food served for sale, and to agencies’ employees is excluded.
In effect since October 2011, Boston's Healthy Beverage Executive Order directs city departments to eliminate the sale of sugar-sweetened beverages on city property and to adhere to the City of Boston's Healthy Options Beverage Standards (developed by the Boston Public Health Commission) in all vending machines, and city-managed food and beverage services programmes, contracted food or beverage services, food or beverage procurement, leases and other agreements for food or beverage concessions in or around city-owned buildings.
The Healthy Options Beverage Standards outline the requirements for beverages that can be sold: no calorically-sweetened cold beverages; fruit and/or vegetable beverages must be 100% juice and where possible servings shall not exceed 8 ounces or 150 calories and be low-sodium varieties; milk, soy milk and other milk substitute offerings are limited to 1% or skim milk, not exceeding 12 ounces in volume with <25g of total sugars per 8 ounce serving; diet or other non-calorically sweetened beverages should be less than one third of total beverage offerings.
In addition, only products that qualify as Healthy Options Beverages are permitted to be promoted on vending machines (eg sides, front graphic panel, etc).
When the Executive Order was issued, the Healthy Options Beverage Standards were visualised on point-of-decision education materials through a traffic light system (eg "drink rarely, if at all" (red), "drink occasionally" (yellow), and "drink plenty" or "healthy choice" (green).
In effect since December 2016, San Francisco’s Healthy Vending Machine Policy (Ordinance No. 91-16) requires that food and drinks sold in vending machines on City property must meet specified nutrition standards and calorie-labelling requirements. Nutritional standards for pre-packaged foods include: <200 calories per serving, <35% of calories from fat, <1g of saturated fat per serving, no trans fat or partially hydrogenated oil on the ingredient list, <35% of weight from total sugars, <240mg of sodium per serving and no candy except for sugar-free mints and gum, no chips except for baked chips and pretzels. No sugary drinks (defined as any non-alcoholic beverage sold for human consumption that has one or more added caloric sweeteners and contains >25 calories per 12 ounces) are permitted in vending machines, with the following exemptions: 100% fruit juice with no added sugars or sweeteners, <230mg of sodium per serving and <120 calories per 8 fluid ounces; low-fat (1%) or fat-free milk; and 25% of drinks sold/offered may be labelled as “diet” or sweetened with artificial sweeteners. Calorie labelling must be clear, conspicuous and must be visible in, on or adjacent to the vending machine. In effect since September 2015, a separate policy (Ordinance No. 99-15) bars City departments from purchasing and city contractors or grantees from selling, serving or distributing sugar-sweetened beverages.
Added in February 2018: In 2014, Good Food, Healthy Hospitals (GFHH) was launched by the Philadelphia Department of Public Health (PDPH) together with The Common Market (a non-profit organisation working to improve food access to vulnerable populations), and the American Heart Association. GFHH is an initiative to promote healthy foods and beverages for patients, staff and visitors in Philadelphia hospitals. GFHH invites hospitals to voluntarily adopt five food standards across five hospital food environments: purchased foods and beverages, cafeteria meals, patient meals, catering, and vending machine operations. The GFHH team engages hospital staff from food service, purchasing, clinical, wellness, and administrative departments to create a cross-disciplinary approach to providing healthier food and beverage options. They also provide technical assistance and resources to support their efforts. As of December 2017, 16 hospitals signed the pledge to adopt GFHH.
Philadelphia’s Comprehensive Nutrition Standards (enacted with Executive Order 4-14 of June 2014) set nutritional standards for all food and beverages purchased, prepared or served by all City agencies. They provide both required and recommended guidelines around foods purchased, meals and snacks served, and vending machines as well as best practice guidelines for special occasions, sustainability, concessions, and catering. The Standards are based on the USDA’s 2015 Dietary Guidelines for Americans. The Philadelphia Department of Public Health (PDPH) provides technical assistance to City Agencies to help implement the Nutrition Standards, which entails collecting menus and nutrition analysis and assessing changes, creating individualized implementation plans for the departments to come into compliance, drafting contract language, and engaging vendors to increase the availability and accessibility of products that meet our nutrition standards. PDPH has also partnered with Health Promotion Council, a non-profit organization, to provide group and one-on-one nutrition and cooking trainings to department staff to help implement the standards (See “G – Give nutrition education and skills). Each year, the City serves or sells over 20 million meals and snacks to almost 64,000 Philadelphians.
Cradock AL et al. (2015) Evaluating the impact of the Healthy Beverage Executive Order for City Agencies in Boson, Massachusetts, 2011–2013. Preventing Chronic Disease 12:140549
Added February 2018: Lederer A et al. (2014) Toward a Healthier City: Nutrition Standards for New York City Government. American Journal of Preventive Medicine 46(4): 423-428
Empirical estimates show that food prices influence, to a varying degree, how much food people buy. Targeted subsidies have been shown to help overcome affordability barriers to healthy food for people on low incomes. Incentives, like financial rewards or price discounts, have also been shown to encourage people to switch to healthier options.
Emerging evidence from implemented taxes, as well as modelling studies, indicate the potential for effectiveness to reduce consumption. Given food choices are influenced by a whole host of factors, especially in modern, complex food markets, taxes must be designed very carefully to maximise effectiveness.
In June 2015, the government of Barbados passed a 10% excise tax on locally produced and imported sugary drinks, including carbonated soft drinks, juice drinks, sports drinks and others. Drinks exempt from the tax include 100% natural fruit juice, coconut water, plain milk and evaporated milk. The tax came into effect on 1 August 2015 and will be reviewed after two years.
Alvarado, Miriam, et al. (2017) Trends in beverage prices following the introduction of a tax on sugar-sweetened beverages in Barbados. Preventive Medicine
In December 2015, the Belgian government increased the excise duty on soft drinks by 0.03 euros per litre as part of a general “health tax” (Law on measures to strengthen job creation and purchasing power–26 December 2015). The now 0.068 euro (around $0.07) per litre excise duty came into effect on 1 January 2016 and is applied to all soft drinks, including non-alcoholic drinks and water containing added sugar or other sweeteners or flavours. An excise duty is also applied to any substance intended for the use of manufacturing soft drinks (liquid: 0.41 euros/litre, around $0.45; powder: 0.68 euros/kg, around $0.70).
In effect since 1 April 2017, Brunei applies an excise duty at a rate of 0.40 BND (around $0.28) per litre for sugar-sweetened beverages with more than 6g of total sugar per 100ml, soya milk drinks with more than 7g of total sugar per 100ml, malted or chocolate drinks with more than 8g of total sugar per 100ml and coffee based drinks or coffee flavoured drinks with 6g of total sugar per 100ml. Milk-based beverages and fruit juices are exempt from the tax.
Since 1 January 2015, Chile has applied an 18% ad valorem tax on sugary drinks that contain more than 6.25g of sugar per 100ml, raised from a 13% ad valorem tax on sugary drinks introduced on 1 October 2014. Sugary drinks include all non-alcoholic drinks with added sweeteners including energy drinks and waters. Sugary drinks with less than 6.25g of sugar per 100ml are taxed at 10%.
In October 2011, Denmark introduced a tax of 16DKK (around $2.70) per kg of saturated fat for products exceeding 2.3g saturated fat per 100g fat. Taxed products included meat, animal fat, dairy products, margarine and spreads, edible vegetable oils and fats as well as items containing these products. The tax was abolished as of 1 January 2013.
Smed S et al. (2016) The effects of the Danish saturated fat tax on food and nutrient intake and modelled health outcomes: an econometric and comparative risk assessment evaluation. European Journal of Clinical Nutrition 70, 681-686
Bødker M et al. (2015) The Danish fat tax—Effects on consumption patterns and risk of ischaemic heart disease. Preventive Medicine 77, 200-203
In effect since 1 September 2015, Dominica applies a 10% excise tax to food and drinks with high sugar content. This includes sweets, candy, chocolate bars, soft drinks and other sweetened drinks (including energy drinks). Revenues from the tax will contribute to a national Get Healthy campaign.
Updated February 2018: In the mid-year budget of 23 June 2016, Fiji raised the excise duty on locally produced sweetened beverages from 10 cents/litre (around $0.05/litre) to 30 cents/litre (around $0.15/litre). In August 2017 the excise duty was further raised to 35 cents/litre (around $0.17/litre). Imported sweetened beverages are subject to an ad valorem excise duty of 15% (raised from 10% in 2011), and imported powders and preparations to make beverages (other than milk-based drinks) as well as flavoured and coloured sugar syrups are taxed at 10% since 2007. Taxed beverages include carbonated and non-carbonated drinks sweetened with sugar or artificial sweeteners. The tax increase aims to protect children from obesity and lifelong poor health. Tax revenue goes to the general fund.
Finland imposed excise taxes on non-alcoholic beverages and confectionery for most of the 20th century for revenue-raising purposes. The excise duty on confectionery was removed in 2000, re-introduced in 2011 and removed again in January 2017. In 2014, the tax rate was 0.95 euros per kg by weight for confectionery and ice cream, 0.22 euros per litre for beverages with more than 0.5% sugar and 0.11 euros per litre for other non-alcoholic beverages. The tax on candy and ice cream was removed on 1 January 2017. Currently an excise tax is levied on non-alcoholic beverages. Producers with an annual production volume of less than 50,000 litres are exempted from the tax.
In effect since 1 January 2012, the French soda tax is an excise duty applied to drinks with added sugar and artificial sweeteners, including sodas, fruit drinks, flavoured waters and "light" drinks (Law no 2011-1977). The tax is around 11 euro cents per 1.5 litres of soda and used to raise revenue for the general budget.
Berardi N et al. (2012) The impact of a ‘soda tax’ on prices: Evidence from French micro data. Working Paper No. 415, Banque de France
Various food and beverage taxes have been in place in French Polynesia since 2002 to discourage consumption and raise revenue: domestic excise duty on sweetened drinks and beer; import tax on sweetened drinks, beer and confectionery; tax on ice cream. Between 2002 and 2006, tax revenue went to a preventive health fund; from 2006, 80% has been allocated to the general budget and earmarked for health. The tax is 40 CFP (around $0.44) per litre on domestically produced sweet drinks, and 60 CFP (around $0.68) per litre on imported sweet drinks.
Thow AM et al. (2010) Taxing soft drinks in the Pacific: implementation lessons for improving health. Health Promotion International 26(1), 55-64
In July 2011, Hungary passed Act CIII on the Public Health Product Tax. Effective since September 2011, the "public health tax" is applied on the salt, sugar and caffeine content of various categories of ready-to-eat food, including soft drinks (both sugar- and artificially-sweetened), energy drinks and pre-packaged sugar-sweetened products. The tax is applied at varying rates. Soft drinks, for example, are taxed 7 forints (about $0.024) per litre, concentrated syrups used to sweeten drinks are taxed 200 forints (about $0.70) per litre and pre-packaged sugar-sweetened products are taxed 130 forints (about $0.45) per kg. The tax also applies to products high in salt, including salty snacks with >1g salt per 100g, condiments with >5g salt per 100g and flavourings >15g salt per 100g.
Bíró A (2015) Did the junk food tax make the Hungarians eat healthier? Food Policy 54, 107-115
National Institute for Food and Nutrition Science Directorate General. Assessment of the impact of a public health product tax, Final report. World Health Organization, Regional Office for Europe, November 2015
Added February 2018: On 1 July 2017, The Constitution (One Hundred and First Amendment) Act 2017 came into force across India which introduced a Goods and Services Tax of 28% on all goods [including aerated waters], containing added sugar or other sweetening matter or flavour with a further 12% cess added on top of the tax. This Act replaces all other GST laws at State level and is applied across India. It is the highest GST rate for goods in India.
In 2014, Kiribati imposed an excise duty of 40% on non-alcoholic beverages (including mineral and aerated waters) that contain added sugar, other sweeteners or flavourings; fruit and vegetable juices as well as fruit concentrates are exempt from the tax.
As of October 2016, Mauritius applies an excise tax to all sugar-sweetened beverages, whether imported or locally manufactured. Sugar-sweetened beverages include juices, milk-based beverages and soft drinks. Previously, the tax was only applied to the sugar content of soft drinks (since 1 January 2013). In 2016, sugar-sweetened beverages were taxed at 0.03 rupees (around $0.0008) per gram of sugar.
In December 2013, the Mexican legislature passed two new taxes as part of the National Strategy for the Prevention and Control of Overweight, Obesity and Diabetes (Estrategia Nacional Para Un Mexico Sin Obesidad). They entered into force on 1 January 2014. An excise duty of 1 peso (around $0.05) per litre applies to sugary drinks. Sugary drinks are defined under the law as all drinks with added sugar, excluding milks or yoghurts. Preliminary price monitoring indicates that the price of sugary drinks has increased by around 10%. The revenue from the sugary drink tax should be allocated to fund programmes addressing malnutrition, obesity and obesity-related chronic diseases, as well as access to drinking water (6th transitory article, Federal Law on Income for the Fiscal Year 2017); however, the revenue is currently being allocated to the general budget. An ad valorem excise duty of 8% applies to food with high caloric density, defined as equal to or more than 275 calories per 100g. The food product categories that are affected by the tax include chips and snacks, confectionery, chocolate and cacao based products, puddings, peanut and hazelnut butters.
In effect since 1 January 2011, a 25% tax is applied to energy drinks. Energy drinks were added to the Special Tax on Production and Services Law (Ley del Impuesto Especial sobre Producción y Servicios) by Decree on 19 November 2010. The Law defines energy drinks as non-alcoholic beverages with >20mg per 100ml of caffeine and mixed with stimulants (eg taurine). The Law also applies to concentrates, powders and syrups used to prepare energy drinks.
Colchero MA et al. (2017) In Mexico, Evidence Of Sustained Consumer Response Two Years After Implementing A Sugar-Sweetened Beverage Tax. Health Affairs 36(3), 564-571
Added February 2018: Taillie L S et al. (2017) Do high vs. low purchasers respond differently to a nonessential energy-dense food tax? Two-year evaluation of Mexico's 8% nonessential food tax. Preventive medicine, 105, S37-S42
Batis C et al. (2016) First-Year Evaluation of Mexico’s Tax on Nonessential Energy-Dense Foods: An Observational Study. PLoS Medicine 13(7): e1002057
Added February 2018: Colchero M et al. (2016) Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. British Medical Journal, 352, h6704
Implemented in 1981, Norway taxes non-alcoholic beverages containing added sugar or sweeteners, chocolate, sugar and sugar products. In 2017, beverages are taxed at 3.34 NOK per litre ($0.40), concentrated syrups at 20.32 NOK per litre ($2.44), chocolate and sugar products at 20.19 NOK per kg ($2.43), and sugar at 7.81 NOK per kg ($0.94).
Added February 2018: In September 2003, the Palau government introduced "Title 40 Chapter 13 § 1301 Imposition of import tax" of the Palau National Code. The Code introduced an import tax of 10 cents per 12oz or fractional part thereof ($0.28175 per litre) on carbonated soft drinks.
Added February 2018: On 1 January 2018, the Philippines government implemented a sweetened beverage excise tax of six pesos per litre (about $0.12) on products using purely caloric and purely non-caloric sweeteners or a mix of both as part of the Tax Reform for Acceleration and Inclusion (TRAIN) tax reform programme under Republic Act 10963. It also implemented a 12 pesos per litre (about $0.24) excise tax on drinks using purely high-fructose corn syrup or in combination with any caloric or non-caloric sweetener. The products taxed include non-alcoholic beverages that contain caloric sweetener (defined as a substance that is sweet and includes sucrose, fructose or glucose) or non-caloric sweetener (defined as a substance that is artificially or chemically processed that produces a certain sweetness, and includes aspartame, sucralose, saccharin, acesulfame potassium, neotame, cyclamates and other non-nutritive sweeteners). Taxed sweetened beverages include the following: sweetened juice drinks; sweetened tea; all carbonated beverages; flavoured water; energy and sports drinks; other powdered drinks not classified as milk, juice, tea or coffee; cereal and grain beverages; and other non-alcoholic beverages that contain added sugar. 100% natural fruit and vegetable juices, milk products, and meal replacement and medically indicated beverages are exempt from the tax.
Added February 2018: The State Budget for 2017 (1 January 2017) introduced a new tax on sugar-sweetened drinks, which came into effect on 1 February 2017. Under the Special Taxes on Consumption (Decreto-Lei No. 73/2010, de 21/06), non-alcoholic beverages with a sugar content of less than 80g per litre will be charged at €0.08 per litre (about $0.10); or €0.16 per litre (about $0.20) when the sugar content exceeds 80g/l. The tax covers mineral, flavoured and aerated waters that contain added sugar or other sweeteners.
Soft drinks, both imported and locally produced, have been taxed in Samoa since 1984. From 1984 until 2008, the excise tax amounted to 0.3 Samoan Tala per litre (around $0.12); in 2008 the rate changed to 0.4 Samoan Tala per litre (around $0.17).
In 2007, Samoa imposed a ban on high fat turkey tails. In 2012 the ban was lifted when Samoa joined the World Trade Organization and a 300% import duty was set for two years followed by a 100% import duty.
The Kingdom of Saudi Arabia’s Government approved the Excise Tax Law which went into effect on 9 June 2017, and all businesses that import or produce stock of excisable goods are expected to register with the General Authority of Zakat and Tax (GAZT). The excise tax rates imposed by the law are a 100% tax rate on energy drinks and a 50% tax rate on carbonated drinks (including soft drinks, carbonated water, and juice). The rates may differ depending on the nature of the product. For example, carbonated drinks may have different tax rates if they are dispensed as fountain drinks or as cans. GAZT has published a user manual for those required to register for excise tax.
In effect since 1 May 2017, the region of Catalonia, Spain, applies a tax on packaged sugary drinks (under Law 5/2017). Sugary drinks include soft drinks, flavoured water, chocolate drinks, sports drinks, cold tea and coffee drinks, energy drinks, fruit nectar drinks, vegetable drinks, and sweetened milk, alternative milk drinks, milkshakes and milk drinks with fruit juice. The Catalan regional government’s levy increases the price of drinks with 5–8g of sugar for every 100ml by 0.08 euros per litre and the price of drinks with >8g of sugar for every 100ml by 0.12 euros. Natural fruit juices, alcoholic beverages, sugar-free soft drinks and alternatives to milk with no added caloric sweeteners are not taxed.
In effect since 27 May 2014, a £0.75 per litre excise duty (about $0.95) is applied to high-sugar carbonated drinks in St Helena (Customs and Excise Ordinance Chapter 145, Section 5). High sugar carbonated drinks are defined as drinks containing ≥15 grams of sugar per litre.
In effect since 1 May 2016, St Vincent and the Grenadines applies a value added tax of 15% to brown sugar. The measure was put in place to help encourage a reduction in sugar consumption. Revenue from the tax goes to a consolidated fund to help finance initiatives to treat diabetes.
Added February 2018: On 16 September 2017, the Excise Tax B.E. 2560 (2017) went into effect in Thailand introducing an excise sugar tax on certain beverages. An ad valorem rate is applied to the following beverages: artificial mineral water, soda water, and carbonated soft drinks without sugar or other sweeteners and without flavour; mineral water and carbonated soft drinks with added sugar or other sweeteners of flavours (14%); fruit and vegetable juices (10%). An additional specific tax on sugar is added to the ad valorem tax starting at 0.10 baht (about $0.0031) per litre for drinks containing over 6 grams to 8 grams; 0.30 baht (about $0.0095) per litre for drinks containing 8 grams to 10 grams; 0.50 baht (about $0.015) per litre for drinks containing 10 grams of sugar to 14 grams and 1 baht (about $0.031) per litre for drinks containing over 14 grams per 100ml of sugar. The sugar tax increases every two years and by the year 2023 onwards the tax will be 1 baht per litre for drinks containing 6 to 8 grams; 3 baht (about $0.095) for drinks from 8 grams to 10 grams; 5 baht (about $0.15) per litre for drinks over 10 grams.
As of 2013, Tonga taxes soft drinks containing sugar or sweeteners at 1 Pa’anga per litre (around $0.50). The 2013 taxes on animal fat products (eg lard and drippings) were increased in 2016 from 1 Pa’anga to 2 Pa’anga per kilogram (around $0.90), and on turkey tails from 1 Pa’anga to 1.5 Pa’anga (around $0.70).
On 17 August 2017, the Federal Decree-Law No.(7) of 2017 on Excise Tax (“UAE Excise Tax Law”) was introduced. The UAE Excise Tax Law came into effect on 1 October 2017. The excise tax applies to the import, manufacture, stockpiling or release of excisable goods. While the law does not list the goods that will be subject to the excise tax, the Federal Tax Authority has outlined that a 50% tax will be applied to all carbonated drinks, and a 100% tax will be applied to energy drinks. Carbonated drinks include any aerated beverage except for unflavoured aerated water. This includes concentrations, powders, gel or extracts intended to be made into an aerated beverage. Energy drinks include beverages which are marked, or sold as an energy drink, and contain stimulant substances that provide mental and physical stimulation.
In November 2014, the city of Berkeley, California, passed a law (Ordinance 7388-NS) taxing sugary drinks. An excise duty of one cent per ounce of a sugar-sweetened beverage applies to soda, energy drinks and heavily pre-sweetened tea, as well as to the “added caloric sweeteners” used to produce them (note: tax on an ounce of added caloric sweeteners would be significantly more than $0.01). Infant formula, milk products, and natural fruit and vegetable juices are exempt. The Ordinance has a duration of 12 years and was implemented in March 2015 (initial effective date had been planned to be 1 January 2015). The revenue goes into the City's general fund, which funds community health and nutrition programmes.
In November 2014, the Navajo Nation adopted the Healthy Diné Nation Act (Legislation No CN-54-14) into law. It includes a 2% tax on “minimal-to-no-nutritional value food items”, including sugar-sweetened beverages, pre-packaged and non-prepackaged snacks stripped of essential nutrients and high in salt, saturated fat and sugar including sweets, chips and crisps. The tax was implemented on 1 April 2015. Revenue from the tax is earmarked for the Community Wellness Development Projects Fund and used for projects such as farming, vegetable gardens, greenhouses, farmers' markets, healthy convenience stores, clean water, exercise equipment and health classes. The tax is collected through self-reporting.
In November 2016, the City of Albany passed Ordinance 2016-02 which introduced a one cent per ounce general tax, with no expiration date. The policy came into effect on 1 April 2017. The ordinance imposes a general tax on the distribution of sugar-sweetened beverages including soda, energy drinks, and heavily sweetened tea, as well as added caloric sweeteners used to produce these sugar-sweetened beverages (for example the premade syrup used to make fountain drinks). “Added caloric sweetener” is defined as any substance or combination of substances that is suitable for human consumption, adds calories to the diet if consumed, is perceived as sweet when consumed and is used for making, mixing, or compounding sugar-sweetened beverages by combining the substance or substances with one or more ingredients including, without limitation, water, ice, powder, coffee, tea, fruit juice, vegetable juice, or carbonation or other gas. Added caloric sweeteners include sucrose, fructose, glucose, other sugars, and high fructose corn syrup. The tax does not apply to infant formula, milk products, natural fruit and vegetable juice.
In effect since 1 January 2017, a 1.5 cents per ounce tax is applied to sugary and diet beverages distributed or supplied in Philadelphia, Pennsylvania (Bill 160176). The tax is applied to any non-alcoholic beverage with caloric sugar-based sweetener or artificial sugar substitute listed as an ingredient, including soda, non-100% fruit drinks, sports drinks, flavoured water, energy drinks, pre-sweetened coffee or tea, and non-alcoholic beverages intended to be mixed into an alcoholic drink. The tax also applies to any non-alcoholic syrups or other concentrate used in beverages (both caloric sugar-based sweetener and artificial sugar substitute) at a rate of 1.5 cents per ounce on the resulting beverage. Revenue from the tax is planned to help fund community initiatives including pre-kindergarten schooling, community schools, parks, recreations centres and libraries. In June 2017, the Philadelphia Court of Common Pleas ruled that the tax is lawful, following an appeal by the American Beverage Association, local restaurants and merchant associations. The case is now on the way to the Supreme Court of Pennsylvania.
In effect since 1 July 2017, a two cents per ounce excise tax is applied on the distribution of sugar- sweetened beverages in Boulder, Colorado (Ordinance No. 8130). A sugar-sweetened beverage is defined as any non-alcoholic beverage which contains at least 5 grams of caloric sweetener per 12 fluid ounces. Products exempt from the tax include any milk product, infant formula, any alcoholic beverage, any beverage for medical use and any distribution of syrups and powders sold directly to a consumer intended for personal use. The Sugar Sweetened Beverage Product Distribution Tax is a voter-initiated tax that was adopted by Boulder voters in the November 2016 election. The revenue will be spent on health promotion, general wellness programmes and chronic disease prevention that improve health equity such as access to safe and clean drinking water, healthy foods, nutrition and food education, physical activity, and other health programmes especially for residents with low income and those most affected by chronic disease linked to sugary drink consumption. Those who fail to file their returns and remit tax payments will be subject to enforcement action.
In effect since 1 July, 2017, a one cent per ounce excise tax is applied on the distribution of sugar-sweetened beverages in Oakland, California (Ordinance No. 86161). Sugar-sweetened beverages are defined as any beverage to which one or more caloric sweeteners have been added and that contain ≥25 calories per 12 fluid ounces of beverage. Taxed beverages include sodas, sports drinks, sweetened teas and energy drinks. Exemptions include milk products, 100% juice, infant or baby formula, diet drinks or drinks taken for medical reasons. The Sugar-Sweetened Beverage Distribution Tax was approved by voters in the November 2016 election. “Distribution” includes the sale of beverages or sweeteners by one business to another (such as a sale from a wholesale business to a retail business) or the transfer of beverages or sweeteners from a wholesale unit of a business to one of its retail units. “Distribution” does not include retail sales to customers. The distribution of sugar-sweetened beverages will not be taxed more than once in the chain of commerce. Revenue from the tax will be deposited into the City’s general fund, and the City could use the revenue for any lawful governmental purpose. The tax will not apply to any distributor that is a small business. “Small Business” is defined as a business with less than $100,000 in yearly gross sales, if the business distributes sugar-sweetened beverages directly to consumers.
Added February 2018: On 1 January 2018, a law taxing sugary drinks (Council Bill 118965 6/5/2017) came into effect in Seattle, Washington. An excise duty of 1.75 cents per fluid ounce of sugar-sweetened beverages and 1 cent per ounce for manufacturers (with a worldwide gross income of more than $2m but less than $5m) applies to beverages with caloric sweeteners and the syrups and powders that are used to prepare them, including sodas, energy drinks, fruit drinks, sweetened teas and ready-to-drink coffee drinks. Beverages that contain fewer than 40 calories per 12-ounce serving: beverages with milk as the principle ingredient, 100% natural fruit and vegetable juice, meal replacement beverages, infant formula and concentrates used in combination with other ingredients to create a beverage are excluded from the tax. The Sweetened Beverage Tax Community Advisory Board will review and make recommendations on the plans to implement and review programmes funded with the revenue. For the first five years, 20% of the funds raised from the tax will be set aside for one-time expenditures, then this allotment will cease. The remainder of the funds will support public health, nutrition education, food security and healthy affordable food access; evidence-based programmes that address disparities, administration of the tax and Advisory Board and programme evaluation.
Added February 2018: On 1 January 2018, a law taxing sugary drinks (Proposition V 11/8/2016) came into effect in San Francisco, California. An excise duty of 1 cent per ounce applies to sugar-sweetened beverages containing added sugar and more than 25 calories per 12 ounces. The tax also applies to syrups and powders that can be made into sugar-sweetened beverages. Beverages containing solely 100% juice, artificially sweetened beverages, infant formula and milk products are exempt from the tax. Revenue from the tax goes into the City’s General Fund. An advisory committee will submit an annual report evaluating the impact of the tax on beverage prices, consumer purchasing behaviour and public health, and make recommendations on the potential establishment and/or funding of programmes to reduce the consumption of sugar-sweetened beverages.
Silver, LD et al. (2017) Changes in prices, sales, consumer spending, and beverage consumption one year after a tax on sugar-sweetened beverages in Berkeley, California, US: A before-and-after study. PLoS Medicine 14(4): e1002283
Falbe J et al. (2016) Impact of the Berkeley Excise Tax on Sugar-Sweetened Beverage Consumption. AJPH 106(10), 1865-1871
In effect since 9 February 2015, a 50 vatu (around $0.47) per litre excise duty is applied to carbonated beverages containing added sugar or other sweetening matter in Vanuatu (Excise (Amendment) Act No.32). Beverage is defined as "waters, including mineral waters and aerated waters, containing added sugar or other sweetening matter or flavoured".
As part of the #SugarSmartCity campaign (see “I – Inform people about food and nutrition through public awareness" for details), Brighton & Hove City Council is promoting a voluntary sugar tax. The City Council actively encourages food outlets to adopt a voluntary £0.10 levy (around $0.15) on all non-alcoholic sugar-sweetened drinks sold. Money raised from the voluntary levy goes to the Children’s Health Fund, set up by Sustain: the Alliance for Food and Farming in partnership with Jamie Oliver in August 2015, to support food education and health initiatives for children.
These countries have all introduced import duties on either soft drinks or sugar; Nauru also taxes high-sugar food. These are either charged ad valorem (Cook Islands – 15% with a subsequent 2% rise per year, since 2013; Fiji – 32%, since 2011; Micronesia – 25%, since 2004; Nauru – 30%, since 2007) or on a certain volume or weight of goods (French Polynesia – around $0.68 per litre for imported drinks, since 2002; Samoa – around $0.17 per litre, since 2008).
In 2012, Fiji implemented an import duty on palm oil and monosodium glutamate of 32%.
In 2016, Tonga implemented an import duty of 15% on turkey tails, lamb flaps and lamb breasts.
To promote vegetable and fruit consumption, Fiji has removed the excise duty on imported fruits, vegetables and legumes. It has also decreased the import tax for most varieties from the original 32% to 5% (exceptions: 32% import tax remains on tomatoes, cucumbers, potatoes, squash/pumpkin; and 15% on coconuts, pineapples, guavas, mangosteens) and removed it for garlic and onions.
In 2013, as part of a broader package of fiscal measures, Tonga lowered import duties from 20% to 5% for imported fresh, tinned or frozen fish in order to increase affordability and promote healthier diets.
*Private insurance providers also offer private subsidy schemes. For example, South Africa’s largest private health insurer, Discovery Health, runs the cash back rebate programme "Vitality", in which healthier items purchased in food shops receive a 10% discount.
Launched on 1 April 2011, Nutrition North Canada (NNC) is a government of Canada subsidy programme that helps provide northerners in isolated communities with improved access to perishable, nutritious food. NNC provides a retail-based subsidy that enables local retailers and registered suppliers to access and lower the cost of perishable healthy foods like meat, fish, eggs, milk and bread, as well as fruit and vegetables, all of which must be transported by air to these isolated communities. NNC also subsidises commercially processed country or traditional foods such as Arctic char, muskox, and caribou. NNC has two subsidy levels: level 1, which is the higher subsidy, is granted to foods that are deemed the most perishable and most nutritious; while level 2, the lower subsidy, is applied to other staple food items.
Eligibility is based on isolation factors and focuses on communities that lack year-round surface access (no permanent road, rail or marine access) requiring goods to be flown in. Effective 1 October 2016, 121 northern communities had full access to the NNC subsidy. Four criteria inform subsidy rates, which vary across communities: 1) geographical distance from the supply centre to the isolated community, 2) distance flown, 3) population according to the census, and 4) minimum wage.
Residents in eligible communities can purchase subsidised food from registered northern retailers. Individuals, local restaurants and social institutions can also access the subsidy by ordering eligible items directly from registered suppliers. Retailers and suppliers are responsible for passing on the full subsidy to consumers and participate in regular compliance reviews as part of their agreement with the department of indigenous and northern affairs Canada. In order to increase programme transparency, on 1 April 2016, NNC implemented a mandatory point-of-sale system allowing customers to clearly see the application of the NNC subsidy on their grocery receipts.
Galloway T (2017) Canada’s northern food subsidy Nutrition North Canada: a comprehensive program evaluation. International Journal of Circumpolar Health 76(1), 1279451
Galloway T (2014) Is the Nutrition North Canada retail subsidy program meeting the goal of making nutritious and perishable food more accessible and affordable in the North? Can J Public Health 105(5): e395-397
The British Healthy Start programme provides pregnant women and/or families with children under the age of four with weekly vouchers to spend on food including milk, plain yoghurt, and fresh and frozen fruit and vegetables. Participants or their family must be receiving income support/jobseekers allowance or child tax credits. Pregnant women under the age of 18 can also apply. Full national implementation of the programme began in 2006.
McFadden A et al. (2014) Can food vouchers improve nutrition and reduce health inequalities in low-income mothers and young children: a multi-method evaluation of the experiences of beneficiaries and practitioners of the Healthy Start programme in England. BMC Public Health 14:148
In 2009, the US Department of Agriculture (USDA) implemented revisions to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) to improve the composition and quantities of WIC-provided food from a health perspective.
The New York City Health Department District Public Health Offices distribute Health Bucks to farmers’ markets (launched in 2006). When customers use income support (eg Food Stamps) to purchase food at farmers' markets, they receive one Health Buck worth $2 for each $5 spent, which can then be used to purchase fresh fruit and vegetables at a farmers’ market.
In 2010, the Philadelphia Department of Public Health partnered with The Food Trust to launch Philly Food Bucks as part of Get Healthy Philly, a public health initiative that promotes healthy eating, active living and smoking cessation. The Philly Food Bucks programme incentivises recipients of income assistance under the Supplemental Nutrition Assistance Program (SNAP), formerly known as the Food Stamp Program, to purchase fresh produce. For every $5 spent using SNAP at a participating farmers’ market, shoppers receive $2 in Philly Food Bucks, which are redeemable for fresh produce. The Philly Food Bucks programme increases the purchasing power of low-income shoppers by 40% and increases access to fruit and vegetables. Between 2010 and 2016, over $350,000 worth of fresh fruit and vegetables have been purchased with Philly Food Bucks, and SNAP sales at participating farmers’ markets have increased by more than 300%. In 2015, with the support of the Philadelphia Department of Public Health, local foundations and funding provided by the United States Department of Agriculture (USDA) through its Food Insecurity Nutrition Incentive (FINI) grant programme, The Food Trust expanded the Philly Food Bucks initiative to other retail settings in the State of Pennsylvania, including supermarkets, corner stores, mobile markets, and additional farmers’ markets. Results from a supermarket pilot showed a 49% increase in produce purchasing among SNAP shoppers who participated in the Food Bucks programme. Funding for the programme’s expansion is currently secured until March 2018.
Lu W et al. (2016) Evaluating the Influence of the Revised Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Food Allocation Package on Healthy Food Availability, Accessibility, and Affordability in Texas. Journal of the Academy of Nutrition and Dietetics, 116(2), 292-301
Baronberg S et al. (2013) The Impact of New York City’s Health Bucks Program on Electronic Benefit Transfer Spending at Farmers Markets, 2006-2009. Preventing Chronic Disease 10:130113
Young CR et al. (2013) Improving Fruit and Vegetable Consumption Among Low-Income Customers at Farmers Markets: Philly Food Bucks, Philadelphia, Pennsylvania, 2011. Preventing Chronic Disease 10:120356
Gleason S et al. (2011) Impact of the Revised WIC Food Package on Small WIC Vendors: Insight From a Four-State Evaluation. Altarum Institute, Portland, ME
There is clear evidence that the advertisements children see influence their food preferences and habits. There is also a lot of evidence that children and adolescents around the world are exposed to a whole host of other promotional techniques, whether on a billboard or through a phone or computer.
Emerging evidence shows that restrictions work to reduce children’s exposure to marketing, but this depends on the criteria used in the restrictions. Given the role played by parents and caregivers in what children eat, consideration is needed of how they are also influenced by promotional activities.
In 2012, the Chilean government approved a Law of Nutritional Composition of Food and Advertising (Ley 20.606). In June 2015, the Chilean authority approved the regulatory norms required for the law’s implementation (Diario Oficial No 41.193). They came into effect on 27 June 2016. The regulatory norms define limits for calories, saturated fat, sugar and sodium content considered "high" in food and beverages. The law restricts advertising directed to children under the age of 14 of food in the "high in" category. The regulatory norms define advertising targeted to children as TV programmes or websites directed to children or with an audience of greater than 20% children, or in commercial breaks before, during or after these shows, and according to the design of the advertisement. Promotional strategies and incentives, such as cartoons, animations and toys that could attract the attention of children are included in the ban, as is advertising of food in schools (see below). (See "N – Nutrition label standards and regulations on the use of claims and implied claims on food” and "O – Offer healthy food and set standards in public institutions and other specific settings" for details of the law's labelling and school food regulations.)
Broadcast advertising of soft drinks has been prohibited in Iran since 2004. In 2014, in the context of its Fifth Five-Year Development Plan (2011–2015), the Ministry of Health and Medical Education prepared a list of 24 food items to be prohibited from advertising in all media. The list has been sent to the Commerce, Industry and Finance ministries for approval.
In Ireland, advertising, sponsorship, teleshopping and product placement of food high in fats, sugars and salt, as defined by a nutrient profiling model, are prohibited during children’s TV and radio programmes where over 50% of the audience are under 18 years old (Children’s Commercial Communications Code, 2013 revision). In addition, there is an overall limit on advertising food high in fats, sugars and salt at any time of day to no more than 25% of sold advertising time and to only one in four advertisements. Remaining advertising targeted at children under the age of 13 must not include nutrient or health claims or include licensed characters.
Scully P et al. (2015) Food and beverage advertising during children’s television programming. Irish Journal of Medical Science 184(1), 207-212
Tatlow-Golden M et al. (2015) Creating good feelings about unhealthy food: children’s televised ‘advertised diet’ on the island of Ireland, in a climate of regulation. The Irish Journal of Psychology 36(1-4), 83-100
In February 2014, the Mexican Ministry of Health issued an Order restricting the advertising of food and sweetened beverages, defined according to a nutrient profiling model. The restrictions apply to TV programmes classified as “A” within the times of 2.30–7.30pm on weekdays and 7:00am–7.30pm on weekends, where over 35% of the audience are under age 13. Advertising for this food is also restricted in films classified as “A”. Implementation began on 15 July 2014 for sweetened drinks, potato chips, chocolates and confectionary, and was expected to be extended to other food covered by the nutrient profiling model in January 2015.
Based on the Broadcasting Act No. 127 of 1992 (Chapter 3.1), Norway prohibits marketing directed at children under 18 and advertising in connection with children’s programmes on television, radio and teletext. The ban includes any product, including food and beverages, but only applies to broadcast media originating in Norway. The Broadcasting Regulation No. 153 of 1997 (Section 3.6) provides guidance on how to determine whether advertising is directed to children under 18: whether the advertised product or service is of particular interest to children; if animation or other forms of presentation are used that particularly appeal to children; the time the advertisement is broadcast; and whether children under the age of 13 appear in the advertisement. The use of persons or figures who have played a prominent role on radio and TV programmes for children and young adults received in Norway in the previous 12 months may not be used for commercial advertising.
In South Korea, TV advertising to children under 18 years of age is prohibited for specific categories of food before, during and after programmes shown between 5–7pm and during other children’s programmes (Article 10 of the Special Act on the Safety Management of Children’s Dietary Life, as amended 2010). The restriction also applies to advertising on TV, radio and internet that includes “gratuitous” incentives to purchase eg free toys.
Lee Y et al. (2017) Effect of TV food advertising restriction on food environment for children in South Korea. Health Promotion International 32(1), 25-34
Kim S et al. (2013) Restriction of television food advertising in South Korea: impact on advertising of food companies. Health Promotion International 28(1), 17-25
The 2010 Radio and Television Act (Chapter 8, Sections 7 and 8) prohibits any advertising directed to children below the age of 12 on broadcast and on-demand TV as well as teletext originating in Sweden. Advertising may not precede or follow programmes directed to children below 12. The use of persons or characters who play a prominent role in programmes primarily aimed at children below the age of 12 may not be used for commercial advertising. This general broadcast advertising ban is applicable to food advertising.
Restrictions on food advertising and promotion to children under the age of 12 came into effect on 1 January 2016 in Taiwan (Regulations Governing Advertisement and Promotion of Food Products Not Suitable for Long-term Consumption by Children, pursuant to Article 28 Paragraph 3 of the Act Governing Food Safety and Sanitation).
Restricted food products include snacks, candies, drinks, ice products and food products with fats >30% of total calorie content, saturated fat >10% of total calorie count, food with >400mg of sodium per serving and food where added sugars account for >10% of total calorie count.
Restricted food products are banned from being advertised on “dedicated TV channels for children” (determined by TV channel operators) between 5–9pm. Currently there are 13 “dedicated TV channels for children”. Restricted food products are also banned from being advertised and promoted with toys that are given as free gifts or with an additional price, including at fast food chain restaurants.
Violations to these regulations result in a fine between NT$40,000–NT$4m (about $1,363–$136,320).
The 2010 UK Code of Broadcast Advertising (BCAP Code), replacing the 2007 scheduling restrictions, prohibits advertising and product placement of food high in fats, sugars and salt, as defined by a nutrient profiling model published by the Food Standards Agency in December 2005, during and adjacent to TV and radio programmes with a particular appeal to viewers under 16 years old (includes sponsorship of TV programmes). A “particular appeal” is assumed for programmes commissioned for, or principally directed at children aged below 16, and those reaching an indexing score of 120 and above (the indexing score is calculated as follows: [% of all children aged 4–15 watching / % of people watching out of the total viewing population] x 100). In 2016, Public Health England started a review of the nutrient profiling model specifically in the context of the BCAP Code which is expected to be finalised in 2018. The advertising restriction system is paid for by industry and enforced by the independent Advertising Standards Agency (ASA) which operates under a contract from Ofcom, the UK’s communications regulator.
Added February 2018:
Evaluations of the 2007 scheduling restrictions
Whalen R et al. (2017) Children’s exposure to food advertising: the impact of statutory restrictions. Health Promotion International, https://doi.org/10.1093/heapro/dax044.
Silva, A et al. (2015) An Evaluation of the Effect of Child‐Directed Television Food Advertising Regulation in the United Kingdom. Canadian Journal of Agricultural Economics/Revue canadienne d'agroeconomie, 63(4), 583-600
In 2012, the Chilean government approved a Law of Nutritional Composition of Food and Advertising (Ley 20.606). In June 2015, the Chilean authority approved the regulatory norms required for the law’s implementation (Diario Oficial No 41.193), which came into effect on 27 June 2016. The law restricts advertising directed to children under the age of 14 of food in the "high in" category. The regulatory norms define advertising targeted to children as TV programmes (see above) or websites directed to children or with an audience of greater than 20% children, and according to the design of the advertisement. It also restricts advertising to children on radio and in magazines. Promotional strategies and incentives, such as cartoons, animations, interactive games, apps and toys that could attract the attention of children are included in the ban, as is advertising food in schools (see below). (See "N – Nutrition label standards and regulations on the use of claims and implied claims on food" and "O – Offer healthy food and set standards in public institutions and other specific settings" for details of the law's labelling and school food regulations).
In South Korea, internet advertising that includes “gratuitous” incentives to purchase (eg free toys) is prohibited (Article 10 of the Special Act on the Safety Management of Children’s Dietary Life, as amended 2010).
The National Council for the Rights of Children and Adolescents (Conanda) of Brazil, coordinated by the federal government, published a resolution (Resolução 163 Conanda, 13 March 2014) that establishes criteria for publicity and marketing aimed at children (up to 11 years) and adolescents (12–18 years) and prohibits any kind of "abusive publicity". This resolution can be applied to food publicity, where "abusive publicity" includes any form of market communication (including TV, radio, internet, apps) intended to persuade children and adolescents to consume a product or service using strategies such as childish language, child songs or music sung by children, child representation, people or celebrities that appeal to children, comics or animations, dolls or puppets, promotions using prizes, collectible gifts, competitions or games that appeal to children.
The Conanda resolution is enforced by the Consumer Defense Code (Law 8078/1990) and the Child and Adolescent Statute (Law 8069/1990) and violations are investigated by public authorities. It is reported that in practice, there are many difficulties in fully implementing these restrictions. However, in March 2016, the Superior Court of Justice (Superior Tribunal de Justiça; Brazil’s highest appellate court for non-constitutional questions of federal law) heard the first case related to food marketing to children based on the Conanda resolution. It ruled that “married sales” to children are prohibited under the resolution (“married sales" are promotions in which a food product is advertised alongside a toy or other object a child would like to acquire, but which can only be obtained if a certain quantity of the food product is purchased).
Since 1978, Section 248 of Quebec’s Consumer Protection Act bans any commercial advertising directed at children under 13 on TV, radio, print, internet, mobile phones and signage as well as through the use of promotional items. The ban is applicable, among others, to food and beverage marketing. Section 249 of the Act specifies the three criteria used to determine if a commercial message is directed at children under 13: whether the promoted product is intended for children and/or appeals to them specifically; whether the advertisement’s presentation is appealing to children; and whether the time and place of the advertisement is such that children are exposed to it. Exemptions exist for advertising in children’s magazines, at children’s entertainment events, in store windows and on-pack advertisement if they meet certain criteria (eg the advertisement must not exaggerate the product or directly entice a child to purchase it).
Potvin Kent M, Dubois L, Wanless A (2012) A Nutritional Comparison of Foods and Beverages Marketed to Children in Two Advertising Policy Environments. Obesity 20(9), 1829-1837
Dhar T, Baylis K (2011) Fast-Food Consumption and the Ban on Advertising Targeting Children: The Quebec Experience. Journal of Marketing Research 48(5), 799-813
The Finnish Consumer Protection Act (1978, last updated 2016) regulates all marketing targeting consumers, including food marketing to children. The Consumer Ombudsman’s Guidelines: Children and Foodstuffs Marketing (2004, developed in cooperation with the National Public Health Institute) set out how to apply the Consumer Protection Act. The Guidelines specify that the purpose of food advertisements must be explicit, that the way of presenting cannot be misleading and that advertising practices should not encourage unhealthy dietary habits in children. They also advise to take special care when using marketing techniques with a special appeal to children. Neither the Consumer Protection Act nor the Guidelines define what unhealthy dietary habits and marketing techniques with a special appeal to children are. Whether food marketing to children violates these requirements is decided on a case-by-case basis by the Consumer Ombudsman and the Market Court (the court that hears marketing cases based on the Consumer Protection Act). Considerations regarding the age-appropriateness of marketing are also made on a case-by-case basis, independent of the general definition of a child being a person below the age of 18 under Finnish law. The Guidelines, which are not legally binding, were developed taking into consideration the Market Court’s case law, and contain examples of cases where marketing was found to violate the Consumer Protection Act. Examples are competitions that a child can only participate in if the product is bought; using collectible toys; giving the impression that buying the advertised food will make the child more popular; and masking advertisement as a story. During the past decade, the Consumer Ombudsman has not had cause to take any case concerning food marketing to children to the Market Court, and has instead successfully collaborated with industry to align marketing practices with the Guidelines.
In 2013, the law Promoting Healthy Eating for Children and Adolescents (Ley No 30021) was passed in Peru. The technical parameters for food and drinks considered high in sugar, salt and saturated fat (required for the law to be applied) were approved in April 2015 (Supreme Decree No 007-2015-SA): sugar: ≥2.5g/100ml of drink, ≥5g/100g of food, salt: ≥300mg/100ml of drink or 100g of food, saturated fat: ≥0.75g/100ml of drink, ≥1.5g/100g of food.
The law includes a range of provisions designed to discourage unhealthy diets, including restrictions for advertising aimed at children and adolescents under the age of 16 years through any medium, including not using age inappropriate portion sizes, not using gifts, prizes or any other benefit to encourage purchase or consumption of food or drinks, not using real or fictional characters known to children. The law also includes warnings on advertising for food high in saturated fats, sugars and salt, and containing trans fats: “High in sodium/sugar/saturated fat: avoid excessive consumption”, “Contains trans fat: avoid consuming”.
It is reported that industry compliance is poor and that industry is waiting for the publication of the full implementing regulations (in addition to the technical parameters).
Added February 2018: Thailand’s Control of Marketing Promotion of Infant and Young Child Food Act (B.E. 2560), launched in 2017, bans all advertising of food for infants (eg breastmilk substitutes) and complementary food for infants. Food for young children cannot be advertised if it is linked to or cross-promoting breastmilk substitutes. It is prohibited to use infants or young children in advertisements. The Act outlines that labels on food for infants must be significantly different from food for young children and other foods. Penalties exist for violating the advertising components of this Act, including up to one-year imprisonment.
In Ireland, the 2009 Children’s Commercial Communications Code (as amended 2010) prohibits featuring celebrities in food advertising to children under the age of 18, and using characters and personalities from children’s programming in food advertising to children under 15.
Product placement is covered by restrictions on broadcast advertising in the UK (see above).
In December 2011, San Francisco implemented the Healthy Food Incentives Ordinance (Article 8 Section 471 of the San Francisco Health Code), which bans restaurants, including takeaway restaurants, to give away toys and other free incentive items with children’s meals unless the meals meet nutritional standards as set out in the Ordinance: meals must not contain more than 600 calories, 640mg sodium, 0.5g trans fat, 35% total calories from fat and 10% total calories from saturated fat, and must include a minimum amount of fruit and vegetables, while single food items and beverages must have <35% total calories from fat and <10% of calories from added caloric sweeteners. Incentive items are defined as physical and digital items appealing to children and teenagers as well as coupons, vouchers or similar which allow access to such items.
In 2010, Santa Clara County, California banned restaurants from providing toys or other incentives with menu items high in calories, sodium, fats or sugars. The law (Ordinance No NS-300-820) sets nutrition standards prohibiting restaurants from linking toys or other incentives with single food items or meals with excessive calories (>200 calories for a single food item, >485 calories for a meal), excessive sodium (>480mg sodium for a single food item, >600mg sodium for a meal), excessive fat (>35% of total calories from fat), excessive saturated fat (>10% of total calories from saturated fat), excessive sugars (>10% of total calories from caloric sweeteners) or more than 0.5g of trans fat. It also applies to drinks with excessive calories (>120 calories), excessive fat (>35% of total calories from fat), excessive sugars (>10% of total calories from added caloric sweeteners), added non-nutritive sweeteners or caffeine.
Otten JJ et al. (2014) Impact of San Francisco’s Toy Ordinance on Restaurants and Children’s Food Purchases, 2011-2012. Preventing Chronic Disease 11:140026
Otten JJ et al. (2012) Food Marketing to Children Through Toys: Response of Restaurants to the First U.S. Toy Ordinance. American Journal of Preventive Medicine 42(1), 56-60
In July 2016, the Brazilian Ministry of Health implemented a ban on advertisement and sales promotions of ultraprocesssed food products on the premises of the Ministry of Health and its entities. The marketing ban is incorporated in its Ordinance No 1.274 of 7 July 2016 on healthy food procurement (see “H – Harness supply chain & actions across sectors to ensure coherence with health”). Ultraprocessed food is defined by the Ordinance as food which is mainly produced from substances extracted from unprocessed food and/or food components derived from materials synthesised from organic matter, and which contain ≥1mg of sodium per 1kcal, ≥10% of total energy from free sugars, ≥30% of total energy from total fat, ≥10% of total energy from saturated fat and ≥1% of total energy from trans fat (in alignment with PAHO’s Nutrient Profile Model).
The Latvian Energy Drinks Law (approved in January 2016 and enforced in June 2016) restricts the marketing of energy drinks containing more than 150mg/l caffeine and one or more other stimulants such as taurine and guarana. The Law prohibits the sale of energy drinks to children under 18. The sale and advertising of energy drinks in educational establishments are banned, as is the advertisement of energy drinks on walls of educational establishments, public buildings and structures. The Law requires energy drink advertisements to include warnings on the negative effects of energy drink overuse, accounting for at least 10% of the advertisement. Energy drinks may not be associated with sports activities, indicate that energy drinks can quench thirst or suggest consumption with alcohol. Energy drink advertisements are prohibited before, during and after TV programmes and in print media targeting children under 18. The Law also bans offering energy drinks free of charge to children under 18 for promotional purposes. At the point of sale, warning signs have to be displayed, reading “High caffeine content. Not recommended for children and pregnant and breastfeeding women.”
Since January 2014, the Lithuanian government prohibits companies producing energy drinks from sponsoring venues and events frequented by, or organising events for, persons under 18, such as schools, cinemas, theatres and sporting events. Advertising energy drinks in media, campaigns or contests, or distributing them for advertising purposes among persons under 18 is also banned. Additionally, since July 2014, sale and promotion of energy drinks must be accompanied by a “Do not consume with alcohol” warning. Energy drinks are defined as non-alcoholic beverages excluding coffees that contain at least 150mg caffeine per litre, independent of whether other stimulants are added.
Added February 2018: Article 10 of Executive Decree No. 36910-MEP-S (2012), updated in 2013 (Executive Decree No. 37869), of the Costa Rican Ministries of Health and Education restricts both direct and indirect advertising of food products with high levels of fats, sugars and salt in elementary and high schools. See “O – Offer health food and set standards in public institutions and other specific settings” for details of school food regulations. Partial implementation is reported and not in all schools. A strategy to enforce the decree is currently being developed and will be implemented in 2018.
In 2012, the Chilean government approved a Law of Nutritional Composition of Food and Advertising (Ley 20.606). In June 2015, the Chilean authority approved the regulatory norms required for the law’s implementation (Diario Oficial No 41.193), which came into effect on 27 June 2016. The law restricts advertising directed to children under the age of 14 of food in the “high in” category, including TV programmes, internet, radio and magazines (see above). In addition, the regulatory norms ban the promotion, marketing or advertising of these products in pre-school, primary and secondary schools. (See "N – Nutrition label standards and regulations on the use of claims and implied claims on food" and "O – Offer healthy food and set standards in public institutions and other specific settings" for details of the law's labelling and school food regulations).
Based on Section 8 of Act XLVIII on Basic Requirements and Certain Restrictions of Commercial Advertising Activities (2008), Hungary prohibits all advertising directed at children under 18 in child welfare and child protection institutions, kindergartens, elementary schools and their dormitories. Advertisements promoting a “healthy lifestyle” are exempt from the ban. The term “healthy lifestyle” is not defined by Section 8, and school boards determine on a case-by-case basis if an advertisement complies with this exception, in addition to adhering to national regulatory mechanisms and EU regulations on health claims. Health promotion and prevention activities in schools may only involve external organisations and consultants who are recommended by the National Institute for Health Development according to Section 128(7) of the Ministerial Decree 20/2012 (VIII. 31.) on the Operation of Public Education Institutions and the Use of Names of Public Education Institutions.
Since January 2014, the Lithuanian government has prohibited companies producing energy drinks from advertising in educational institutions attended by persons under 18. Energy drinks are defined as non-alcoholic beverages excluding coffees that contain at least 150mg caffeine per litre, independent of whether other stimulants are added.
In Poland, the 2006 Act on Food and Nutrition Safety (Journal of Laws, item 1225) was amended in November 2014 (Journal of Laws, item 1256) to include rules on sale, advertising and promotion of food (based on a list of food categories) and nutrition standards for canteens in pre-schools, primary and secondary schools (see “O – Offer healthy food and set standards in public institutions and other specific settings” for details). The amended act prohibits the advertising and promotion of food in schools that does not meet the nutrition standards set out in the new regulation (Act of 28 November 2014 amending the act on food and nutrition safety), created by the Ministry of Health. The new act came into effect on 1 September 2015.
In 2011, the Spanish Parliament approved a Law on Nutrition and Food Safety (Ley 17/2011), which stated that kindergartens and schools should be free from advertising. Criteria for the authorisation of food promotion campaigns, nutritional education and promotion of sports or physical activity campaigns were developed jointly by the Spanish Agency for Consumer Affairs, Food Safety and Nutrition (AECOSAN) and the Regional Health Authorities, and implemented in July 2015. AECOSAN and the Spanish Regional Education and Health Administrations monitor enforcement of the law.
In September 2013, the government of Uruguay adopted Law No. 19.140 Alimentación saludable en los centros de enseñanza (Healthy food in schools). The Law prohibits the advertising and marketing of food and drinks that don’t meet the nutrition standards, referenced in Article 3 of the Law, and outlined in school nutrition recommendations published by the Ministry of Health in 2014 (see “O – Offer healthy food and set standards in public institutions and other specific settings”). Advertising in all forms is prohibited, including posters, billboards, use of logos/brands on school supplies, sponsorship, distribution of prizes, free samples on school premises and the display and visibility of food. The law began to be implemented in 2015.
In 2007, the state of Maine passed a law prohibiting brand-specific advertising of certain unhealthy food and beverages on school grounds, at any time. The ban applies to "food of minimum nutritional value" as defined by federal law. It is reported that compliance with the ban is poor.
Polacsek M et al. (2012) Examining compliance with a statewide law banning junk food and beverage marketing in schools. Public Health Reports 127(2), 216-223
All television advertising in France (targeted at children or adults) for processed food and drinks, or food and drinks containing added fats, sweeteners and/or salt, must be accompanied by a message on the principles of dietary education as approved by the National Institute of Health Education. The messages were defined by a 2007 Decree: "For your health, eat at least five fruit and vegetables a day"; "For your health, exercise regularly"; "For your health, avoid eating too many foods that are high in fat, sugar or salt"; "For your health, avoid snacking between meals".
The Danish Code of Responsible Food Marketing Communication was issued by the Forum of Responsible Food Marketing Communication, a cooperation between Danish industry organisations of the food and beverage, retail and media sectors. The Code is a voluntary, self-regulatory initiative effective since January 2008, applicable to food and beverage marketing to children aged 13 and under via media outlets (TV, radio, internet, SMS, newspapers, comic books). The Code sets guideline limits for salt, sugar and fat content in ten food categories. It is recommended that food products exceeding these limits should not be marketed to children. Food manufacturers themselves determine if their products are suitable for marketing to children. Compliance is checked by the secretariat of the Forum. The Danish government follows the results of the Code, and annual status meetings are held between the Danish Veterinary and Food Administration and the Forum.
In 2011, the Latvian Ministry of Health signed a Memorandum of Cooperation with the Federation of Food Enterprises and the Association of Soft Drink Companies to encourage companies not to advertise soft drinks to children aged 12 or under. The Memorandum applies to soft drink marketing in movie theatres and on TV if the audience consists of at least 50% children, and includes marketing activities on the internet and in the press.
In 2008, the Malaysian Ministry of Health developed the voluntary Guidelines of Advertisement and Nutrition Labelling for Fast Food Restaurants which ask fast food restaurants not to advertise in, and act as sponsors of, children's TV programmes. The Ministry of Health does not monitor implementation of the Guidelines.
The Norwegian government already restricts all broadcast advertising to children through legislation (See "Mandatory regulation of broadcast food advertising to children" above). A voluntary initiative agreed in 2013 calls on industry to follow standards (set largely by government) on a further range of communications channels. It applies to marketing to children under the age of 13. In 2011, the Ministry of Health signed a Memorandum of Cooperation with the Federation of Food Enterprises and the Association of Soft Drink Companies to encourage companies not to advertise soft drinks to children aged 12 or under. The Memorandum applies to soft drink marketing in movie theatres and on TV if the audience consists of at least 50% children, and includes marketing activities on the internet and in the press.
Updated February 2018: In 2005, the Spanish Self-regulatory Code for Food and Non-alcoholic Beverage Advertising Aimed at Children (Código de Autoregulación de Publicidad de Alimentos y Bebidas No Alcohólicas dirigida al Público Infantil 2005), developed between government and industry, sets general guidelines and restricts product placement and use of celebrities in food advertising for signatories. The Code applies to advertising on audiovisual and print media as well as internet to children aged 12 or below; some of the guidelines are extended to internet advertising to children aged 15 or below. In 2009, public and private television channels subscribed to the Publicidad, Actividad, Obesidad, Salud [PAOS] Code which regulates food advertising directed at children under the age of 12 years. In 2012, the PAOS Code was renewed to include, among other things, internet advertising directed at children and teenagers under the age of 15 years.
León-Flández K et al. (2017) Evaluation of compliance with the Spanish Code of self-regulation of food and drinks advertising directed at children under the age of 12 years in Spain, 2012. Public health, 150, 121-129
The EU Pledge was launched in 2007 as a commitment by the food industry, supported by the World Federation of Advertisers (WFA), to the European Union Platform for Action on Diet, Physical Activity and Health. Companies commit to not advertising food on mass media where children under 12 make up 35% of the audience unless their products comply with category-based thresholds on sodium, saturated fat and total sugar. Soft drinks and sugar-based products (chocolate, confectionary, jam/marmalade, sugar/honey/syrup) may not be marketed to children under 12. Members can comply with their own criteria if they are demonstrably stricter than the ones developed by the EU Pledge. Members also commit to not advertise in primary schools except when there is agreement with the school for educational purposes. The European Commission mediates the communication between the EU Platform and the WFA. Belgium, Hungary, Portugal and Turkey have national pledges modelled after the EU Pledge. (See Yale Rudd Center for Food and Obesity's database on Pledges on Food Marketing to Children Worldwide).
Governments have stated they support the implementation of "pledges" developed by food companies that restrict advertising of food (varies by company) to children under 12 through specified communications channels (typically TV, radio and internet). (See Yale Rudd Center for Food and Obesity's database on Pledges on Food Marketing to Children Worldwide).
Schermbeck RM, Powell LM (2015) Nutrition Recommendations and the Children’s Food and Beverage Advertising Initiative’s 2014 Approved Food and Beverage Product List. Preventing Chronic Disease 12:140472
Powell LM et al. (2011) Trends in the Nutritional Content of TV Food Advertisements Seen by Children in the US: Analyses by Age, Food Categories and Companies. Archives of Pediatrics and Adolescent Medicine 165(12), 1078-1086
We are all influenced by the food that is available and affordable when we grow up, and the habits of the people around us. That’s why people in different countries and communities consume differently. We know that when the food supply changes, so does what people eat. This is why we need to improve the quality of the food supply. Evidence from salt reduction indicates that people’s tastes can change.
The Less Salt, More Life Initiative aims to reduce population-level salt consumption in Argentina. It has three components: the reduction of salt in processed food through voluntary agreements with food manufacturers and retailers; the reduction of salt in bread through voluntary agreements with bakers; and creating public awareness of the health effects and the need to reduce discretional salt. A National Committee for Salt Reduction sets targets for the Initiative through negotiation with industry. The aim is to achieve a 5–10% reduction of salt content between 2013 and 2015. 60 companies representing 487 processed food products and more than 9,000 bakeries have signed the agreement. In addition, the government adopted a law on mandatory maximum levels of sodium in 2013 (see "Mandatory limits on level of salt in food products").
The Less Salt is Healthier programme is a joint initiative of the Ministry of Health in Austria and the Industrial Bakers of Austria. It has a voluntary target to reduce the salt content in bakery products by 15% by 2015.
The Belgian Ministry of Public Health agreed with the food processing and distribution sector in 2009 to reduce the salt content of food products by 10% by 2012 via a self-reporting framework.
Brazil has a national strategy for reducing sodium consumption. It aims to achieve a maximum daily salt intake of 5g by 2020, by reducing the intake from the main sources of sodium (added salt and processed food). The strategy involves dialogue with the food industry, setting biannual food category-specific targets (eg a 10% decrease per year until 2014) and addressing the reduction of added salt through education and information actions.
Added February 2018: Nilson EAF, et al. (2017) Sodium Reduction in Processed Foods in Brazil: Analysis of Food Categories and Voluntary Targets from 2011 to 2017. Nutrients 9(7): E472
In July 2010, a multi-stakeholder Sodium Working Group, established by Health Canada, agreed a Sodium Reduction Strategy for Canada. The Strategy set an interim goal of reducing daily sodium intake from 3,400mg to 2,300mg by 2016. The multi-staged strategy included recommendations in the areas of education, voluntary reduction of sodium levels in processed food products and food sold in food service establishments, research, and monitoring and evaluation. Health Canada established voluntary sodium reduction targets for 94 processed food categories following extensive consultation with the food industry and encouraged the food industry to achieve these targets by the end of 2016.
Added February 2018: Health Canada (2018) Sodium reduction in processed foods in Canada: An evaluation of progress toward voluntary targets from 2012 to 2016
In 2011, the Chilean government agreed a voluntary target with bakers to reduce the salt content of bread to 600mg/100g. The assessment of the progress towards the voluntary targets was made public in 2012, with average salt content dropping from 800mg to 480mg/100g.
The National Plan to Reduce Public Consumption of Salt 2011–2021 was established in Costa Rica in 2011. The aim of the Plan was to reduce population-wide salt consumption to 5g per person per day. Implementation of the Plan began in 2012, and included voluntary agreements with the food industry to reduce salt content in processed food.
In 2012, the Croatian National Institute of Public Health initiated a project with the food industry to achieve a 30% reduction of salt in certain bread varieties.
Producers of dehydrated culinary products associated in the Food Federation of the Czech Republic voluntarily committed in 2008 to gradually decrease the sodium content in their branded dehydrated culinary products (mainly soups and ready meals) in 2011–14. The commitment included voluntary food labelling of, among other values, sodium content per 100g/100ml and per portion.
Ecuador has a national salt reduction programme, which includes voluntary agreements with bread and sausage producers to reduce salt in their products.
In 2007, as part of the second phase of France’s National Nutrition and Health Programme (PNNS), a standard reference document was developed to enable the signing of voluntary nutrition commitments by members of the food industry (eg producers, food industry companies, distributors and caterers). The standard reference document outlines nine principles used in the approval process for the charters. Commitments within the charters must meet certain criteria and cover the composition and nutritional characteristics of the food product (eg reduced amounts of fat, sugar, salt; increased amounts of fibre) and/or a consumption intervention (eg action on portion sizes or marketing). A committee of volunteer experts from the public sector (eg research institutes, hospitals, universities and public schools) reviews the proposed charters. To date, over 35 companies have made voluntary commitments, which are reviewed and approved by an external committee of experts to ensure they are “significant”. Approved charters of voluntary commitment for nutritional improvement are signed by the food industry and monitored by the Food Quality Observatory (created in 2008).
As part of the Hungarian Stop Salt – National Salt Reduction Programme the Hungarian Baker Association signed an agreement to reduce the salt content of bread by 10.7% by 2014, and by another 5.3% by 2017.
The Food Safety Authority of Ireland (FSAI) initiated a Salt Reduction Programme in 2003 to achieve a voluntary reduction of salt content in processed food. In 2012, 54 companies and trade associations were registered with the Programme, reporting yearly to the FSAI on undertakings and achievements on reaching the agreed guideline values on sodium content for bread and processed meats.
A voluntary agreement was entered into in 2009 between the main four Italian associations of bakers and the Ministry of Health to reduce the salt content in some of their products by 10–15% in a timeframe of two years.
In January 2013, the Ministry of Health in Kuwait established the Kuwait Salt and Fat Intake Reduction Task Force (SIRTF). The Food Standards Department of the Public Authority for Industry has voluntary agreements with industry to reduce the salt content of bread and cheese. For cheese, for example, they are following the gradual reduction of salt content over the next 10 years, using various European countries and Australia as role models.
In 2012, the Mexican Health Secretariat signed an agreement on voluntary salt reduction in bread with the Mexican National Chamber of the Bread Industry (CANAINPA), the Mexican National Association of Supermarkets and Department Stores (ANTAD) and Bimbo SA (largest Mexican-owned baking company). ANTAD, CANAINPA and Bimbo pledge to reduce the salt content of sliced bread and bolillo (similar to a baguette) by 10% within five years. In 2013, the Ministry of Health announced a national target for salt reduction of 5g salt/person/day by 2020, consistent with the regional target.
On 23 January 2014, the Dutch Ministry of Health, Welfare and Sport signed an agreement with trade organisations representing food manufacturers, supermarkets, hotels, restaurants and caterers to lower the levels of salt, saturated fat and calories in food products. The agreement includes "ambitions" for the period up to 2020 and aims to increase the healthiness of the food supply. Under the agreement, the aim is to reduce the amount of salt consumed in food from 9g to a maximum of 6g a day by 2020. Regulations set the maximum level of salt in bread (see below).
Added February 2018: Temme EHM (2017) Salt reductions in some foods in the Netherlands: monitoring of food composition and salt intake. Nutrients 9, 791
Since 2007, the New Zealand Heart Foundation has received funding from the government to implement a national food reformulation programme. The programme – HeartSAFE (Sodium Advisory and Food Evaluation) – focuses on salt reduction in packaged food. Best Practice Guidelines have been established as orientation for food manufacturers, outlining maximum levels of sodium in mg per 100g for bread, breakfast cereals, soups, processed meat, savoury pies, savoury snacks, cheese, cooking sauces and edible oil spreads including proposed timelines until 2017 for reformulation. For savoury pies, maximum levels of saturated fat in g per 100g are also included. The programme's objective is to achieve at least 80% of the market share (by sales volume) to meet the targets, which ensure high-volume food is prioritised. Currently in the majority of categories (eg bread, breakfast cereals, processed meats) this objective has been met and, as a result, over 210 tonnes of salt has been removed from these categories. Work is currently being done on establishing best practice guidelines for further categories.
Added February 2018: The Diabetes Prevention and Care Taskforce, which sits in the Ministry of Health, is working with beverage manufacturers to reduce the amount of sugar in sugar-sweetened beverages. In 2017, seven beverage manufacturers voluntarily pledged to reduce the sugar content in their drinks to a maximum of 12% by 2020. These manufacturers constitute 70% of the pre-packaged sugar-sweetened beverages in Singapore.
The Korea Center for Less Salt Campaign is a joint initiative of the Ministry of Food and Drug Safety (MFDS, formerly KFDA), academia and NGOs in Korea. It was launched in March 2012 and has been working to increase the awareness of the general population and encourage the food and catering industry to participate in sodium content reduction in food. MFDS set the goal to decrease the sodium intake of the population by 20% by 2017 (base 2010), and has developed sodium reduction guidelines for certain food products including Kimchi, soy sauce, soybean paste, noodles and salted fish to be used by food manufacturers. In 2013, 13 food manufacturers voluntarily produced or reformulated 87 processed food products with lower sodium content, and some large supermarkets also provide separate sections for the sale of lower sodium products.
In 2005, the Spanish Ministry of Health and Consumption signed a cooperation agreement with the Spanish Bakers Confederation to reduce the salt content in bread.
In 2009, the Swiss Ministry of Health launched actionsanté – "make the healthy choice the easy choice" as part of the National Programme Nutrition and Exercise. actionsanté includes voluntary agreements between the food industry and the Ministry of Health to reduce the salt, sugar, fat and calorie content in bread and processed food. The food industry has made commitments to the government in line with the EU reformulation framework.
In England, through the government’s Responsibility Deal launched in 2011, the food industry has made voluntary commitments ("pledges") to reformulate their products to reduce salt, saturated and trans fats, and calories. In March 2014, the government introduced new salt reduction targets covering 76 categories of food to be met by 2017, along with new salt targets for the most popular meals consumed out of home. To date, all major supermarkets and many big manufacturing and catering brands have signed up to achieve these salt reduction targets, which replaced the original salt reduction pledge. The pledges to reformulate products continue to exist even though the Responsibility Deal, while not officially terminated, has not seen any activity since elections in May 2015 replaced the 2010–15 coalition government.
Knai C et al. (2017) An evaluation of a public–private partnership to reduce artificial trans fatty acids in England, 2011–2016. European Journal of Public Health ckx002, 1-4
Durand MA et al. (2015) An evaluation of the Public Health Responsibility Deal: Informants’ experiences and views of the development, implementation and achievements of a pledge-based, public–private partnership to improve population health in England. Health Policy 119(11), 1506-1514
Knai C et al. (2015) Has a public-private partnership resulted in action on healthier diets in England? An analysis of the Public Health Responsibility Deal food pledges. Food Policy 54, 1-10
Salt reduction is part of Uruguay’s national non-communicable disease prevention and national nutrition programmes led by the Ministry of Health. The strategy includes a voluntary agreement with the bakery industry to reduce sodium in bread products. Engagement with the bread industry to reduce salt began in September 2013.
The National Salt Reduction Initiative in the US, initiated in 2009, was a partnership of more than 100 state and local health authorities and national health organisations, coordinated by the New York City Health Department. It set voluntary targets for salt levels in 62 categories of packaged food and 25 categories of restaurant food to guide food company salt reductions of 25% by 2014, with an intermediary milestone in 2012. The initiative included mechanisms to monitor sodium in the food supply to track companies’ progress towards specific targets, and to monitor changes in people’s actual salt intake. To maintain momentum, the New York City Board of Health approved the sodium warning rule in 2015 (see “N – Nutrition label standards and regulations on the use of claims and implied claims on food"). In June 2016, the Food and Drug Administration (FDA) announced draft voluntary sodium reduction targets, which were partly informed by the design of the National Salt Reduction Initiative.
Curtis C et al. (2016) US Food Industry Progress During the National Salt Reduction Initiative: 2009–2014. AJPH 106(10), 1815-1819
NYC Health. National Salt Reduction Initiative. Sodium reformulation in top U.S. chain restaurant foods: 2009-2014, New York 2016
In 2014, the Malaysian Ministry of Health started implementing an initiative in collaboration with Malaysia’s major fast food restaurants to encourage the reduction of portion sizes and the provision of healthier alternatives for high-calorie meals, food and beverages; the initiative does not define targeted food and beverages. As of August 2016, Malaysia’s seven major fast food restaurants were involved in the initiative.
In 2015, the Ministry of Public Health, in partnership with the Thai Health Promotion Foundation, Thai sugar producers and Thai hotels, implemented a voluntary policy to reduce the size of sugar packets from 6–8g to 4g.
In England, through the Responsibility Deal (see above), 43 companies have signed up to the calorie reduction "pledge", including major retailers, manufacturers and caterers (last company signed up in March 2015). These companies are taking a range of actions, including reducing portion sizes, to help people consume fewer calories. For example, major confectionery manufacturers have agreed to reduce all single serving confectionery to a maximum of 250 calories. The pledge continues to exist even though the Responsibility Deal, while not officially terminated, has not seen any activity since elections in May 2015 replaced the 2010–15 coalition government.
Durand MA et al. (2015) An evaluation of the Public Health Responsibility Deal: Informants’ experiences and views of the development, implementation and achievements of a pledge-based, public–private partnership to improve population health in England. Health Policy 119(11), 1506-1514
In 2013, the Argentine government adopted a law on mandatory maximum levels of sodium permitted in meat products and their derivatives, breads and farinaceous products, soups, seasoning mixes and tinned food (Law no. 26.905 on Maximum Levels of Sodium Consumption). Large companies have to meet the sodium targets by December 2014, small and medium sized companies by June 2015. Infringements by producers and importers may be sanctioned, the most severe penalties being fines of up to 1m pesos, in case of repeat infringements up to 10m pesos, and the closing of the business for up to five years. The Law is also applicable to salt levels in restaurant dishes, and it provides for awareness campaigns, warnings on salt bags on the excessive use of salt, the reduction of salt bags available in restaurants and the introduction of low-sodium salt in salt shakers in restaurants.
Since 1985, legislation in Belgium establishes a 2% maximum salt content in bread.
In 2011–12, Bulgaria introduced mandatory maximum salt levels for breads (three types of flour and three typical national bread types), milk products (cheese), meat and poultry products, and lutenica (vegetable relish on tomato base).
In Greece, mandatory maximum levels of salt permitted in bread, tomato juice and tomato concentrates/purees have been in place since 1971.
In 2012, Hungary introduced maximum salt levels in bread: <1.67g salt/100g bread from 1 January 2015 and <1.57g salt/100g bread from 1 January 2018.
As part of a national salt reduction strategy, the Iranian government has reduced the standard of salt content of select food groups, including snacks (from 2.5% to 1.5%); canned tomato paste (3% to 2%); potato chips (1.5 % to 1%) and bread (2.3% to 1.8%). Revising the standard for further food items is being discussed by a government committee.
Added in February 2018: In 2012, the Netherlands Ministry of Health, Welfare and Sport further reduced the maximum salt content in bread to 1.8% per 100g dry matter (amendment to Commodities Act Decree, Nov 2012), which came into effect 1 January 2013. The maximum level of salt in bread has gradually decreased over time (2.5% in 2009, 2.1% in 2011, 1.9% in 2012).
In 2013, the Ministry of Public Health and Social Wellbeing of Paraguay enacted a mandatory reduction of 25% of salt content in wheat flour used in widely consumed breads and farinaceous products (from 2g salt/100g to 1.5g salt/100g). Companies had to switch to using wheat flour not exceeding 1.5g salt per 100g by June 2013 (Resolution 248).
In 2009, the Portuguese government adopted legislation that established a maximum level of salt in bread at 1.4g/100g.
In 2013, the South African Department of Health adopted targets for salt reduction in 13 food categories by means of regulation (Foodstuffs, Cosmetics and Disinfectants Act). There is a stepped approach, with food manufacturers given until June 2016 to meet one set of category-based targets and another three years, until June 2019, to meet the next.
Added February 2018: Peters SAE et al. (2017) The sodium content of processed foods in South Africa during the introduction of mandatory sodium limits. Nutrients 9(4):404
In 2010, the Argentine Food Code was amended to set limits on trans fat permitted in food (Article 155 tris), with full implementation by food companies scheduled for 10 December 2014. Trans fat content must not exceed 2% of total vegetable fats in oils and margarines, and 5% of total fat in all other food.
In 2009, a ministerial regulation was passed in Austria setting a limit on trans fats of 2g per 100g of a food item. If a food product is composed of various ingredients, the limit of trans fats is 4g per 100g if the total fat content of the product is less than 20%, and 10g per 100g if the total fat content of the food product does not exceed 3%. This differentiation of maximum fat levels incentivises food manufacturers to not only replace trans fats with saturated fats, but to reduce the overall fat content of their food products. The regulation is not applicable to trans fats of animal origin.
A law introduced in 2003 prohibits the sale of products containing trans fats, a move that effectively bans its use in products destined for sale on the Danish market. The law is enforced by local authorities under the supervision of the Danish Veterinary and Food Administration. Persons infringing the law may incur a fine or imprisonment, and companies can be prosecuted according to the Danish Penal Code.
Restrepo BJ, Rieger M (2016) Denmark’s Policy on Artificial Trans Fat and Cardiovascular Disease. Am J Prev Med 50(1) 69-76
Leth T et al. (2006) The effect of the regulation on trans fatty acid content in Danish food. Atherosclerosis Supplements 7(2), 53-56
A 2013 decree sets limits on the trans fat content allowed in food products in Hungary. It covers the trans fat content of oils, fats and fat emulsions intended for consumers, either on their own or as ingredients of a food product. The general provisions establish a limit of 2g trans fat per 100g of total fat content. In the case of processed multi-ingredient food, the limit depends on the percentage total fat content: food containing less than 20% total fat have a trans fat limit of 4g per 100g of fat; for food containing less than 3% total fat the trans fat limit is 10g per 100g.
In 2010, Iceland opted to follow Denmark and introduced stricter rules that effectively ban trans fats.
In 2005, the Iranian government revised the national standards for corn oil, palm oil, frying oil and mixed liquid oils to reduce the permissible trans fat content to <10% (existing levels tended to be >20%). All government organisations were mandated to use standard oils with less than 10% trans fat content. In 2011, the oil industries were mandated to reduce the level to <5%. In 2013, the level was reduced to <2% with compliance required by 2016.
In May 2016, the Cabinet of Ministers of Latvia approved the regulation on the maximum permissible content of trans fatty acids in food. The regulation limits the content of trans fats in food items to 2g per 100g of the total fat content of products produced in Latvia, including those in public catering establishments, and/or sold in Latvia. In products where total fat content is less than 3%, trans fat may not exceed 10g per 100g of total fat content, and where total fat content is between 3–20%, trans fats may not exceed 4g per 100g of total fat content. The regulation does not apply to naturally occurring trans fats. Market compliance is required by 1 June 2018.
In 2014, the Norwegian Food Act was amended to prohibit the sale of fats or food with fats that contains more than 2g of trans fats per 100g of fat, in effect since January 2014. The regulation does not apply to naturally occurring trans fats.
In 2012, an amendment to regulation 78 of the Singaporean Food Regulations, made under the Sale of Food Act (1973), set a limit of 2% on trans fats in pre-packaged edible fats and oils for sale or for use as an ingredient in the preparation of food. The limits came into effect on 2 May 2012.
In February 2011, Regulation 127 relating to trans fat in foodstuffs amended Section 15(1) of the South African Foodstuffs, Cosmetics, and Disinfectants Act to prohibit the sale, manufacturing and importation of any oils or fats, alone or as part of processed food, that exceed 2g per 100g of oil or fat. This applies to retail, catering businesses, restaurants, institutions and bakeries. The regulations came into effect in August 2011.
In 2008, Switzerland set a limit on trans fats of 2g per 100g of vegetable oil or fat, with a one-year entry period.
In June 2015, the US Food and Drug Administration (FDA) determined that partially hydrogenated oils (PHOs), the primary source of trans fats, are not "generally recognised as safe (GRAS)" for any use in food. Food manufacturers have three years to remove PHOs from products, after which time no PHOs can be added to human food without prior FDA approval. This will result in a de facto ban of trans fats. Several local bans of trans fat exist for food establishments (eg New York City, California; see "S – Set incentives and rules to create a healthy retail and food service environment"). The national ban of PHOs does not preempt local laws as long as they are not in conflict with the FDA’s regulation. However, preemption has to be assessed on a case-by-case basis.
In 2000, Fiji introduced a sales ban on mutton flaps, which have very high fat and very low meat content.
Ghana set standards in the early 1990s to limit the level of fats in beef, pork, mutton and poultry in response to rising imports of low-quality meat following liberalisation of trade. The standards are also applicable to domestically produced meat. The relevant standards establish maximum percentage fat content for de-boned carcasses/cuts for beef (<25%), pork (<25%) and mutton (<25% or <30% where backfat is not removed), and maximum percentage fat content for dressed poultry and/or poultry parts (<15%). The standards are currently being enforced for turkey tails and chicken feet.
Thow AM et al. (2014) Development, implementation and outcome of standards to restrict fatty meat in the food supply and prevent NCDs: learning from an innovative trade/food policy in Ghana. BMC Public Health 14:249
In 2011, Samoa banned the sale of turkey tails and turkey tail products (Sale of Turkey Tails Prohibition Order 2001, Section 7A), which replaced an import ban of turkey tails. The import ban had to be lifted to enable Samoa to join the World Trade Organization.
Implemented in June 2016, the Latvian Energy Drinks Law bans the sale of energy drinks containing more than 150mg/l caffeine and one or more other stimulants such as taurine and guarana to persons under 18, and places strict regulations on their advertising (see “R – Restrict food advertisement and other forms of commercial promotion”). Retailers are also required to display such energy drinks separately from other food items.
In effect since November 2014, the Lithuanian food law bans the sale of energy drinks to persons aged under 18. Energy drinks are defined as non-alcoholic beverages excluding coffees, containing at least 150mg caffeine per litre independent of whether other stimulants are added. Strict regulations on their advertising accompany the sales ban (see “R – Restrict food advertisement and other forms of commercial promotion”).
The neighbourhood food environment – the retailers and other outlets where we buy our food – are the means through which people access the food supply. There is clear evidence that this environment influences the decisions we make about what we eat.
In February 2014, the US Congress formally established the Healthy Food Financing Initiative (HFFI). This follows a three-year pilot established in 2011, in which over $140m was distributed in grants to states to provide financial and/or other types of assistance to attract healthier retail outlets to under-served areas.
To date, 23 US states have implemented financing initiatives. For example, the New Jersey Food Access Initiative provides affordable loans and grants for costs associated with building new supermarkets, expanding existing facilities, and purchasing and installing new equipment for supermarkets offering a full selection of unprepared, unprocessed, healthy food in under-served areas; the Initiative targets both for-profit and not-for-profit organisations and food cooperatives. More information on state-based initiatives can be found at the Healthy Food Access Portal weblink below.
There are also initiatives at the city level. For example, in 2008, New York City made 1,000 licences for Green Carts available (through Local Law 9). Green Cart licences were issued to street vendors who exclusively sell fresh fruit and vegetables in neighbourhoods with limited access to healthy food.
In 2009, New York City established the Food Retail Expansion to Support Health Program of New York City (FRESH). Under the programme, financial and zoning incentives are offered to promote neighbourhood grocery stores offering fresh meat, fruit and vegetables in under-served communities. The financial benefits consist of an exemption or reduction of certain taxes. The zoning incentives consist of providing additional floor area in mixed buildings, reducing the amount of required parking, and permitting larger grocery stores as-of-right in light manufacturing districts.
Li KY et al. (2014) Evaluation of the Placement of Mobile Fruit and Vegetable Vendors to Alleviate Food Deserts in New York City. Preventing Chronic Disease 11:140086
As part of the Healthier Dining Programme launched in Singapore in June 2014 (formerly called the Healthier Hawker Programme, launched in 2011), food operators are encouraged to offer lower calorie meals and use healthier ingredients such as oils with reduced saturated fat content, and/or whole grains, without compromising taste and accessibility. To participate, food and beverage companies must complete an application form and implement nutrition guidelines set by the Health Promotion Board (HPB) in all outlets for a period of two years. Following HPB approval the Healthier Choice Symbol Identifiers (see "N – Nutrition label standards & regulations on the use of claims and implied claims on food") are used next to healthier dishes in all menu and marketing materials to help consumers identify healthier dishes (eg "We serve lower-calorie options", "We use healthier oil"). To date, the HPB has partnered with 45 widely known food service providers (food courts, coffee shops, restaurants) to offer lower calorie and healthier meals across 1,500 outlets and stalls. Between the launch of the programme and September 2015, the number of healthier meals sold more than doubled, from 525,000 in June 2014 to 1.1 million in September 2015. The government increases the availability and use of healthier ingredients through a subsidy scheme called the Healthier Ingredient Development Scheme (see "H – Harness supply chain and actions across sectors to ensure coherence with health").
Updated February 2018: As part of the Healthier Dining Programme, the Health Promotion Board offers a Healthier Dining Grant to food and beverage establishments to help promote healthier menu choices. The grant reimburses up to 80% of establishments’ marketing and publicity costs related to the promotion of their healthier dishes. Establishments under the Healthier Dining Programme are eligible to apply for the grant every two years, with incremental commitment of healthier dishes after the initial grant period.
The Change4Life Convenience Stores programme is a partnership between the Department of Health in England and the Association of Convenience Stores to increase the availability of fresh fruit and vegetables in convenience stores. Pilot shops started operating in 2008, with full rollout of the programme covering each English region in 2011.
In London, local government authorities manage the Healthier Catering Commitment for London scheme, launched in 2012, to encourage businesses to commit to providing healthier options for customers. Businesses must meet specified requirements and conditions to achieve a Healthy Catering Commitment. Businesses that meet the commitment are able to show a special window sticker.
Brighton & Hove City Council, in partnership with the Food Partnership, created the Healthy Choice Award in 2008 to encourage food outlets to prepare, cook and serve healthier meals. To receive a Healthy Choice Award, businesses must meet nutrition criteria (revised in 2015) and have a compliant food hygiene rating. Successful businesses can display a window sticker and certificate, and the details of award holders are listed on the council website. The Healthy Choice scheme is open to takeaways, cafes and restaurants, as well as outlets operating in early years and residential care settings.
Adams J et al. (2012) The Change4Life Convenience Store Programme to Increase Retail Access to Fresh Fruit and Vegetables: A Mixed Methods Process Evaluation. PLoS ONE 7(6): e39431
In 2009, the US Department of Agriculture’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) implemented revisions to the composition and quantities of WIC-provided food, and required WIC authorised stores to stock certain healthier products (eg wholegrain bread).
New York City initiated Shop Healthy NYC (formerly called Healthy Bodegas) in 2005. The aim of Shop Healthy NYC is to work with communities – including residents, food retailers, and food suppliers and distributors – to increase access to healthy food. Shop Healthy NYC’s main focus is on neighbourhoods with high rates of obesity and limited access to nutritious food. In the initiative, Department of Health staff work with shop owners to sell more low-fat milk, low-salt and no-sugar-added canned goods, and to improve the quantity, quality and display of fresh food. The initiative targets both supply and demand by helping retailers to stock and promote healthy food, and by collaborating with distributors and suppliers to facilitate wholesale purchases. It also engages communities by encouraging New Yorkers to adopt a shop in their neighbourhood. The Department of Health issued a guideline, How to Adopt a Shop, in 2013 as a guide to communities working with local retailers.
Bassett MT (2014) Shop Healthy NYC: Year 1 Evaluation Report – West Farms and Fordham, Bronx. New York City Department of Health and Mental Hygiene
Dannefer R et al. (2012) Healthy Bodegas: Increasing and Promoting Healthy Foods at Corner Stores in New York City. AJPH 102(10), e27–e31
In March 2009, the Ministry of Healthy Living and Sport of British Columbia passed the Public Health Impediments (BC Trans Fat) Regulation, effective since September 2009. Under the Regulation, food service establishments are not permitted to use margarines and oils with a trans fat content exceeding 2%, and other food with a trans fat content of above 5%. Food exempt from the restriction are pre-packaged food products with a nutrition facts table required under the Canadian Food and Drugs Act that are sold or offered directly to the consumer without any alteration to the nutritional contents, and food that only contains naturally occurring trans fats. Food service establishments must also keep documentation on site on the trans fat content of the food they use. In case of violations, operators can be fined $230 for exceeding the prescribed trans fat content and $115 for failing to provide adequate documentation upon request. Food service establishments are defined in the Food Premises Regulation (B.C. Reg. 210/99) as premises on which food is processed, served, and consumed immediately (article 1.1).
Heart & Stroke Foundation of BC & Yukon and ActNowBC (2012) Measuring Up: An Evaluation of the BC Trans Fat Initiative. Vancouver, June 2010
In 2006, New York City’s Health Code was amended to restrict the amount of trans fats allowed in food served by all food service establishments required to hold a licence from the New York City Health Department, including restaurants, bakeries, cafeterias, senior-meal programmes, mobile food vendors, soup kitchens, concession stands and others. The maximum amount of trans fat allowed per serving is 0.5g. Violators are subject to fines of $200 to $2,000. A range of other US cities and counties have followed suit and banned restaurants from serving trans fats.
In March 2008, the Boston Public Health Commission's Board of Health passed the Artificial Trans Fat Regulation, which prohibits food service establishments in Boston to store, prepare, distribute, hold for service or serve any food or beverage containing artificial trans fat. Food items and beverages are exempt from the Regulation if they contain less than 0.5g of trans fat per serving, or if they are served in a manufacturer’s original, sealed package containing a nutrition label required by federal or state law (eg crackers or potato chips). Food service establishments are defined as establishments that are required to hold a permit from Boston’s Inspectional Services Department (ISD), including restaurants, grocery and convenience stores, delis, cafeterias in businesses and public and private schools, bakeries and mobile food vendors. The Regulation was implemented in a collaboration between the Office of Environmental Health, the Chronic Disease Division and ISD, and food service establishments had to fully comply with the Regulation by March 2009. Violations of the Regulation are fined from $100 for the first offence to $1,000 for three or more violations within a 24-month period.
Law No. 120 of 13 September 2007 in the US territory of Puerto Rico bans artificial trans fat in food establishments (restaurants, home delivery services, mobile units), except when food is served directly to the clients in the original package seal of the manufacturer. It also includes school canteens, day care centres and homes for the elderly. Violations are subject to a fine.
Assembly Bill 97 of 25 July 2008 amends California’s Health and Safety Code to require all food facilities (restaurants) in the state, with the exception of public school cafeterias, to cease using artificial trans fats by January 2011. Packaged food in a manufacturer’s sealed, original packaging is exempt. Violation of the law is punishable by a fine ranging from $25 to $1,000.
Some US states also have provisions restricting the availability of trans fats in schools (see "O – Offer healthy food and set standards in public institutions and other specific settings").
The national ban of partially hydrogenated oils, the main source of trans fats (see "I – Improve nutritional quality of the whole food supply"), does not preempt these local regulations as long as they are not in conflict with the FDA’s ban. However, preemption has to be assessed on a case-by-case basis.
Brandt EJ et al. (2017) Hospital Admissions for Myocardial Infarction and Stroke Before and After the Trans-Fatty Acid Restrictions in New York. JAMA Cardiology Published online April 12, 2017, E1-E8
Restrepo B, Rieger M (2014) Trans Fat and Cardiovascular Disease Mortality: Evidence from Bans in Restaurants in New York. EUI Working Paper MWP 2014/12
Angell S et al. (2012) Change in Trans Fatty Acid Content of Fast-Food Purchases Associated With New York City’s Restaurant Regulation. Annals of Internal Medicine, 157(2), 81-86
Since 2010, the nutrition section of the Ministry of Health in Bahrain recommends that fast food chain restaurants offer 100% fruit juices (fresh or packaged) in serving sizes no larger than 250ml as default options in children’s menus instead of carbonated drinks. The main fast food chains operating in Bahrain have implemented the menu labeling recommendations (such as Burger King, McDonald’s, Dairy Queen, Kentucky Fried Chicken, Subway and Jasmi’s).
In September 2013, the Los Angeles County Department of Public Health launched Choose Health LA Restaurants in partnership with local restaurants to promote healthier meal choices. Restaurants must apply to become a partner. Participating restaurants offer customers smaller portion size options (in addition to existing items on the menu), healthier meals for children that include vegetables and fruit, healthy beverages, non-fried food and free chilled water. Participating restaurants are recognised as Public Health partners in promoting healthier communities.
Ordinance 2451 (effective 1 September 2015), amending chapter 17 of the City of Davis Municipal Code, and the Healthy-by-Default Kids’ Beverage Ordinance (2016) (effective 8 July 2016), of the City of Stockton, require restaurants in the Californian cities of Davis and Stockton, including fast food and takeaway restaurants, to make water, milk or non-dairy milk alternatives the default beverage in children’s meals. Purchasers of children’s meals may still request a sugary drink or juice for the child. Restaurants have to annually self-certify; compliance is enforced under administrative citation procedures.
The Californian cities of Perris (Ordinance 1340 – effective 14 April 2017), and Berkeley (Ordinance 7560 – effective 1 July 2017) require all restaurants, including fast food and takeaway restaurants, to make water, sparkling or flavoured water, with no added natural or artificial sweeteners, milk or non-dairy milk alternatives the default beverage in children’s meals. The city of Perris allows 100% juice in a serving size of no more than 8 ounces. Purchasers of children’s meals may still request a sugary drink or juice for the child. Restaurants have to annually self-certify, and compliance is enforced under administrative citation procedures.
Since 27 January 2017, France has banned unlimited offers of sweetened beverages for free or at a fixed price in schools, public restaurants and any facility used to teach, accommodate or receive children below the age of 18, eg dormitories, sports facilities, youth prisons (Article L. 3232-9 of the Public Health Act). Sweetened beverages are defined as any (non-alcoholic) drink sweetened with sugar or artificial (caloric and non-caloric) sweeteners, including flavoured carbonated and still beverages, fruit syrups, sports drinks, energy drinks, fruit and vegetable nectars, fruit- and vegetable-based drinks, as well as water-, milk- or cereal-based beverages.
In 2013 in Mexico City, the Less Salt, More Health initiative was launched. It is a voluntary agreement between city government and the trade group representing restaurants to encourage restaurants to provide salt shakers only if guests ask for them. In April 2014, it was announced that 2,438 restaurants had voluntarily joined the initiative. Employers in these sectors supported its implementation for the benefits involved for the health of the population.
In England, as part of the government’s Responsibility Deal launched in 2011, voluntary commitments (“pledges”) are made by caterers and their suppliers to contribute to salt reduction, including training and kitchen practice, reformulation and procurement (eg reducing the amount of salt used in kitchens, training chefs on the importance of salt reduction and increasing awareness of food or ingredients that are high in salt, meeting salt targets for a certain amount of food procured). These salt-specific pledges aim to reduce the amount of salt eaten from meals out of home. The pledges continue to exist even though the Responsibility Deal, while not officially terminated, has not seen any activity since elections in May 2015 replaced the 2010–15 coalition government.
Added February 2018: In 2012, the Philadelphia Healthy Chinese Take-Out Initiative was established in partnership with Temple University’s Center for Asian Health, the Asian Community Health Coalition, the Greater Philadelphia Chinese Restaurant Association and the Philadelphia Department of Public Health. The aim of the initiative is to reduce the sodium content of dishes and to promote awareness of the impact of sodium consumption on health.
Dishes from Chinese take-out restaurants contain large amounts of sodium, mainly due to the sauces used in preparation and cooking. In Philadelphia, there are approximately 400 Chinese take-out restaurants clustered in low-income and high-risk communities. As part of the initiative, restaurant owners and chefs received support and training on reducing sodium in their menu (see "G – Give nutrition education and skills"). Common sodium reduction strategies implemented by the restaurant staff included enhancing flavours with herbs and spices, using less sauce and switching to lower sodium ingredients. The programme helped decrease sodium levels in the three most common dishes served by 181 Chinese take-out restaurants by about 30% over 36 months in 2015. This successful model is now being replicated in Chinese buffet restaurants in Philadelphia.
Around 15 local authorities in the UK have developed supplementary planning documents on the development of hot food takeaways. The policies typically exclude hot food takeways from a 400m zone around the target location (eg primary schools). For example, Barking and Dagenham’s Local Borough Council, London, adopted a policy in 2010 restricting the clustering of hot food takeaways and banning them entirely from 400m exclusion zones around schools. In 2009, the Local Borough Council of Waltham Forest, London, developed a planning policy restricting the development of hot food takeaways in local centres, and excluding them completely from areas within a 10-minute walk from schools, parks or other youth centres. St Helens Council adopted a planning document in 2011, and Halton in 2012. In 2012, the City of Birmingham adopted a restriction on hot food takeaways to 10% of units in towns, districts and neighbourhood centres. Around nine of the local authorities have cited these planning policies when refusing planning applications by hot takeaways.
Detroit’s zoning ordinance (1998) requires a distance of at least 500 feet between elementary, junior and senior high schools and restaurants, including carry-out, fast food and drive-through restaurants.
Policies within this category aim to harness the whole food system, and the sectors which influence it, to ensure coherence with healthy eating. This is because the food system, and the policies that affect it, influence our food environment.
What our food industry produces is in part a response to incentives in the supply chain. Sectors outside of health influence our ability to take policy action. Likewise, if governments implement policies contained in NOURISHING, they have repercussions upstream for the actors and activities in food systems. This wider relationship to the food supply chain presents an opportunity to support all the policies in NOURISHING with actions in the food supply chain.
Updated February 2018: In July 2017, the Health Promotion Board introduced the Healthier Ingredient Development Scheme to encourage manufacturers to innovate and develop a wider variety of healthier ingredients suited to local taste and to promote the uptake of healthier ingredients, focusing on oil and grain staples (mainly rice and noodles). The scheme offers support under three categories: 1) Research, Product Development, Packaging and Certification; 2) marketing and publicity; 3) trade promotions, such as bulk purchase rebates and bonus incentives for incremental sales of healthier ingredient product(s). Eligibility criteria exist for applicants to the scheme. Up to 80% of qualifying projects will be funded by the scheme, while the scheme participant co-pays the remaining 20%. Products must meet the Healthier Choice Symbol nutritional guidelines (see “N – Nutrition label standards and regulations on the use of claims and implied claims on food – Clearly visible “interpretative labels and warning labels”). This Scheme evolved from the Healthier Ingredient Scheme, which was formerly part of the Healthier Hawker programme launched in 2011.
In July 2016, the Brazilian Ministry of Health implemented procurement guidelines for any food served or sold within the Ministry’s facilities and in its entities (Ordinance No 1.274 of 7 July 2016). The guidelines also apply to independent companies contracted to provide food services on the premises of the Ministry and its entities. The Ordinance aims to address overweight, obesity and non-communicable diseases, and is based on the right to adequate food. The guidelines are based on the Food Guide for the Brazilian Population, and state that only unprocessed and minimally processed food may be procured. The purchase of processed food (eg canned food, fruit compote, candied fruit, salt-preserved meats) should be minimised, and food from organic and agroecological production preferred whenever possible. Ultraprocessed food may only be used in exceptional cases if it is used in meals which are prepared from mostly unprocessed or minimally processed food. Ultraprocessed food and beverages that are not used for meal preparation may not be purchased (eg soft drinks, sugar-sweetened fruit juices, industrialised sweets). Ultraprocessed food is defined by the Ordinance as food which is mainly produced from substances extracted from whole food and/or food components derived from materials synthesised from organic matter, and which contains ≥1mg of sodium per 1kcal, ≥10% of total energy from free sugars, ≥30% of total energy from total fat, ≥10% of total energy from saturated fat and ≥1% of total energy from trans fat (in alignment with PAHO’s Nutrient Profile Model). The Ordinance also prohibits the advertisement and sales promotions of ultraprocessed food in the Ministry of Health and its entities.
The UK Government Buying Standard for Food and Catering Services (GBSF of 2014, updated March 2015) by the Department of Environment, Food and Rural Affairs (Defra) sets out standards for the public sector when buying food and catering services. It is supported by the Plan for Public Procurement: Food and Catering Services (2014), which includes a toolkit consisting of the mandatory GBSF (revised to strengthen the commitment to buy to UK standards of production, or equivalent), a balanced scorecard (an approach to weigh different criteria against each other to serve as an evaluation tool to base procurement awards on), an e-marketplace, case studies and access to centralised framework contacts in order to improve and facilitate procurement in the public sector. The nutrition requirements have to be followed by schools, hospitals, care homes, communities and the armed forces. To improve diets, the GBSF sets maximum levels for sugar in cereals, and generally for saturated fat and salt, in addition to a minimum content of fibre in cereals and fruit in desserts. Meal deals have to include vegetables and fish, and fruit as dessert on a regular basis. Other standards may take precedence over these requirements, eg for military personnel overseas or special needs patients.
Based on Executive Order 509 (2009), the Massachusetts State Agency Food Standards set standards per category for all food purchased by state agencies and their contractors. The Standards, based on the Dietary Guidelines for Americans (see “O – Offer healthy food and set standards in public institutions”), define targets for nutrient requirements, including guidelines for specific populations (ie children, elderly). The Standards contain a ban on trans fat and deep-frying, and maximum levels of sodium in food and calories in beverages. They are applicable to food served to agencies’ clients and patients (ie hospitals, prisons, childcare services). Food served for sale, and to agencies’ employees, is excluded.
New York City (Executive Order 122 of 2008, revised in 2014) and Santa Clara County (Nutrition Standards, passed 28 February 2011 and effective since 1 July 2012) have also established nutrition standards for all food purchased and served by public entities. The standards are based on the Dietary Guidelines for Americans.
Los Angeles County has used health impact assessments relating to healthy food to inform public procurement bid specifications.
Added February 2018: In 2013, a multi-sector State Food Procurement Work Group (formed by the California Health in All Policies Task Force) developed nutritional guidelines for food procurement in adult correctional facilities. The guidelines are aligned with federal nutritional standards, and include specific targets and recommendations for fruits, vegetables, cereals and grains, bread, dairy products, protein foods and beverages served. Since 2014, these voluntary nutritional guidelines have been systematically applied to food contracts as they have come up for renewal.
In Brazil, a 2009 law (Ley 11.947/2009 Regulamento de Programa Nacional de Alimentação Escolar) requires that 30% of the national budget for food served in the school meals programme must be spent on food from family farms, with priority given to food produced using agroecological methods.
The Food Acquisition Programme (Programa de Aquisicao de Alimentos) allows states, municipalities and federal agencies to buy food from family farms through a simplified public procurement procedure. The programme thereby encourages the purchase of perishable food and minimally processed food and makes them available to public institutions (eg hospitals, social assistance agencies, schools).
The Brazilian Institute of Horticulture and the Brazilian Central Food Supply Association are responsible for the promotion, regulation and organisation of food sales in the country. The Brazilian Market Modernisation Programme (Programa Brasileiro de Modernização do Mercado Hortigranjeiro) supports states and municipalities to modernise and adapt the supply of food to meet local needs. For example, supply centres (CEASAs) initiated the campaign Encouraging Intake of Fruit and Vegetables in the Central Food Supply. The first phase focuses on internal CEASA stakeholders (dealers, licensees and producers) and aims to increase the availability of fruit and vegetables. The second phase will target external audiences in the form of consumer information and promotion of healthy eating.
New York City issued the New York State Food Purchasing Guidelines to encourage city agencies to procure food products that are grown, produced or harvested in New York State. The Guidelines apply to any solicitation of a value of more than $100,000. City agencies may mandate that certain products must be procured from New York State, and they may grant a bid to a bidder whose price is up to 10% higher than the one offered by the lowest bidder’s price for food not from New York State.
As part of the Singaporean Healthier Dining Programme (formerly called the Healthier Hawker Programme, launched in 2011), manufacturers are able to tap into non-health related government funding for productivity and innovation to improve logistics and efficiency in supplying healthier oils and healthier staples, with the goal to make prices competitive.
Added February 2018: In Brazil, urban agriculture is integrated into agriculture and urban policy to increase access and availability of food, improve health and nutrition, improve institutional feeding programmes, stimulate healthy eating habits, and provide employment and income. Legislation 15973, launched in 2006, encourages the use of private estates and underutilised public buildings as urban agriculture spaces. Brazil’s National Plan for Food and Nutrition Security (PLANSAN 2016–2019) sets a specific goal for the Ministry of Agriculture to promote and develop urban and peri-urban agriculture, working with federal, state and municipal governments.
Added February 2018: In 2007, the City of Bulawayo in Zimbabwe launched the Bulawayo Urban Agriculture Policy to support and promote urban agriculture as an instrument to improve nutrition and health, poverty alleviation and promote social inclusion. The City Council ensures land is accessible, available and suitable for urban agriculture by negotiating with private landowners for the use of their land and preventing soil erosion in sensitive areas. The Council charges a nominal fee to the farmers for the use of the private land. The Council encourages the production of balanced nutritional diets and herbs, especially among the subsistence sectors and vulnerable groups, such as women, orphans and the elderly. In addition, farmers decide which diverse and local staple foods are produced and consumed at a subsistence level.
Community food projects are in place to promote the domestic cultivation of fruit and vegetables in place of imported food products.
The Brazilian National Council of Food and Nutrition Security (CONSEA), established in 2003, is a body made up of civil society and government representatives, which advises the President’s office on matters involving food and nutrition security.
Active NCD Commissions exist in eight of the 20 CARICOM member states (Antigua and Barbuda, Bahamas, Barbados, Bermuda, British Virgin Islands, Dominica, Grenada, Saint Lucia), which are all housed in their Ministries of Health, with members recommended by the Minister of Health and appointed by the Cabinet of Government for a fixed duration; all include government agencies, and, to a varying degree, civil society and the private sector.
Added February 2018: The National Council of Food Security and Nutrition (CONASAN), established in 2009, is responsible for providing guidelines to tackle malnutrition; formulating and monitoring the National Policy and the Strategic Plan for Food Security and Nutrition; monitoring food security and nutrition through relevant indicators, and coordinating institutional and inter-sectoral efforts on food security and nutrition.
The Council includes the Technical and Planning Secretariat of the Presidency and the Ministries of Health, Agriculture and Livestock, Environment and Natural Resources, Governance and Territorial Development, Economy, Labor, Foreign Affairs, Consumer Advocacy, and the Secretariat of Social Inclusion, and works with various public and private sectors, academia, cooperation agencies and civil society.
CONASAN has a Technical Committee on Food Security and Nutrition (COTSAN), which seeks to address the double burden of malnutrition in El Salvador through a multi-sectoral and multi-level governance system. It works at national, departmental and municipal levels with representatives from different sectors. Municipal Committees of Food Security and Nutrition (COMUSAN) are led by mayors and are responsible for preparing and implementing plans to address malnutrition with a territorial approach, and conducting Food Security and Nutrition (FSN) monitoring and evaluation.
The Finnish National Nutrition Council is an inter-governmental expert body under the Ministry of Agriculture and Forestry with advisory, coordinating and monitoring functions. It is composed of representatives elected for three-year terms from government authorities dealing with nutrition, food safety, health promotion, catering, food industry, trade and agriculture.
Added February 2018: The National Council for Food and Nutrition Security (CONASAN), established in 2005 by Decree No. 32/2005 (Ley del Sistema Nacional de Seguridad Alimentaria y Nutricional (SINASAN) – Law of the National Food and Nutritional Security System) leads nutrition policy direction in Guatemala. CONASAN is responsible for encouraging actions that promote food and nutrition security at the national level in political, economic, cultural, operational and financial spheres. The Council is chaired by the Vice President and consists of eight representatives from Ministries (Agriculture; Livestock and Food; Public Health and Social Assistance; Education; Environment and Natural Resources; Economy; Public finances; Communications, Infrastructure and Housing; and Labour and Social Welfare); the Secretariat for Food and Security Nutrition Security (SESAN); the Presidential Secretariat for Executive Coordination; the Secretariat for Social Works of the President's Wife; two representatives from the private sector, and five representatives from civil society. SESAN, which acts as Secretary of the Board, supports stakeholder and institution coordination. CONASAN approves and promotes compliance with the National Food and Nutrition Security Policy and implements government regulations that allow for the reduction of malnutrition in all its forms.
The Malaysian National Coordinating Committee on Food and Nutrition (NCCFN), chaired by the Deputy Director General of Health (Public Health) and in operation since 1994, consists of representatives of the Ministry of Health and other ministries (such as the Ministries of Education, Agriculture, Youth and Sport, Domestic Trade, Rural and Regional Development), ministerial agencies, universities, professional bodies, the food industry and NGOs.
Based on the Healthy Lifestyle Promotion and Care of Non-Communicable Diseases Act (2016), Malta established an inter-ministerial Advisory Council on Healthy Lifestyles in August 2016 to advise the Minister of Health on any matter related to healthy lifestyles. In particular, the Advisory Council advises on a life course approach to physical activity and nutrition, and on policies, action plans and regulations intended to reduce the occurrence of non-communicable diseases. The prime minister appoints the chair and the secretary of the Advisory Council, while the ministers of education, health, finance, social policy, sports, local government, and home affairs appoint one member each.
In 2014, the Pacific Non-Communicable Disease Partnership was established to encourage a multi-sector approach to prevent and control non-communicable diseases (NCDs). The partnership includes Pacific Island Forum Leaders, Pacific Ministers of Health, Pacific Islands Permanent Missions at the United Nations, Pacific Island Countries and Territories (PICTs), Secretariat of the Pacific Community (SPC), World Health Organization (WHO), United Nations Development Programme (UNDP), World Bank, Australia Department of Foreign Affairs and Trade (DFAT), New Zealand Aid Programme (NZAP), US Department of State, Pacific Island Health Officers’ Association (PIHOA) and the NCD Alliance. The Partnership aims to strengthen and coordinate capacity and expertise to support Pacific Island countries achieve globally agreed NCD targets and implement the new NCD roadmap.
Added February 2018: The Tanzania Food and Nutrition Centre (TFNC), established in 1973, focuses on improving nutrition via policy, strategy development and planning, providing technical advice to the government and other organisations and nutrition education. This semi-autonomous Centre is housed under the Ministry responsible for Health and collaborates with the Ministry of Finance and Development Planning to integrate food and nutrition into national development plans.
The TFNC acts as the Secretariat for the High-Level Steering Committee on Nutrition (HLSCN), which is a national multi-sectoral coordination body housed under the Prime Minister’s Office. The Committee includes key nutrition stakeholders such as development partners, civil society organisations, the private sector and government ministries responsible for health, community development, gender, education, agriculture, finance and planning, industry, trade and investment, minerals and water and irrigation. In 2017, the Prime Minister launched a five-year Multisectoral Nutrition Action Plan (2016/17–2020/21) to address Tanzania’s double burden of malnutrition. The action plan was developed through the technical coordination of the TFNC, together with policy leadership from the HLSCN.
The United Nations Inter-Agency Task Force on Non-Communicable Diseases, established in 2013, coordinates the activities of the relevant UN funds, programmes and specialised agencies to support the realisation of the commitments in the UN Political Declaration on NCDs.
The UN Standing Committee on Nutrition promotes cooperation among UN agencies and partner organisations in support of community, national, regional and international efforts to end malnutrition in all of its forms.
Added February 2018: Since 2016, 8 local authority councils in the UK have signed the voluntary Local Government Declaration on Healthy Weight, developed and advocated by Food Active. The declaration contains 14 commitments, which can be adapted by local authorities to align policies across different council departments to promote healthy weights. Aside from the public health department, the declaration recommends involving departments from leisure services, planning and environmental health. Commitments include increasing the availability and affordability of healthy food and drinks in public buildings and facilities, engaging with the local food and drink sector to consider healthy retailing, increasing access to fresh drinking water on local authority controlled sites, protecting children from inappropriate food and drink marketing at events on local authority controlled sites, ensuring healthy eating messages are comprehensive and coherent with government guidelines, and considering how town planning can contribute positively to physical activity. Local councils are putting these commitments into action.
Added February 2018: In 2010, the California Health in All Policies (HiAP) Task Force was created by Executive Order S-04-10 and is housed under the Strategic Growth Council, bringing together 22 state agencies, departments and offices to support a healthier and more sustainable California. The Task Force works with government departments to integrate health and equity into programmes and policies that advance state priorities, such as healthy food, transportation and land use planning. The Task Force provides capacity building and training to support departments to incorporate health and equity considerations into grant programes and policy documents, facilitates collaboration between departments, and develops health and equity tools and resources.
The Task Force improves accessibility and affordability of healthy food by supporting “farm-to-fork” and healthy food procurement policies and programmes. The Task Force supported creation of the Office of Farm to Fork at the California Department of Food and Agriculture to support a robust sustainable food system, alleviate hunger, promote consumption of healthy foods, and to work in partnership with the Task Force. In addition, the Task Force developed nutritional guidelines for food procurement in adult California correctional facilities.
Awareness is one precursor to eating well. The evidence suggests that public campaigns can boost awareness. To influence consumption, they need to be sustained and use multiple channels.
New countries added February 2018: Food-based dietary guidelines are an information and communication tool involving the translation of recommended nutrient intakes or population targets into recommendations of the balance of food that populations should be consuming for a healthy diet. They typically promote increased intake of fruit and vegetables and limited intake of salt/sodium and sugar. They may also include guidance on physical activity and healthy weight, and provide guidelines for different population groups. Countries use various formats of presenting the guidelines including cooking pots (Guatemala, Paraguay), pineapples (Fiji), pyramids (Australia, India, US), plates (Colombia, UK), pagodas (China), spinning top (Venezuela), traditional African house (Benin) and circles (Argentina). Some countries have started to include sustainability criteria in their dietary guidelines (eg Germany in 2013, Finland and Brazil in 2014, Sweden and Qatar in 2015, the Netherlands and UK in 2016). Brazil’s revised dietary guidelines, launched in 2014, present food- and meal-based recommendations that take into account cultural dimensions and promote the consumption of minimally processed food as well as health, wellbeing and sustainable food systems, and recommend avoiding ultra-processed food. Details on the content of national dietary guidelines can be found on the FAO database on Food-based dietary guidelines.
China has developed guidelines specific to snacks, Guidelines on Snacks for Chinese Children and Adolescents (2008).
In 2009, the Finnish National Nutrition Council developed recommendations for beverages for children and adolescents, adults and older people that split beverages into three categories: drink daily (eg water), you can also drink daily (eg a glass of fruit juice) and drink only infrequently (eg soft drinks). Recommendations differ by age category.
Mexico developed a set of Beverage Guidelines for Healthy Hydration in 2008.
In June 2012, the Department of Health of Western Australia initiated the public health campaign LiveLighter. In 2014, it extended to Victoria and the Australian Capital Territory and in 2015 to the Northern Territory. In all locations, the campaign is managed by the Heart Foundation in partnership with the local Cancer Council. LiveLighter uses a website, social media, advocacy and provocative radio, print and TV advertisements to encourage people to eat healthily and be physically active to maintain a healthy weight. The website provides free resources such as recipes, a meal and activity planner, and a BMI, sugary drink and risk calculator. The campaign is ongoing.
Morley B et al. (2016) Population-based evaluation of the ‘LiveLighter’ healthy weight and lifestyle mass media campaign. Health Education Research 31(2), 121-135
There are two public campaigns on healthy eating ongoing in Canada: the Nutrition Facts Education Campaign (Phase I with a focus on % Daily Value 2010-2014 and Phase II with a focus on Serving Size since 2015) and the Eat Well Campaign (since September 2012). They aim to improve the understanding of healthy eating, including reading the Eating Well with Canada’s Food Guide, reading nutrition labels (in particular the % Daily Value), the importance of reducing sodium intake and improving food skills to maintain a healthy weight. The campaigns are managed by Health Canada’s Office of Nutrition Policy and Promotion and involve public private partnerships with various stakeholders, including food manufacturers, grocery retailers, produce marketing associations, health NGOs and health professional organisations, as well as provinces and territories.
The Caribbean Community (CARICOM) celebrates Caribbean Wellness Day every year on 13 September to raise awareness of healthy lifestyle options, including promoting healthy food choices. The main slogan is “Love that body” and the campaign elements include posters, stickers, a logo, a jingle, a website and public service announcements.
The French Ministry of Social Affairs and Health and the National Institute of Health Prevention and Education run a healthy living campaign called Eat Move (Manger Bouger) as part of the National Nutrition and Health Programme (PNNS). Launched in 2001 and ongoing, it includes mass media, informational videos, print advertisement and a website that has a range of resources including targeted nutrition education tools and La fabrique à menus (added in 2013), a menu planner with seasonal recipes that are in line with the PNNS nutrition guidelines.
From October 2014 to December 2015 the Macedonian government ran a campaign called Health is a Choice! Healthy Food and Healthy Lifestyle for a Long Life! to raise awareness about the importance of eating healthy food, leading a healthy lifestyle and exercising. The campaign included TV and radio commercials, media advertisements and billboards.
As part of the Mexican National Strategy on the Prevention and Control of Overweight, Obesity and Diabetes (La Estrategia Para Un Mexico Sin Obesidad), the Presidency and Secretary of Health launched a national health promotion campaign focusing on the prevention of non-communicable diseases, Check, Monitor and Move Yourself (Chécate, Mídete, Muévate). The objective of the campaign is to foster a culture of taking care of personal health, promote exercise and discourage the consumption of high-calorie food. The campaign uses a variety of media channels, including television, radio, cinema, billboards, advertisements on public transport and social media. The Mexican Social Security Institute and the Safety and Social Services Institute for State Workers are co-sponsors. The campaign launched in October 2013 and is expected to run until 2018.
The Netherlands Nutrition Centre (part of the National Institute for Public Health) runs online public awareness campaigns to encourage healthier food choices. Examples of campaigns include Balansdag (Balance Day), launched in 2006 as part of the campaign Maak je niet dik (Do not get fat) started in 2002 – encouraging people to compensate for overeating one day by eating healthy meals with no snacks and moving more the next day to balance out calorie intake, and Het Nieuwe Eten (New-style Eating), launched on 29 December 2008 – encouraging people to make step-by-step changes at their own speed. Recipes and tips are provided.
The Social and Health Agency of New Caledonia introduced the Eat better, Move more (Mange mieux, Bouge plus) campaign in 2011 to improve the diet of families with practical, easy tips for a healthy lifestyle. It is aimed at women and encourages families to eat more fruits and vegetables and to limit the amount of food and drinks high in sugar and fat. The campaign uses a website, Facebook, flyers and booklets as well as a Super Mom heroine to deliver cooking and health messages.
The Norwegian Health Directorate runs a national dietary advice campaign called Small steps, big difference (Små grep, stor forskjell), launched in 2012, using brochures, online webpages, TV and social media.
The Peruvian Ministry of Production launched the Dame Anchoveta (Give me Peruvian Anchovy) campaign in December 2013 (ongoing) to increase awareness of the nutritional benefits of fish (specifically anchovies) compared with other meat (red meat, pork, chicken). The campaign uses advertising on TV, radio and on the street, recipe books, and an interactive website with information about the nutrition, sustainability and biology of the Peruvian anchovy. This campaign aims to reconnect Peruvians with healthy traditional food.
In October 2011, the Ministry of Health, supported by the private sector, launched the campaign Come rico, come sano, come peruano (Eat delicious, eat healthy, eat Peruvian food). It aims to improve eating patterns by promoting the high nutritional quality of Peruvian food through recipe books, TV and radio spots, conferences and Mistura – Peru’s biggest food festival. The campaign is ongoing.
The annual month-long National Healthy Lifestyle Campaign organised by the Singapore Health Promotion Board has been running since 1992 and aims to increase awareness about the importance of a healthy lifestyle. The campaign takes a multi-pronged approach and involves different activities each year. For example, in 2010 the campaign focused on raising awareness of maintaining a healthy weight through healthy eating and physical activity, in 2011 the focus was on creating communities that are health promoting ecosystems (including an emphasis on the Healthier Hawker centres) and in 2014 the focus was on healthy living everyday.
The Tonga Health Promotion Foundation runs 30-minute weekly healthy lifestyle programmes on TV and radio and has issued posters in print media promoting healthy ways of living.
Updated February 2018: The Change4Life social marketing campaign started in England in January 2009, targeting families. It promotes healthy eating and physical activity using the slogan Eat well, move more, live longer. A sister campaign, Start4Life, is aimed primarily at pregnant women and new mothers. Change4Life also runs targeted campaigns such as the healthier snacks for kids campaign – “Look for 100-calorie snacks, two a day max” (January 2018), the Be Food Smart campaign (January 2017), which included an app to highlight how much sugar, saturated fat and salt can be found in everyday food and drink, the Sugar Swaps campaign (January 2015) designed to help parents cut down the sugary foods and drinks consumed by their children, and the Smart Swaps campaign that encouraged alternatives to help cut sugar and fat from snacks, drinks and meals (January 2014).
From October 2012 to December 2012, the Los Angeles County Department of Public Health ran a portion control public education campaign Choose less, weigh less to help residents of LA County reduce the consumption of surplus calories. The campaign included print media on transit shelters, buses and rail cars, billboards, radio and online advertising, website content, and social media.
In February 2016, the Los Angeles County Department of Public Health launched a public awareness campaign to encourage parents to choose healthier meals for their children when eating out. The campaign centred around tips such as “Choose milk or water every time” or “Choose fruits or vegetables on the side”. The ads appear in public transit, on radio stations and on digital and social media in English, Spanish, Korean, Mandarin and Cantonese. The campaign is expected to run until mid-March 2016.
In August 2014, the Venezuelan National Institute of Nutrition launched Agarra dato, come sano (Get informed, eat healthy), a national campaign against overweight and obesity. The campaign aims to halve the number of obese people in Venezuela by 2019, reduce the consumption of fat and sugars and increase the consumption of vegetables and fruit in the population. Ads aim to raise awareness about the amount of sugar in sugary drinks and fat in fast food as contributors to weight gain.
Governments in these countries manage, or are involved in, fruit and vegetable campaigns that promote the consumption of a certain number of fruit and vegetable portions a day, often "5 a day" (eg Argentina, Chile, Germany, Mexico, New Zealand, South Africa, Spain, Tonga) but also "6 a day" (Denmark), "Go for 2&5" (Western Australia), “Fruits & Veggies – More Matters” (United States) or 5–10 (France).
Capacci S, Mazzocchi M (2011) Five-a-day, a price to pay: An evaluation of the UK program impact accounting for market forces. Journal of Health Economics 30(1), 87-98
Carter OBJ et al. (2011) ‘We’re not told why – we’re just told’: qualitative reflections about the Western Australian Go for 2&5® fruit and vegetable campaign. Public Health Nutrition 14(6), 982-988
Pollard CM et al. (2008) Increasing fruit and vegetable consumption: success of the Western Australian Go for 2&5® campaign. Public Health Nutrition 11(3), 314-320
Piloted in 2009 and launched in 2011 by Oregon State University’s Extension Service as part of SNAP-Ed, Food Hero is a targeted social marketing campaign to help low-income Oregonians increase their consumption of vegetables and fruit and increase home-cooked family meals to improve health. With public, non-profit and private sector partners in all 36 Oregon counties, Food Hero uses community kits, a website (with recipes and tips & tools), a Food Hero monthly newsletter, social media, media (web banners, billboards, bus shelters and buses, movie theatre, radio), grocery stores (cart ads, shelf talkers, freezer decals, food demos and in-store announcements) to reach its target audience. All campaign materials are also available in Spanish. Food Hero works on direct education with the target population as well as work on policy, systems and environmental change.
The New York City Department of Health launched the Take me with you campaign in August 2014 (ongoing) to remind New Yorkers that packing an apple, banana or some carrot sticks is an easy way to add more vegetables and fruits into their diet instead of less healthy options. The ads appear at bus stops, checkouts and banners throughout the city.
*Civil society organisations have also developed public awareness campaigns on unhealthy food. For example, Cancer Council Victoria in Australia has a social marketing team that runs campaigns related to cancer prevention, including on diet and obesity. In January 2013, it launched the Rethink Your Sugary Drink campaign on YouTube and social media focused on the amount of sugar in soft drinks. In Mexico, the civil society network Alianza por la Salud Alimentaria ran a public campaign against soft drinks in May–August 2013. A series of adverts were posted on buses, billboards and in the subway showing 12 heaped spoonfuls of sugar next to a bottle of soda. The adverts asked "Would you eat 12 spoonfuls of sugar? Why do you drink soda?”
The Hungarian Aqua Promoting Programme in the Young (HAPPY), run by the National Institute for Food and Nutrition Science, aims to reduce the excessive consumption of sugary drinks and to popularise water consumption among primary school students. Running nationwide since 2010, the programme promotes water consumption by educating students on adequate fluid consumption and makes free water available on school premises. More than 43,500 students from 144 schools participated in HAPPY in 2014.
The Reduce Sugar campaign has been run by the Malaysian Ministry of Health in conjunction with the Ministry of Domestic Trade, Cooperatives and Consumerism since 1998. Educational material on sugar reduction is distributed to the public using leaflets and posters, and messages are disseminated via social media, smart phone apps and food outlets with Healthy Cafeteria or BeSS recognition (see "O – Offer healthy food and set standards in public institutions and other specific settings" for more information) as well as media during major festivals such as Eid Mubarak, Chinese New Year and Deepavali.
The Life’s Sweeter with Less Sugar campaign ran from October 2014 to February 2015 to encourage Singaporeans to choose reduced sugar or no sugar beverages when they dine out. More than 1,000 partner drink outlets in food courts, hawker stalls, coffee shops and kiosks promoted these healthier beverage choices to nudge consumers into making these their default choice.
In Thailand, the Sweet Enough Network was established in 2003 by a group of dentists, paediatricians and public health workers in the Ministry of Public Health’s Dental Health Division to endorse regulations to reduce added sugar in food products and raise awareness of the risk associated with excess sugar consumption. They have a logo and mascot, which is promoted through books, games and videos.
The Tonga Health Promotion Foundation launched the campaign A Mouthful of Sugar in 2012, which used print and video to discourage the consumption of soda. The print campaign features a bottle of soda with the label "diabetes", from which sugar – rather than liquid – is poured. The poster features healthier alternatives, such as water or coconut water.
Brighton & Hove City Council launched the #SugarSmartCity campaign in October 2015. Through a dedicated webpage, social media and events, the campaign aims to raise awareness about the sugar content of food and drink products and to educate and inform about the impact of high sugar intake on health. The campaign started with a debate that explored how everyone – individuals, schools, retail shops and food outlets – can work together to tackle sugar intake in the city. Residents and target groups including food outlets were asked for their views via surveys focus groups and discussions. The development of a Sugar Smart City Strategy will follow analysis of the debate results. The campaign is ongoing.
In 2009, the New York City Department of Health launched the Pouring on the Pounds campaign throughout the public transport system. The campaign raised awareness about the amount of sugar in sugary drinks with slogans such as “Don’t drink yourself fat. Cut back on soda and other sugary beverages. Go with water, seltzer or low-fat milk instead”. The campaign has been adapted for use in other US states, including San Francisco Department of Public Health’s Pouring on the Pounds (February 2010–March 2010) and Los Angeles County Department of Public Health’s Choose Health LA Sugar Pack campaign (October 2011–December 2012).
The Choose Health LA Sugar Pack campaign used paid media on billboards, buses, railways and a short video on transit TV, a website that included a sugar calculator and social media platforms. Campaign materials and resources were produced in Spanish and English.
From November 2013 to January 2014, the New York City Health Department ran an obesity prevention campaign with the taglines "Your kids could be drinking themselves sick" and “You could be drinking yourself sick”. The adverts, which encourage consumers to swap sugary drinks for water, fat-free milk and fresh fruit, appeared on TV and on the subway in both English and Spanish.
In June 2015, the New York City Department of Health ran an ad campaign highlighting the health risks of children consuming sugary drinks. The ads explain that though a child may not be overweight or obese, sugary drinks can lead to increased visceral fat, which increases the risk of several diseases. Parents are encouraged in the ads to choose water or fruit for their children instead of sugary drinks.
Added February 2018: The #LiveSugarFreed campaign ran for 15 weeks from September 2015 to January 2016 warning people about the health risks of sugary drinks. It ran in the Tri-Cities region, a rural, mountainous area mostly in north-east Tennessee and portions of south-west Virginia and south-east Kentucky, targeting adults aged 18–45 years, with a special focus on those aged 18–29 years – adults with the highest consumption of sugary drinks. The campaign included ads and messages across multiple channels including TV, internet and social media with a core image of a man holding a bottle of soda in one hand and a pack of cigarettes in the other, comparing the health risks of sugary drinks to cigarettes, citing heart disease, cancer and tooth loss. The campaign was supported by a website (livesugarfreed.org) that included ads, factsheets and ways for organisations to participate.
The campaign also asked local businesses and organisations to adopt #LiveSugarFreed pledges. Gold, silver and bronze designations were awarded to organizations who promoted water instead of sugar drinks: Bronze – if water was made available wherever other beverages were available; Silver – if active steps to discourage sugary drink consumption were taken; and Gold – if sales or distributions of sugary drinks were stopped.
Farley TA et al. (2017) Mass media campaign to reduce consumption of sugar-sweetened beverages in a rural area of the United States. American Journal of Public Health 107: 989-995
The Estonian National Institute for Health Development runs an online campaign to reduce salt consumption. The web-based calculator allows consumers to place food items typical in the Estonian diet onto a plate and estimates their contribution to recommended daily salt intake. A free dietary analysis software lets consumers look up products by name, brand name, ingredient and source (ie fast food restaurant, supermarket) to learn about their detailed nutritional value; the software can be used like a nutrition diary.
In 2012, the Malaysian Ministry of Health started a campaign to reduce salt consumption in collaboration with governmental and non-governmental organisations such as the Ministry of Education, the Malaysian Society of Hypertension, the Malaysian Dietitian Association, the Nutrition Society of Malaysia, and the Malaysian Alliance of Salt Reduction Initiatives. The campaign comprised a variety of actions, including cooking demonstrations of low-salt recipes, talks on salt, factsheets and videos on salt and articles in newspapers and magazines. In addition, a logo was launched for the World Salt Awareness Week which has been celebrated yearly with a different theme, eg on salt and stroke prevention (2012), salt consumption when eating out-of-home (2015) and salt hidden in processed food as well as the link between salt and hypertension (2016).
The Low Salt Network in Thailand is funded by the Thai Health Promotion Foundation. In 2014, it collaborated with the Ministry of Public Health on a Low Salt Week involving a mass media campaign on public television and cable networks.
The UK’s Food Standards Agency (FSA) ran a four-phase salt campaign to raise awareness of salt consumption and to inform consumers how to lower salt intake. The first phase (launched in September 2004) focused on educating the population on why too much salt is a health concern. The second phase (launched in October 2005) encouraged consumers to check food labels for salt content and to consume no more than 6g of salt per day. The messaging of the third phase (launched in March 2007) focused on the high salt content of everyday food and the need to choose low-salt products. The fourth phase (launched in October 2009) contained all the messages of the previous three phases. The campaign focused on women aged 35–65 because they are mainly responsible for buying and preparing food in family households. The FSA used its website, TV advertising, posters and printed material, articles in women’s journals and national newspapers as well as news coverage, in addition to leveraging stakeholders of the food industry and civil society organisations to get the message across to hard-to-reach groups. The campaign was part of a larger salt reduction effort, which also included front-of-pack labelling (see "N – Nutrition label standards and regulations on the use of claims and implied claims on food") and reformulation (see "I – Improve nutritional quality of the whole food supply").
Shankar B et al. (2013) An evaluation of the UK Food Standard Agency’s salt campaign. Health Economics 22, 243-250
Sutherland J et al. (2012) Fewer adults add salt at the table after initiation of a national salt campaign in the UK: a repeated cross-sectional analysis. British Journal of Nutrition 110(3), 552-558
In 2010, the Canadian government launched a Nutrition Facts Education Campaign with the industry trade organisation Food & Consumer Products of Canada (FCPC). The ongoing multi-media initiative aims to improve understanding and use of nutrition information on labels.
People with elevated risk factors for cancer and other non-communicable diseases – such as heavy bodyweight, high cholesterol or glucose intolerance – can benefit from advice provided by their healthcare provider. Such advice can also be given to people at low risk for prevention into the future.
There is potentially a wide range of mechanisms for integrating nutrition advice into primary care, including counselling, self-help materials and computer-tailored messages. Randomised controlled trials suggest they can be effective if carefully designed and well targeted. The most positive outcomes appear to be for people already at risk.
Based on the Clinical Practice Guidelines (CPG) on Management of Obesity (2004), overweight and obese adults and adolescents should receive dietary counselling, exercise prescription, support in behaviour change and pharmacotherapy. Overweight or obese patients are referred to a nutritionist by a physician. Based on the 2016 Standard Operating Procedure (SOP) Nutrition Management for Overweight & Obesity (Adults & Children), the patient receives individual menu planning which is based on the Malaysian Dietary Guidelines and the patient’s food frequency questionnaire (FFQ). Patients see a nutritionist within three months of referral and at least two follow-up visits, or until the discharge criteria are met, to ensure progress and compliance. The discharge criteria are a 10% reduction of body weight; if this is not achieved within two years, patients are discharged if their waist circumference has reduced by 4cm or reached 80cm for women and 90cm for men, or if they haven’t gained more than 3kg since referral.
Clinical management for obese and severely obese adults in Singapore is offered in four specialist hospitals. The Health Promotion Board has also offered the 12-week weight loss challenge Lose to Win™ since 2009. Under the guidance of qualified trainers, participants receive a health assessment, and take part in group exercise, nutrition and mental wellbeing workshops (including goal-setting). There is follow-up at 3, 6, and 12 months post programme.
Diet and Physical Activity Clinics are available in Thai Ministry of Health-run hospitals, focused on evaluating health status and developing individual weight-loss plans.
Many National Health Service (NHS) authorities in the UK offer weight management referral schemes, in which primary care doctors can refer a patient to weight management programmes free of charge. In December 2006, the National Institute of Clinical Excellence issued guidance (CG43) for healthcare professionals on the prevention, identification, assessment and management of overweight and obesity in adults and children. In February 2010, the Scottish Intercollegiate Guidance Network (part of NHS Quality Improvement Scotland) issued guidance (SIGN115) for the management of obesity, including diagnosis, identification of high-risk groups, and dietary and behaviour-change interventions.
An expert committee on the assessment, prevention and treatment of child and adolescent obesity, convened by the American Medical Association, the US Department of Health and Human Resources, and the Centers for Disease Control, issued recommendations on weight management in primary care settings in 2007. The committee recommended that health professionals conduct a yearly assessment of body mass index status, dietary behaviour and readiness to change. For at-risk groups, the committee recommended a set of behaviour-change goals, relating in particular to dietary behaviours.
Nutrition is part of comprehensive healthcare and provided by all services within Brazil’s system of universal health coverage (Brazilian Unified Health Systems), particularly primary care. The Ministry of Health encourages health teams to promote healthy eating, evaluate food intake and anthropometry of individuals in all stages of life, prevent and control nutritional deficiencies and obesity and provide nutritional counselling. To support and structure this work, the government provides manuals, materials and self-learning courses on these topics for health professionals and transfers funds to municipalities annually.
The Chilean national food-based dietary guidelines (established in 2005, and revised in 2013) are promoted in the healthcare sector. The Institute of Nutrition and Food Technology has produced, in conjunction with the health promotion department of the Ministry of Health, guidance for the provision of advice in healthcare settings, including on healthy diets.
Fiji’s Ministry of Health, assisted by Diabetes Fiji, have established three Diabetes Hub Centres in Labasa, Lautoka and Suva. Following diagnosis, patients are referred to a Diabetes Hub Centre, which are set up with a team to provide a "one stop shop" for diabetes care, including dietitians who provide nutrition advice.
In Finland, nutrition guidance by public health nurses is provided free of charge on a mandatory basis as part of antenatal care, and during appointments at child health clinics post-partum. Nutrition counselling is tailored to the family’s needs and targets both parents. It is based on the 2016 Food Recommendations for Families with Children developed by the Finnish National Institute for Health and Welfare.
Nutrition is part of the comprehensive primary healthcare services in most Malaysian government-run health clinics. Nutrition counselling is provided by dietitians or nutritionists and targets pregnant women with gestational diabetes, overweight or obese patients and those suffering from chronic diseases.
The Mexican Integrated Nutrition Strategy (EsIAN), first piloted in 2008 and since rolled out nationally, includes individual counselling to pregnant women and mothers of children under 5, and the distribution of micronutrient supplements. It promotes breastfeeding and appropriate complementary feeding, as well as linear growth.
The South African Integrated Nutrition Programme was implemented in 1995 and focuses on children under 6 years old, pregnant and lactating women and all people living with chronic diseases, and targets malnutrition in South Africa. It is located in the primary healthcare framework and includes protocols and guidelines on nutrition education and counselling.
Based on the 2012 Brazilian Breastfeeding and Complementary Feeding Strategy, 18,125 health professionals and 3,400 tutors were trained by 2015 to support the promotion of breastfeeding and healthy complementary feeding in primary care. A distance learning course in breastfeeding and healthy complementary feeding was established by the Ministry of Health.
The German national IN-FORM initiative, launched in 2008 by the Ministry of Health and the Ministry of Food and Agriculture, promotes healthy diets and physical activity, and includes provisions to integrate diet and physical activity into training programmes for health professionals. These provisions have not been implemented nationally, but through actions in some states and communities.
The standardised curriculum to train community health workers in South Africa, dating from July 2012, contains a mandatory lesson on healthy lifestyle and eating, providing information on overweight and obesity, non-communicable diseases and undernutrition, as well as how nutrition affects health.
The reason for nutrition education is to improve knowledge and the ability to put that knowledge into practice. Studies have demonstrated that nutrition knowledge and healthy dietary behaviour are positively correlated. Higher levels of general education have been found to increase the ability of individuals to obtain and understand the health-related information needed to develop health-promoting behaviours.
The evidence shows that interventions to provide education can be effective, but this depends on the pre-existing attitude, knowledge and habit strength of the targeted group. Education should thus be accompanied by changes in the food environments to effect longer-lasting change.
The Australian Curriculum (version 8), developed by the Australian Curriculum Assessment and Reporting Authority (ACARA), was published in October 2015 after endorsement by the Education Council in September 2015. It addresses food and nutrition education in both the Health and Physical Education and Design and Technologies curriculum. Students learn about food production, the benefits of healthy eating and the preparation of healthy foods, as well as how culture and context shape what they eat. States and territories are responsible for implementing the Australian Curriculum. All states and territories have implementation plans in place with varying implementation timeframes to deal with compatibility issues with state curriculums; however, the aim is for nationwide implementation of the curriculum by 2020.
Brazil’s School Health Programme (PSE) was established in 2007 by Presidential Decree No 6.286/200 and is managed by the Ministries of Health and Education. Through the programme, schools must monitor and evaluate student health and take actions to promote healthy eating and food and nutrition security. In 2009, a new mandate established that food and nutrition education should be fully integrated across the entire curricula of basic education. In 2012, the Ministries of Social Development, Health and Education launched the Framework of Reference for Food and Nutrition Education in Public Policies, identifying kindergartens, schools and universities as important areas for food and nutrition education.
Education is a key part of awareness raising on health issues in Finland, and compulsory classes in health education and home economics are part of basic education. Home economics includes food preparation, meal planning (taking nutritional recommendations into account) and how to interpret food labelling and assess the reliability of different types of nutrition information.
In 2005, the Japanese Basic Law on Shokuiku (Shoku = diet, iku = growth and education) was enacted to promote dietary education, including in schools and nursery schools. Diet and nutrition teachers are trained by a programme started by the Ministry of Education and Science that uses professional registered dietitian programmes in universities.
As part of the formal curriculum, pupils in primary and secondary schools learn about the Malaysian Food Pyramid, the importance of fruit and vegetables, a balanced diet and active living in Physical and Health Education. Nutrition is also taught informally through activities in school sports clubs, academic associations and youth organisations such as scouts and cadets.
In Mexico, the General Law on Education (Ley General de Educación) of 1993, last amended in 2016, establishes that schools must provide nutrition education alongside minimum standards for physical activity and sports, with the aim of promoting a culture of healthy eating.
The Slovenian national nutrition policy requires nutrition education to be included on school curricula. Nutrition education in primary schools is mainly delivered through science subjects, but also in home economics, and is designed to both aid knowledge and skills acquisition (eg understanding healthy eating guidelines; classifying foods according to nutritional content).
In South Africa, the inclusion of nutrition is compulsory in the Life Orientation curriculum in schools.
The Vietnamese Ministry of Education and Training is responsible for incorporating nutrition education into the school curriculum at all levels and providing capacity building for teachers as part of the Vietnam National Nutrition Strategy (2011–20).
Food Sensations® is a comprehensive nutrition and cooking initiative offered by Foodbank WA to schools, adolescent and adults groups across Western Australia (WA).
Food Sensations in schools is an interactive, hands-on nutrition and cooking programme with curriculum linked lesson plans that are available to schools registered with Foodbank WA’s School Breakfast Program. The lesson plans and many other resources including recipe booklets are available on the Superhero Foods website. It is is funded by the Department of Education (WA), Department of Health (WA), Department of Regional Development and Lands (WA).
Food Sensations for Adults is a four-week comprehensive adult food literacy programme which covers topics such as the Australian Guide to Healthy Eating, label reading, meal planning and budgeting, mindful eating, supermarket tours as well as cooking and food safety. The Food Sensations programme is offered to people from low to middle incomes with an interest in improving their food literacy skills. The programme is predominately face to face, but can be accessed via videoconference to regional and remote areas of WA. It is funded by the Department of Health (WA).
Community-based nutrition education sessions are conducted through a variety of initiatives by the nutrition division of the Malaysian Ministry of Health. The Healthy Community Kitchen Initiative, based in rural settings, organises group cooking classes, cooking demonstrations, nutrition talks and nutrition training as well as community gardening, in addition to health screenings. Nutrition Information Centres, based in urban settings, disseminate nutrition information to the public; some also conduct weight management programmes which comprise nutritional assessments, diet consultations and physical activity. The Healthy Supermarket Initiative conducts supermarket tours teaching participants to read labels and choose healthier food products while supermarket staff receive training on healthy eating and food safety.
Empowering Communities, Strengthening the Nation, known as KOSPEN, is a community-based programme to address lifestyle risk factors of non-communicable diseases (NCDs). KOSPEN is a collaborative effort between the Ministry of Health, the Department of Rural Development (KEMAS), the Neighbourhood Watch Programme of the Department of Unity and National Integrity, and non-governmental organisations. KOSPEN covers healthy eating, weight management, physical activity, smoking and early detection of NCD risk factors. Volunteers are trained to promote and advocate for health and facilitate the establishment of healthy environments that enable healthy lifestyle practices. Volunteers also carry out health screenings on blood pressure, blood sugar and body mass index. If screened individuals show an elevated risk for NCDs, volunteers refer them to the nearest health clinic. By June 2016, 31,940 volunteers were trained in 5,551 localities.
The Empowerment Initiative of the Parents and Teachers Association (PTA), known as C-HAT, aims to increase the knowledge and awareness of parents and teachers about a healthy lifestyle in childhood including healthy eating and physical activity. PTA representatives of each school receive one training session conducted at district level. The initiative also encompasses BMI measurements by school health teams, and referral of overweight and obese children to a nutritionist at a health clinic using the 2016 Standard Operating Procedure (SOP) Nutrition Management for Overweight & Obesity (see "N – Nutrition advice and counselling in health care settings" for more information on the SOP). It plans to enroll 10,000 schools by 2018.
The US National Institute of Food and Agriculture runs the Expanded Nutrition Education Program nationwide and in US Territories. The programme is designed to assist resource-limited audiences to acquire the knowledge, attitudes, and skills in food production and preparation in order to encourage behaviour change. Participants learn to better manage their food budgets and resources from federal, state, and local food assistance agencies. The programme also engages young people through after-school activities, residential camps, community centres, and home gardening workshops, which complement the educational curriculum.
The US Department of Agriculture runs a programme to provide education to recipients of the Supplemental Nutrition Assistance Program (SNAP). They provide online resources and guidance to support state and local SNAP education providers. The SNAP-Ed Connection site provides curricula, lesson plans, research and participant materials.
In 2007, the voluntary “nutrition licence” programme for elementary school children in Germany was introduced through “IN FORM”, an initiative to promote healthy diets and exercise by the Ministry of Nutrition and Agriculture and the Ministry of Health. Children are taught cooking skills, hygiene rules and the nutrition pyramid in year 3 of elementary school. After taking an oral and written exam, they receive a personalised nutrition licence (“Ernährungs-Führerschein”). As of May 2016, 780,000 pupils have taken part in the programme. With the support of the Ministry of Nutrition and Agriculture, aid infodienst, a German non-profit association, trained 5,000 elementary teachers and 600 trainers to deliver the “nutrition licence” programme. aid infodienst also supplies the teaching material.
Children in Malaysian secondary schools are taught cooking skills in the elective course Life Skills, while kindergarten teachers learn how to prepare healthy menus for pre-school children in their care. The Life Skills course and the cookery education for teachers are under the auspices of the Ministry of Education.
Health clinics routinely give cooking demonstrations as part of their activities on healthy eating promotion.
Community Kitchens (Comedores Populares) are an important channel for the provision of food to families living in poverty in Peru. They are community-focused and involve cooking programmes to develop food skills and basic nutrition education. A project is currently underway to increase the use and consumption of fruits in the kitchens, and reduce the use of saturated fat and salt.
In England, from September 2014, the National Curriculum includes mandatory hands-on cookery for children up to Year 9. Students learn how to cook and apply the principles of nutrition and healthy eating.
The non-governmental organisation Plenty Belize manages a series of school garden projects in close liaison with local government and non-governmental agencies.
Classes on agricultural gardening became part of the school curriculum in Bhutan in 2002, under a joint initiative by the Ministries of Agriculture and Education with the support of the World Food Program.
The EduPlant programme is endorsed by the South African Department of Education. It supports the development of school gardens, where children learn to grow fruit and vegetables, eat some of the produce and sell the rest to raise funds. Schools receive support for two years until they can manage on their own.
In Uganda, agriculture is part of the primary school curriculum and there is extensive vegetable gardening in schools, some supported by the non-governmental organisation Seeds for Africa.
The Garden in Every School programme in California was launched in 1995 by the California Department of Education and covers thousands of schools. It establishes an instructional programme, publicises best practice and provides a grant programme. It is linked to school meals and is supported by classroom nutrition education.
New York City’s Grow to Learn NYC: the Citywide School Garden Initiative aims to establish a sustainable school garden in every public school in the city. By 2013, 350 schools had registered in the initiative. If school gardens meet the criteria of GreenThumb, a division of the New York City Department of Parks and Recreation, they receive technical assistance, materials and educational workshops. The initiative partners with the Garden-to-Café Program of the NYC Department of Education, Office of School Food, connecting school gardening with school cafeterias.
The Health Promotion Board in Singapore encourages employers to establish a Workplace Nutrition Programme. They provide guidelines on developing comprehensive programmes, which include organisational policies, supporting creative environments, and building awareness and personal skills.
Since 2005, the Malaysian Ministry of Health has run the voluntary Healthy Catering Initiative, which provides training for food outlet and canteen operators on healthy eating, preparing healthy menus, the effects of unhealthy eating habits, and food safety. Most of the caterers who have so far attended the course are those serving food to government authorities or institutions. School canteen operators are encouraged to take the training course alongside the mandatory Food Handlers Training course, and private sector companies are trained on request. The Healty Catering training is mandatory for operators of hospital cafeterias (see "O – Offer healthy food and set standards in public institutions and other settings" for more information).
Linked to the Healthy Meals in Schools Programme (see "O – Offer healthy food and set standards in public institutions"), the Singapore Health Promotion Board supports schools by organising culinary and nutrition training for canteen vendors to equip them with knowledge of healthy nutrition and culinary skills to prepare healthier meals using healthier ingredients.
Linked to the voluntary Smart Meal Seal Programme (a point-of-purchase labelling scheme for healthy options), the Colorado Department of Health provides nutrition training for catering managers in participating restaurants and canteens to encourage the development of healthier options that meet nutritional standards.
Added February 2018: Linked to Philadelphia’s Healthy Chinese Take-Out Initiative implemented in 2012 (see “S – Set incentives and rules to create a healthy retail and food service environment”), Chinese restaurant owners and chefs were given training to help reduce the sodium content of dishes on their menus. This included professional-chef led group training at the beginning of the initiative that included information about sodium, its impact on health and low-sodium cooking techniques with practice cooking sessions with the chef, as well as ongoing technical assistance to help implement menu changes. One-on-one "booster training" was offered to restaurant owners and chefs to reinforce what they learned in the initial training, distribute promotional materials and address any issues or concerns. A toolkit and video was also developed and made available.
Added in February 2018: Linked to Philadelphia’s Comprehensive Nutrition Standards, in effect since 2014 (see “O – Offer healthy food and set standards in public institutions and other specific settings”) training is provided to all City staff and other providers who work in City agencies serving, selling or preparing food. There are four training modules – introduction to the Nutrition Standards, basic nutrition, healthy cooking and shopping strategies, and kitchen and culinary basics (knife skills, flavour perceptions, using spices, healthy substitutions). These modules are used with different audiences, such as kitchen staff who prepare food, programmatic support staff, and residents or constituents at sites. Toolkits are also available to help sites implement the standards and host interdepartmental meetings to share resources and get feedback on the implementation process.