We developed the NOURISHING framework to highlight where governments need to take action to promote healthy diets and reduce overweight and obesity.
The framework is accompanied by a regularly updated database (last updated 24 October 2018), providing an extensive overview of implemented government policy actions from around the world.
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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. (2015) A systematic review of the prevalence of nutrition labels and completeness of nutrient declarations on pre-packaged food in China. Journal of Public Health 37(4), 649-658
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.
Added December 2018: Jones A, Shahid M, Neal, B (2018) Uptake of Australia’s Health Star Rating System. Nutrients 10(8): 997.
Added December 2018: Mhurchu CN, Eyles H, Choi YH (2017) Effects of a voluntary front-of-pack nutrition labelling system on packaged food reformulation: The Health Star Rating system in New Zealand. Nutrients 9(8):918.
Added December 2018: Health Star Rating Advisory Committee (2017) Two year progress review report on the implementation of the Health Star Rating system – June 2014 – June 2016.
Updated October 2018: 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), Queensland (amendments to Food Act 2006, passed in March 2016, enforceable from March 2017) and Victoria (amendment to Food Act 1984 in effect since 1 May 2018) 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 (except in Victoria where voluntary display need not comply with 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.
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. 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.
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.
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.
Added October 2018: Myers G et al (2018). A process and outcome evaluation of an in-class vegetable promotion program. Appetite 125, 182-189
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
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.
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 food.
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
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.
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 food 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
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.
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.
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.
Added October 2018: Morley BC et al. (2018) Controlled cohort evaluation of the LiveLighter mass media campaign’s impact on adults’ reported consumption of sugar-sweetened beverages. BMJ Open 8(4): e019574.
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
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.
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).