NOURISHING database

Our database of implemented polices to promote healthy diets & reduce obesity

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 8 May 2019), providing an extensive overview of implemented government policy actions from around the world.

Contact us on policy@wcrf.org with further examples of implemented policies, evaluations of implemented policies or with any other questions or comments.

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^{Copyright © 2019 World Cancer Research Fund International. Please contact us on policy@wcrf.org for permission to replicate any part of the NOURISHING framework and/or policy database. Please do not attempt to create your own version.}

Nutrition label standards and regulations on the use of claims and implied claims on food

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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Examples of policy actions

Mandatory nutrient lists on packaged food*

*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

What the action involves and where implemented

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).

Evaluation
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

Clearly visible "interpretative" labels and warning labels

What the action involves and where implemented

Mexico

Updated May 2019: In 2014, the Mexican Federal Commission of Sanitary Risk Prevention (COFEPRIS)— the regulating body in Mexico responsible for food safety — published Front-of-Package labelling regulations (Decree DOF: 24/04/2012) required for most pre-packaged foods and non-alcoholic beverages sold and distributed in Mexico. The regulation format follows the guideline daily amount (GDA) format and outlines that the nutrients shown on the front-of-pack labels must be listed in Spanish and include, in this order: 1) Saturated fat (Grasa saturada) 2) Other fats (Otras grasas) 3) Total sugars (Azucares totales) 4) Sodium (sodio) 5) Energy (Energía) - either per serving or per package, or both. The labels of pre-packaged foods and non-alcoholic beverages show the total energy, saturated fat, other fats and total sugar content of the product expressed in kilocalories or calories and in percentages of recommended daily amounts as well as the sodium content expressed in miligrams or grams and in percentages of recommended daily amounts. Saturated fat, other fats, total sugars, sodium, energy (per serving and per pack) are included using a Guideline Daily Amounts format. Products that must display the label include: cereals, flavoured beverages, dairy, dressings, processed fruits, vegetables, legumes, meat, poultry, fish, ready-made dishes, chocolate, candy, desserts and miscellaneous (ice cream, marmalade, oíl). Herbs and spices, vinegar, food and beverages with less than 1% of recommended daily amounts or bulk sale products are exempt from the label. The Regulation also proposes a voluntary logo called “Sello Nutrimental” an interpretative front-of-pack label that can be added to a product if it complies with a nutrition profile established by COFEPRIS. This is aimed to distinguish healthier products amongst similar category of food products available in the market. A special application must be submitted to COFEPRIS for approval to use the label.

Offer healthy food and set standards in public institutions and other specific settings

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.

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Examples of policy actions

Mandatory standards for food available in schools, including restrictions on unhealthy food

What the action involves and where implemented

Mexico

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.

Standards in social support programmes

What the action involves and where implemented

Mexico

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.

Use economic tools to address food affordability and purchase incentives

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.

Please note, $ refers to USD.

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Examples of policy actions

Health-related food taxes

What the action involves and where implemented

Mexico

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 more than 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.

Evaluations
Hernández-F M et al. (2018) Reduction in purchases of energy-dense nutrient-poor foods in Mexico associated with the introduction of a tax in 2014. Preventive Medicine 118: 16-22.

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

Taillie LS 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

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

Added May 2019: Alvarez-Sanchez C et al (2018). Does the Mexican sugar-sweetened beverage tax have a signalling effect? ENSANUT 2016. PLOS ONE 13(8)

Added May 2019: Ng SW et al. (2018). Did high sugar-sweetened beverage purchasers respond differently to the excise tax on sugar-sweetened beverages in Mexico? Public Health Nutrition 22(4):1-7

Restrict food advertising and other forms of commercial promotion

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.

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Examples of policy actions

Mandatory regulation of broadcast food advertising to children

What the action involves and where implemented

Mexico

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 2.30am–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.

Improve nutritional quality of the whole food supply

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.

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Examples of policy actions

Voluntary reformulation of food products

What the action involves and where implemented

Mexico

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.

Set incentives and rules to create a healthy retail and food service environment

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.

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Examples of policy actions

Incentives and rules to reduce salt in food service outlets

What the action involves and where implemented

Mexico

Launched in 2013 in Mexico City, the Less Salt, More Health initiative 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.

Inform people about food & nutrition through public awareness

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.

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Examples of policy actions

Development and communication of food-based dietary guidelines

What the action involves and where implemented

Updated May 2019: 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 (India, US), plates (Australia, 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. Canada’s new food guide, launched in 2019, provides guidance on what to eat, as well as how to eat. This includes recommendations on healthy eating habits that encourage people to cook more often, to be mindful of their eating habits, to use food labels, to cook at home and to eat meals with others. The new food guide is an online suite of resources that provides information targeted to different audiences, including the general public, health professionals and policy makers.

Details on the content of national dietary guidelines can be found on the FAO database on Food-based dietary guidelines.

Development and communication of guidelines for specific food groups

What the action involves and where implemented

Mexico

Mexico developed a set of Beverage Guidelines for Healthy Hydration in 2008.

Public awareness, mass media and informational campaigns and social marketing on healthy eating

What the action involves and where implemented

Mexico

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.

Public awareness campaigns specific to fruit and vegetables

What the action involves and where implemented

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).

Evaluations
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

Nutrition advice and counselling in healthcare settings

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.

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Examples of policy actions

Nutrition counselling in primary care

What the action involves and where implemented

Mexico

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 the age of 5, and the distribution of micronutrient supplements. It promotes breastfeeding and appropriate complementary feeding, as well as linear growth.

Give nutrition education and skills

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.

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Examples of policy actions

Nutrition education on curricula

What the action involves and where implemented

Mexico

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.

NOURISHING database

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