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. (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
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
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. Despite implementation being delayed several times, the regulation went into effect 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
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.
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 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.
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
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)
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).
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 fruit 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.
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
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.
Please note, $ refers to USD.
In November 2014, the city of Berkeley, California, passed a law (Ordinance 7388-NS) taxing sugary drinks. An excise duty of $0.01 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 $0.01 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 $0.15 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 $0.15 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 $0.02 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 5g 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 $0.01 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 or more 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.
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 $0.175 per fluid ounce of sugar-sweetened beverages and $0.01 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.
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 $0.01 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.
Zhong Y et al. (2018) The short-term impacts of the Philadelphia beverage tax on beverage consumption. American Journal of Preventive Medicine 55(1): 26-34.
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
*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.
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 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 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
Governments have stated they support the implementation of "pledges" developed by food companies that restrict advertising of food (varies by company) to children under the age of 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 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 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 had three years to remove PHOs from products. As of 18 June 2018, food manufacturers and restaurants are no longer allowed to produce foods that contain PHOs. 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.
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
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 in 2005 (formerly called Healthy Bodegas). 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 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
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.
Updated October 2018: The Californian cities of Davis (Ordinance 2451 – effective 2 July 2015), Stockton (Ordinance 2016-06-07-1502 – effective 7 July 2016), Perris (Ordinance 1340 – effective 14 April 2017), Berkeley (Ordinance 7560 – effective 1 July 2017), Cathedral City (Ordinance 803 – effective 8 December 2017), Long Beach (Ordinance ORD- 17-0027 – effective 17 December 2017), Daly City (Ordinance 1415 – effective 1 June 2018) and Santa Clara County (Ordinance NS-300.908 – effective 7 August 2017), and Lafayette, Colorado (Ordinance 40, Series 2017 – effective 27 October 2017), Baltimore, Maryland (Council Bill 17-0152 – effective 18 July 2018), Louisville, Kentucky (Ordinance O-064-18 – effective 5 October 2018), 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 cities of Perris, Baltimore and Louisville allow 100% juice in a serving size of no more than 8oz. The city of Long Beach allows 100% juice under 40 calories. Berkeley, Long Beach, Daly City, Santa Clara County and Lafayette limit the allowable types of milk based on milkfat, calories, or added sweeteners. Purchasers of children’s meals may still request a sugary drink or juice for the child, except in Berkeley and Santa Clara County, where they must be purchased separately from a children’s meal or at an extra charge. Compliance is enforced through the restaurant food safety inspection process or an annual self-certification process, depending on the jurisdiction, and fines are assessed for violations.*
*The Center for Science in the Public Interest maintains a comprehensive table of Local Restaurant Kids’ Meal Policies.
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.
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.
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.
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.
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.
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 programmes 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.
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.
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.
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?”
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 the month of 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.
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
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.
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.
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 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.
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.
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.