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
In Malaysia, a nutrient list detailing energy, protein, carbohydrates and fat per 100g/100ml and per serving must be provided on select categories of packaged food, including bread, confectionery, dairy products, canned food, fruit juices, salad dressings and mayonnaise; ready-to-drink beverages must also include total sugars. A nutrient list is also mandatory for any product bearing a nutrition claim, products with added vitamins and minerals, and special purpose food for infants and young children. Details are provided in the Malaysian Guide to Nutrition Labelling and Claims (2010), which reflects labelling legislation from 2003 (as incorporated into the Food Act of 1983 and Food Regulations of 1985) and subsequent amendments.
On 20 April 2017, the Minister of Health of Malaysia launched the Healthier Choice Logo in collaboration with food and beverages industries in Malaysia. The objectives of the Healthier Choice Logo are to: help consumers quickly identify healthier products within the same food category; assist consumers in making informed food choices through authentication of the logo displayed on the food products; educate the public on the use of approved products within a healthy and balanced eating pattern; and encourage and promote good practices among food industries in producing “healthier choice” products. Implementation of the Healthier Choice Logo is voluntary. Products bearing the logo indicate they meet a set of nutrient criteria, which exist for 42 sub-categories of foods and beverages. As of 15 May 2017, 48 products from various food and beverage companies have the Healthier Choice Logo.
Based on the voluntary 2008 Guidelines of Advertisement and Nutrition Labelling for Fast Food Restaurants, Malaysian fast food restaurants are encouraged to display nutrient information on energy, carbohydrates, protein, fat and sodium for food and total sugar for beverages. Restaurants are free to decide how they display this information (eg on-pack labelling, brochures, posters in the outlet). Implementation of the Guidelines is not monitored but the Ministry of Health periodically engages with the fast food industry to urge companies to implement the Guidelines.
The Malaysian Guide to Nutrition Labelling and Claims (as at December 2010) establishes rules on the use of nutrient content claims (ie levels of fat for a low-fat claim) and nutrient comparative claims (eg comparison between an old and new product formulation). The Guide also contains a list of permitted nutrient function claims (ie a claim about the physiological role of a nutrient), including the minimum required amount and additional conditions to be fulfilled (eg the source of the nutrient). Disease risk reduction claims are prohibited. Although nutrition content claims need to meet certain criteria set out in the Guide, there are no generalised nutritional criteria that restrict their use on "unhealthy" food. Labelling legislation was overhauled in 2003 and all new legislation was incorporated into the existing Food Act of 1983 and Food Regulations of 1985. The Malaysian Guide to Nutrition Labelling and Claims (as at December 2010) contains the legislation as of 2003 as well as all amendments up to December 2010.
Regulation NOM-051-SCFI/SSA1 (2010) sets rules for the use of nutrition content claims. It prohibits the use of false and misleading claims on labels, especially those that relate to dietary guidance, eating habits and nutritional properties of food. No disease risk reduction claims are allowed. Although nutrition content claims need to meet certain criteria set out in the Regulation, there are no generalised nutritional criteria that restrict their use on "unhealthy" food.
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 Guide for Healthy School Canteen Management (2012), developed by the Ministry of Education and mandatory for public schools, categorises food items into those which may be sold, those which are not encouraged to be sold and those whose sale is prohibited in school canteens. Prohibited food includes sweets, preserved food, extruded snacks containing artificial flavours and colourings (which are snacks mainly based on corn flour or a combination of flours undergoing extrusion and then coating with a combination of vegetable oil and seasoning), and food and beverages containing alcohol. The list of prohibited food is under review (2016), in particular with respect to carbonated drinks.
In 2010, the Malaysian Ministry of Health developed the voluntary Guidelines on Healthy Menu Provision During Meetings. All government departments are encouraged to implement these Guidelines to provide healthy meeting catering, including the provision of plain water, low-fat milk and unsweetened hot beverages (though sugar remains available separately), serving fruit and vegetables, and calorie labelling.
From 2008 onwards, the Healthy Cafeteria Initiative encouraged the promotion of healthier food options in cafeterias operated in government health facilities. In 2012, a circular by the Director General of Health made the requirements of the Initiative mandatory. In order to receive Healthy Cafeteria recognition, cafeterias need to display the energy content of food items, information on the Recommended Daily Nutrient Intake and a poster or food replica of one food serving containing less than 500 calories. They also have to provide smaller portion sizes for any food items/dishes exceeding 500 calories, sell at least one type of fresh fruit, plain water, and low-sugar drinks. They are not allowed to sell junk and processed food, sweets, premixed drinks, carbonated drinks and alcohol, as well as pickles preserved in salt, sugar and vinegar. The premises have to be smoke-free. In addition, cafeteria operators have to complete the Healthy Catering training (see "G – Give nutrition education and skills" for more information). As of December 2016, 98% of cafeterias in government health facilities have obtained Healthy Cafeteria status.
Since 2012, the Clean, Safe, Healthy Initiative (BeSS) promotes clean, safe and healthy food in food outlets. In order to obtain BeSS recognition, food outlets have to fulfil some of the same criteria as the Healthy Cafeteria Initiative: plain water as default option, low-sugar drinks upon request; at least one type of fresh fruit sold; condiments to be served separately; display of information on dietary intake recommendations and posters/replicas of food items containing less than 500kcal; smaller serving sizes for food containing more than 500kcal promoted; calorie labelling for a minimum of 10 food items, and calorie information displayed for sugar, sugar syrups, creamer and condensed milk. Operators can voluntarily attend the Healthy Catering training. 1,520 food outlets have received BeSS recognition by October 2016.
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 2008, the Malaysian Ministry of Health developed the voluntary Guidelines of Advertisement and Nutrition Labelling for Fast Food Restaurants which ask fast food restaurants not to advertise in, and act as sponsors of, children's TV programmes. The Ministry of Health does not monitor implementation of the Guidelines.
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.
In 2014, the Malaysian Ministry of Health started implementing an initiative in collaboration with Malaysia’s major fast food restaurants to encourage the reduction of portion sizes and the provision of healthier alternatives for high-calorie meals, food and beverages; the initiative does not define targeted food and beverages. As of August 2016, Malaysia’s seven major fast food restaurants were involved in the initiative.
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.
The Malaysian National Coordinating Committee on Food and Nutrition (NCCFN), chaired by the Deputy Director General of Health (Public Health) and in operation since 1994, consists of representatives of the Ministry of Health and other ministries (such as the Ministries of Education, Agriculture, Youth and Sport, Domestic Trade, Rural and Regional Development), ministerial agencies, universities, professional bodies, the food industry and NGOs.
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.
*Civil society organisations have also developed public awareness campaigns on unhealthy food. For example, Cancer Council Victoria in Australia has a social marketing team that runs campaigns related to cancer prevention, including on diet and obesity. In January 2013, it launched the Rethink Your Sugary Drink campaign on YouTube and social media focused on the amount of sugar in soft drinks. In Mexico, the civil society network Alianza por la Salud Alimentaria ran a public campaign against soft drinks in May–August 2013. A series of adverts were posted on buses, billboards and in the subway showing 12 heaped spoonfuls of sugar next to a bottle of soda. The adverts asked "Would you eat 12 spoonfuls of sugar? Why do you drink soda?”
The Reduce Sugar campaign has been run by the Malaysian Ministry of Health in conjunction with the Ministry of Domestic Trade, Cooperatives and Consumerism since 1998. Educational material on sugar reduction is distributed to the public using leaflets and posters, and messages are disseminated via social media, smart phone apps and food outlets with Healthy Cafeteria or BeSS recognition (see "O – Offer healthy food and set standards in public institutions and other specific settings" for more information) as well as media during major festivals such as Eid Mubarak, Chinese New Year and Deepavali.
In 2012, the Malaysian Ministry of Health started a campaign to reduce salt consumption in collaboration with governmental and non-governmental organisations such as the Ministry of Education, the Malaysian Society of Hypertension, the Malaysian Dietitian Association, the Nutrition Society of Malaysia, and the Malaysian Alliance of Salt Reduction Initiatives. The campaign comprised a variety of actions, including cooking demonstrations of low-salt recipes, talks on salt, factsheets and videos on salt and articles in newspapers and magazines. In addition, a logo was launched for the World Salt Awareness Week which has been celebrated yearly with a different theme, eg on salt and stroke prevention (2012), salt consumption when eating out-of-home (2015) and salt hidden in processed food as well as the link between salt and hypertension (2016).
People with elevated risk factors for cancer and other non-communicable diseases – such as heavy bodyweight, high cholesterol or glucose intolerance – can benefit from advice provided by their healthcare provider. Such advice can also be given to people at low risk for prevention into the future.
There is potentially a wide range of mechanisms for integrating nutrition advice into primary care, including counselling, self-help materials and computer-tailored messages. Randomised controlled trials suggest they can be effective if carefully designed and well targeted. The most positive outcomes appear to be for people already at risk.
Based on the Clinical Practice Guidelines (CPG) on Management of Obesity (2004), overweight and obese adults and adolescents should receive dietary counselling, exercise prescription, support in behaviour change and pharmacotherapy. Overweight or obese patients are referred to a nutritionist by a physician. Based on the 2016 Standard Operating Procedure (SOP) Nutrition Management for Overweight & Obesity (Adults & Children), the patient receives individual menu planning which is based on the Malaysian Dietary Guidelines and the patient’s food frequency questionnaire (FFQ). Patients see a nutritionist within three months of referral and at least two follow-up visits, or until the discharge criteria are met, to ensure progress and compliance. The discharge criteria are a 10% reduction of body weight; if this is not achieved within two years, patients are discharged if their waist circumference has reduced by 4cm or reached 80cm for women and 90cm for men, or if they haven’t gained more than 3kg since referral.
Nutrition is part of the comprehensive primary healthcare services in most Malaysian government-run health clinics. Nutrition counselling is provided by dietitians or nutritionists and targets pregnant women with gestational diabetes, overweight or obese patients and those suffering from chronic diseases.
The 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.
As part of the formal curriculum, pupils in primary and secondary schools learn about the Malaysian Food Pyramid, the importance of fruit and vegetables, a balanced diet and active living in Physical and Health Education. Nutrition is also taught informally through activities in school sports clubs, academic associations and youth organisations such as scouts and cadets.
Community-based nutrition education sessions are conducted through a variety of initiatives by the nutrition division of the Malaysian Ministry of Health. The Healthy Community Kitchen Initiative, based in rural settings, organises group cooking classes, cooking demonstrations, nutrition talks and nutrition training as well as community gardening, in addition to health screenings. Nutrition Information Centres, based in urban settings, disseminate nutrition information to the public; some also conduct weight management programmes which comprise nutritional assessments, diet consultations and physical activity. The Healthy Supermarket Initiative conducts supermarket tours teaching participants to read labels and choose healthier food products while supermarket staff receive training on healthy eating and food safety.
Empowering Communities, Strengthening the Nation, known as KOSPEN, is a community-based programme to address lifestyle risk factors of non-communicable diseases (NCDs). KOSPEN is a collaborative effort between the Ministry of Health, the Department of Rural Development (KEMAS), the Neighbourhood Watch Programme of the Department of Unity and National Integrity, and non-governmental organisations. KOSPEN covers healthy eating, weight management, physical activity, smoking and early detection of NCD risk factors. Volunteers are trained to promote and advocate for health and facilitate the establishment of healthy environments that enable healthy lifestyle practices. Volunteers also carry out health screenings on blood pressure, blood sugar and body mass index. If screened individuals show an elevated risk for NCDs, volunteers refer them to the nearest health clinic. By June 2016, 31,940 volunteers were trained in 5,551 localities.
The Empowerment Initiative of the Parents and Teachers Association (PTA), known as C-HAT, aims to increase the knowledge and awareness of parents and teachers about a healthy lifestyle in childhood including healthy eating and physical activity. PTA representatives of each school receive one training session conducted at district level. The initiative also encompasses BMI measurements by school health teams, and referral of overweight and obese children to a nutritionist at a health clinic using the 2016 Standard Operating Procedure (SOP) Nutrition Management for Overweight & Obesity (see "N – Nutrition advice and counselling in health care settings" for more information on the SOP). It plans to enroll 10,000 schools by 2018.
Children in Malaysian secondary schools are taught cooking skills in the elective course Life Skills, while kindergarten teachers learn how to prepare healthy menus for pre-school children in their care. The Life Skills course and the cookery education for teachers are under the auspices of the Ministry of Education.
Health clinics routinely give cooking demonstrations as part of their activities on healthy eating promotion.
Since 2005, the Malaysian Ministry of Health has run the voluntary Healthy Catering Initiative, which provides training for food outlet and canteen operators on healthy eating, preparing healthy menus, the effects of unhealthy eating habits, and food safety. Most of the caterers who have so far attended the course are those serving food to government authorities or institutions. School canteen operators are encouraged to take the training course alongside the mandatory Food Handlers Training course, and private sector companies are trained on request. The Healty Catering training is mandatory for operators of hospital cafeterias (see "O – Offer healthy food and set standards in public institutions and other settings" for more information).