We developed the NOURISHING framework to highlight where governments need to take action to promote healthy diets and reduce overweight and obesity.
The framework is accompanied by a regularly updated database (last updated 24 October 2018), providing an extensive overview of implemented government policy actions from around the world.
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The evidence suggests people who want to eat well use nutrient lists to choose healthier options. Interpretative labels help them when they find the labels hard to understand. Nutrition labels also create incentives for food manufacturers to reformulate their products, so helping populations more broadly by increasing the availability of food of higher nutritional value.
Clear standards are also needed on the use of nutrient and health claims. Evidence shows these claims alter the perception people have of these products – making it essential that they do not mislead.
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*Most other countries follow Guideline CAC/GL 2-1985 from the Codex Alimentarius Commission in requiring nutrition labels only when a nutrition or health claim is made and/or on food with special dietary uses
Producers and retailers are required by law to provide a list of the nutrient content of pre-packaged food products (with limited exceptions), even in the absence of a nutrition or health claim. The rules define which nutrients must be listed and on what basis (eg per 100g/per serving).
Huang L et al. (2015) A systematic review of the prevalence of nutrition labels and completeness of nutrient declarations on pre-packaged food in China. Journal of Public Health 37(4), 649-658
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
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.
Resolution No 38 (16 July 2009) promulgated by the Brazilian Ministry of Education sets food- and nutrition-based standards for the food available in the national school meal programme (Law 11.947/2009 – Regulamento del Programa Nacional de Alimentação Escolar). Article 17 prohibits drinks of low nutritional value (eg soda), canned meats, confectionary, and processed food with a sodium and/or saturated fat content higher than a specified threshold.
School “canteens” – kiosks and stores where food can be purchased for takeaway inside public schools – are covered by voluntary guidelines (see O – "Voluntary guidelines for food availabe in schools”).
Mandatory standards are in place for the national school meal programme in Brazil (see "O – Mandatory standards for food available in schools, including restrictions on unhealthy food"). For “school canteens” – kiosks and stores where food can be purchased for takeaway inside public schools – there are voluntary guidelines. The Healthy Schools Canteens Manual, published by the Ministry of Health in 2010, contains voluntary guidelines for the operators of school canteens on how to promote healthy eating in canteens. In 2012, a self-learning course was made available to support canteen managers implement the manual, as part of the Cooperation Agreement signed by the Ministry of Health and the Private Schools National Federation. The Agreement sets out to plan, implement and evaluate strategies that promote health in private schools at a national level (particularly in the areas of healthy eating and the prevention of obesity related non-communicable diseases). A website monitors actions taken by schools and promotes learning between them.
In July 2016, the Brazilian Ministry of Health implemented procurement guidelines for any food served or sold for purchase in the Ministry and its entities (Ordinance No. 1.274 of 7 July 2016). The guidelines are based on the Food Guide for the Brazilian population. At least one seasonal fruit has to be offered, and sugar-sweetened juice, soft drinks or sweets cannot be sold or served. Ultraprocessed food may only be used in exceptional cases if it is used in meals which are prepared from mostly unprocessed or minimally processed food. Ultraprocessed food is defined by the Ordinance as food which is mainly produced from substances extracted from whole food and/or food components derived from materials synthesised from organic matter, and which contain ≥1mg of sodium per 1kcal, ≥10% of total energy from free sugars, ≥30% of total energy from total fat, ≥10% of total energy from saturated fat and ≥1% of total energy from trans fat (in alignment with PAHO’s Nutrient Profile Model). The Ordinance also mandates sufficient chairs and tables are provided for employees to eat their food.
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.
The National Council for the Rights of Children and Adolescents (Conanda) of Brazil, coordinated by the federal government, published a resolution (Resolução 163 Conanda, 13 March 2014) that establishes criteria for publicity and marketing aimed at children (up to 11 years) and adolescents (12–18 years) and prohibits any kind of "abusive publicity". This resolution can be applied to food publicity, where "abusive publicity" includes any form of market communication (including TV, radio, internet, apps) intended to persuade children and adolescents to consume a product or service using strategies such as childish language, child songs or music sung by children, child representation, people or celebrities that appeal to children, comics or animations, dolls or puppets, promotions using prizes, collectible gifts, competitions or games that appeal to children.
The Conanda resolution is enforced by the Consumer Defense Code (Law 8078/1990) and the Child and Adolescent Statute (Law 8069/1990) and violations are investigated by public authorities. It is reported that in practice, there are many difficulties in fully implementing these restrictions. However, in March 2016, the Superior Court of Justice (Superior Tribunal de Justiça; Brazil’s highest appellate court for non-constitutional questions of federal law) heard the first case related to food marketing to children based on the Conanda resolution. It ruled that “married sales” to children are prohibited under the resolution (“married sales" are promotions in which a food product is advertised alongside a toy or other object a child would like to acquire, but which can only be obtained if a certain quantity of the food product is purchased).
In July 2016, the Brazilian Ministry of Health implemented a ban on advertisement and sales promotions of ultraprocesssed food products on the premises of the Ministry of Health and its entities. The marketing ban is incorporated in its Ordinance No 1.274 of 7 July 2016 on healthy food procurement (see “H – Harness supply chain & actions across sectors to ensure coherence with health”). Ultraprocessed food is defined by the Ordinance as food which is mainly produced from substances extracted from unprocessed food and/or food components derived from materials synthesised from organic matter, and which contain ≥1mg of sodium per 1kcal, ≥10% of total energy from free sugars, ≥30% of total energy from total fat, ≥10% of total energy from saturated fat and ≥1% of total energy from trans fat (in alignment with PAHO’s Nutrient Profile Model).
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.
Brazil has a national strategy for reducing sodium consumption. It aims to achieve a maximum daily salt intake of 5g by 2020, by reducing the intake from the main sources of sodium (added salt and processed food). The strategy involves dialogue with the food industry, setting biannual food category-specific targets (eg a 10% decrease per year until 2014) and addressing the reduction of added salt through education and information actions.
Nilson EAF, et al. (2017) Sodium Reduction in Processed Foods in Brazil: Analysis of Food Categories and Voluntary Targets from 2011 to 2017. Nutrients 9(7): E472
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.
In July 2016, the Brazilian Ministry of Health implemented procurement guidelines for any food served or sold within the Ministry’s facilities and in its entities (Ordinance No 1.274 of 7 July 2016). The guidelines also apply to independent companies contracted to provide food services on the premises of the Ministry and its entities. The Ordinance aims to address overweight, obesity and non-communicable diseases, and is based on the right to adequate food. The guidelines are based on the Food Guide for the Brazilian Population, and state that only unprocessed and minimally processed food may be procured. The purchase of processed food (eg canned food, fruit compote, candied fruit, salt-preserved meats) should be minimised, and food from organic and agroecological production preferred whenever possible. Ultraprocessed food may only be used in exceptional cases if it is used in meals which are prepared from mostly unprocessed or minimally processed food. Ultraprocessed food and beverages that are not used for meal preparation may not be purchased (eg soft drinks, sugar-sweetened fruit juices, industrialised sweets). Ultraprocessed food is defined by the Ordinance as food which is mainly produced from substances extracted from whole food and/or food components derived from materials synthesised from organic matter, and which contains ≥1mg of sodium per 1kcal, ≥10% of total energy from free sugars, ≥30% of total energy from total fat, ≥10% of total energy from saturated fat and ≥1% of total energy from trans fat (in alignment with PAHO’s Nutrient Profile Model). The Ordinance also prohibits the advertisement and sales promotions of ultraprocessed food in the Ministry of Health and its entities.
In Brazil, a 2009 law (Ley 11.947/2009 Regulamento de Programa Nacional de Alimentação Escolar) requires that 30% of the national budget for food served in the school meals programme must be spent on food from family farms, with priority given to food produced using agroecological methods.
The Food Acquisition Programme (Programa de Aquisicao de Alimentos) allows states, municipalities and federal agencies to buy food from family farms through a simplified public procurement procedure. The programme thereby encourages the purchase of perishable food and minimally processed food and makes them available to public institutions (eg hospitals, social assistance agencies, schools).
The Brazilian Institute of Horticulture and the Brazilian Central Food Supply Association are responsible for the promotion, regulation and organisation of food sales in the country. The Brazilian Market Modernisation Programme (Programa Brasileiro de Modernização do Mercado Hortigranjeiro) supports states and municipalities to modernise and adapt the supply of food to meet local needs. For example, supply centres (CEASAs) initiated the campaign Encouraging Intake of Fruit and Vegetables in the Central Food Supply. The first phase focuses on internal CEASA stakeholders (dealers, licensees and producers) and aims to increase the availability of fruit and vegetables. The second phase will target external audiences in the form of consumer information and promotion of healthy eating.
In Brazil, urban agriculture is integrated into agriculture and urban policy to increase access and availability of food, improve health and nutrition, improve institutional feeding programmes, stimulate healthy eating habits, and provide employment and income. Legislation 15973, launched in 2006, encourages the use of private estates and underutilised public buildings as urban agriculture spaces. Brazil’s National Plan for Food and Nutrition Security (PLANSAN 2016–2019) sets a specific goal for the Ministry of Agriculture to promote and develop urban and peri-urban agriculture, working with federal, state and municipal governments.
The Brazilian National Council of Food and Nutrition Security (CONSEA), established in 2003, is a body made up of civil society and government representatives, which advises the President’s office on matters involving food and nutrition security.
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.
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.
Nutrition is part of comprehensive healthcare and provided by all services within Brazil’s system of universal health coverage (Brazilian Unified Health Systems), particularly primary care. The Ministry of Health encourages health teams to promote healthy eating, evaluate food intake and anthropometry of individuals in all stages of life, prevent and control nutritional deficiencies and obesity and provide nutritional counselling. To support and structure this work, the government provides manuals, materials and self-learning courses on these topics for health professionals and transfers funds to municipalities annually.
Based on the 2012 Brazilian Breastfeeding and Complementary Feeding Strategy, 18,125 health professionals and 3,400 tutors were trained by 2015 to support the promotion of breastfeeding and healthy complementary feeding in primary care. A distance learning course in breastfeeding and healthy complementary feeding was established by the Ministry of Health.
The 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.
Brazil’s School Health Programme (PSE) was established in 2007 by Presidential Decree No 6.286/200 and is managed by the Ministries of Health and Education. Through the programme, schools must monitor and evaluate student health and take actions to promote healthy eating and food and nutrition security. In 2009, a new mandate established that food and nutrition education should be fully integrated across the entire curricula of basic education. In 2012, the Ministries of Social Development, Health and Education launched the Framework of Reference for Food and Nutrition Education in Public Policies, identifying kindergartens, schools and universities as important areas for food and nutrition education.