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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The government of Singapore introduced a Healthier Choice symbol in 1998 with defined nutrition criteria. Food manufacturers and retailers can voluntarily use the label on front-of-pack for products that meet the nutritional criteria. In 2003, the use of the symbol was extended to food service operators such as hawkers and restaurants. Food service operators can display the symbol next to dishes meeting the criteria. There is also a Healthy Snack symbol for products that are individually packed in small portions and meet specific nutrition guidelines. A refreshed Healthier Choice symbol, based on revised nutrient guidelines, was launched in September 2015 and existing products with the current symbol will have to be depleted by 1 January 2018. Products carrying the current symbol will need to re-apply to carry the revised symbol. Currently there are nutrition guidelines covering >60 food categories.
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.
In 2011, the Health Promotion Board of Singapore, in collaboration with the Ministry of Education, launched the Healthy Meals in Schools Programme (HMSP), which was formerly the Model School Tuckshop Programme, launched in 2003. The programme enhances the availability of healthier food and beverage choices in schools through an integrated programme that involves teachers, canteen vendors and students. Canteen vendors from participating schools are expected to follow food service guidelines which aim to reduce the amount of saturated fat, sugar, and salt in school meals and make available whole grains, fruit and vegetables as part of a balanced meal. The Health Promotion Board supports schools by organising culinary and nutrition training for canteen vendors (see “G – Give nutrition education and skills"), and engages nutritionists and dietitians to assess participating schools to ensure compliance to the HMSP criteria. Educational resources are also provided as part of the programme to encourage students to eat a healthy diet. Revised food service guidelines came into effect on 1 January 2016.
The National Workplace Health Promotion Programme, launched in Singapore in 2000, is run by the Health Promotion Board. Both private and public institutions are encouraged to improve the workplace environment by providing tools and grants. Grants are awarded to help companies start and sustain health promotion programmes. Tools include a sample Healthy Workplace Nutrition Policy, a sample Healthy Workplace Catering Policy, and a detailed Essential Guide to Workplace Health, setting out ways to transform the workplace into a health-supporting work environment by providing a guide on how to improve the nutritional environment in the work place (for example training for canteen providers, engaging a nutritionist).
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 Diabetes Prevention and Care Taskforce, which sits in the Ministry of Health, is working with beverage manufacturers to reduce the amount of sugar in sugar-sweetened beverages. In 2017, seven beverage manufacturers voluntarily pledged to reduce the sugar content in their drinks to a maximum of 12% by 2020. These manufacturers constitute 70% of the pre-packaged sugar-sweetened beverages in Singapore.
In 2012, an amendment to regulation 78 of the Singaporean Food Regulations, made under the Sale of Food Act (1973), set a limit of 2% on trans fats in pre-packaged edible fats and oils for sale or for use as an ingredient in the preparation of food. The limits came into effect on 2 May 2012.
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.
As part of the Healthier Dining Programme launched in Singapore in June 2014 (formerly called the Healthier Hawker Programme, launched in 2011), food operators are encouraged to offer lower calorie meals and use healthier ingredients such as oils with reduced saturated fat content, and/or whole grains, without compromising taste and accessibility. To participate, food and beverage companies must complete an application form and implement nutrition guidelines set by the Health Promotion Board (HPB) in all outlets for a period of two years. Following HPB approval the Healthier Choice Symbol Identifiers (see "N – Nutrition label standards & regulations on the use of claims and implied claims on food") are used next to healthier dishes in all menu and marketing materials to help consumers identify healthier dishes (eg "We serve lower-calorie options", "We use healthier oil"). To date, the HPB has partnered with 45 widely known food service providers (food courts, coffee shops, restaurants) to offer lower calorie and healthier meals across 1,500 outlets and stalls. Between the launch of the programme and September 2015, the number of healthier meals sold more than doubled, from 525,000 in June 2014 to 1.1 million in September 2015. The government increases the availability and use of healthier ingredients through a subsidy scheme called the Healthier Ingredient Development Scheme (see "H – Harness supply chain and actions across sectors to ensure coherence with health").
As part of the Healthier Dining Programme, the Health Promotion Board offers a Healthier Dining Grant to food and beverage establishments to help promote healthier menu choices. The grant reimburses up to 80% of establishments’ marketing and publicity costs related to the promotion of their healthier dishes. Establishments under the Healthier Dining Programme are eligible to apply for the grant every two years, with incremental commitment of healthier dishes after the initial grant period.
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 2017, the Health Promotion Board introduced the Healthier Ingredient Development Scheme to encourage manufacturers to innovate and develop a wider variety of healthier ingredients suited to local taste and to promote the uptake of healthier ingredients, focusing on oil and grain staples (mainly rice and noodles). The scheme offers support under three categories: 1) Research, Product Development, Packaging and Certification; 2) marketing and publicity; 3) trade promotions, such as bulk purchase rebates and bonus incentives for incremental sales of healthier ingredient product(s). Eligibility criteria exist for applicants to the scheme. Up to 80% of qualifying projects will be funded by the scheme, while the scheme participant co-pays the remaining 20%. Products must meet the Healthier Choice Symbol nutritional guidelines (see “N – Nutrition label standards and regulations on the use of claims and implied claims on food – Clearly visible “interpretative labels and warning labels”). This Scheme evolved from the Healthier Ingredient Scheme, which was formerly part of the Healthier Hawker programme launched in 2011.
As part of the Singaporean Healthier Dining Programme (formerly called the Healthier Hawker Programme, launched in 2011), manufacturers are able to tap into non-health related government funding for productivity and innovation to improve logistics and efficiency in supplying healthier oils and healthier staples, with the goal to make prices competitive.
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.
The annual month-long National Healthy Lifestyle Campaign organised by the Singapore Health Promotion Board has been running since 1992 and aims to increase awareness about the importance of a healthy lifestyle. The campaign takes a multi-pronged approach and involves different activities each year. For example, in 2010 the campaign focused on raising awareness of maintaining a healthy weight through healthy eating and physical activity, in 2011 the focus was on creating communities that are health promoting ecosystems (including an emphasis on the Healthier Hawker centres) and in 2014 the focus was on healthy living everyday.
*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 Life’s Sweeter with Less Sugar campaign ran from October 2014 to February 2015 to encourage Singaporeans to choose reduced sugar or no sugar beverages when they dine out. More than 1,000 partner drink outlets in food courts, hawker stalls, coffee shops and kiosks promoted these healthier beverage choices to nudge consumers into making these their default choice.
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.
Clinical management for obese and severely obese adults in Singapore is offered in four specialist hospitals. The Health Promotion Board has also offered the 12-week weight loss challenge Lose to Win™ since 2009. Under the guidance of qualified trainers, participants receive a health assessment, and take part in group exercise, nutrition and mental wellbeing workshops (including goal-setting). There is follow-up at 3, 6, and 12 months post programme.
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 Health Promotion Board in Singapore encourages employers to establish a Workplace Nutrition Programme. They provide guidelines on developing comprehensive programmes, which include organisational policies, supporting creative environments, and building awareness and personal skills.
Linked to the Healthy Meals in Schools Programme (see "O – Offer healthy food and set standards in public institutions"), the Singapore Health Promotion Board supports schools by organising culinary and nutrition training for canteen vendors to equip them with knowledge of healthy nutrition and culinary skills to prepare healthier meals using healthier ingredients.