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
EU Regulation 1169/2011 on the Provision of Food Information to Consumers, passed in 2011, requires a list of the nutrient content of most pre-packaged food to be provided on the back of the pack from 13 December 2016. This Regulation is also applicable in Iceland, Norway and Liechtenstein as members of the European Economic Area. In Switzerland, nutrient content labelling is only mandatory for products bearing nutrient or health claims or sold to the EU (but most manufacturers already label nutrient content on their food products voluntarily).
EU Regulation 1169/2011 on the Provision of Food Information to Consumers, passed in 2011, permits EU Member States to develop voluntary guidelines for front of pack nutrition information, to be used in addition to the mandatory nutrition information on the back of pack. Information on energy value, fat, saturated fat, sugar and salt content is permitted. Different styles of presentation (eg % Guideline Daily Allowances or traffic lights) are permitted. This Regulation is also applicable in Iceland, Norway and Liechtenstein as members of the European Economic Area and Switzerland based on its bilateral agreements with the EU.
On 26 January 2016, the French Ministry of Health introduced Article 5 of the Health Act that recommended introducing a system of nutrition labelling. The Directorate-General for Health requested Public Health France to design the nutrition labelling and the decision to recommend the NutriScore system was informed by research that trialled four different types of nutrition labels in 80 supermarkets in September 2016. The NutriScore system was chosen as the most consumer-friendly. The NutriScore label uses a nutrient-profiling system, based on the UK Food Standards Agency model. It classifies food and drinks according to five categories of nutritional quality, indicated via a colour scale ranging from dark green to dark red. Each colour is also associated with a letter from A (dark green) to E (dark red) to make the labelling more accessible and understandable to consumers. The score takes into account for every 100 grams of produce whether the contents of the product include nutrients and food that should be favoured (positive nutrients including fibre, protein, fruit and vegetables) or nutrients that should be limited (negative nutrients including energy, saturated fatty acids, sugars, salt). The amount of nutrients per 100 grams contained in the product is scored using a points system (0–40 for negative nutrients and 0–15 for positive nutrients that should be favoured). The nutritional score of the product is calculated by subtracting the negative nutrient points from the positive nutrient points. All processed food is included, except aromatic herbs, teas, coffees and yeasts, and all beverages, except alcoholic beverages.
The European Commission approved the use of the NutriScore label and on 31 October 2017 the French government signed a decree outlining that the NutriScore label would be used in France. The label is voluntary and to date six major retailers and manufacturers have already entered into a Charter of Commitment to use the labelling on their products.
Regulation 1924/2006 establishes EU-wide rules on the use of specified nutrient content and comparative claims (ie levels of fat for a low-fat claim). As of January 2010, only nutrition claims as listed in the Regulation’s annex are permitted. In theory, these nutrition claims may only be used on food defined as "healthy" by a nutrient profile. This nutrient profiling restriction was due to be implemented in 2010 but no model has yet been established. Therefore, permitted nutrition claims can be used as long as the conditions for use of the claim as set out in the annex are met. Once nutrient profiles are established, nutrition claims may only be used on food products deemed "healthy", though two notable exceptions will apply: nutrition claims referring to the reduction of fat, saturated fats, trans fats, sugars and salt/sodium will be allowed without reference to a profile for the specific nutrient, provided the claims comply with the conditions of the Regulation; and a nutrition claim may be used even if a single nutrient exceeds the nutrient profile as long as a statement in relation to this nutrient appears on the label in close proximity to, on the same side and with the same prominence, as the claim (the statement must read: 'High [name of nutrient] content'). This Regulation is also applicable in Iceland, Norway and Liechtenstein as members of the European Economic Area; Switzerland amended its foodstuff law based on its bilateral agreements with the EU to include permitted EU nutrient claims.
Regulation 1924/2006 (applicable as of July 2007) establishes EU-wide rules on the use of health claims (claims on nutrient function, disease risk reduction and children’s health). Companies may only use health claims that are substantiated and authorised by the European Commission and Member States (various regulations authorising health claims to date). The European Food Safety Authority is responsible for verifying the scientific substantiation of claims; it has done so for claims currently in use and continues to do so for claims that are proposed and applied for by companies that want to use health claims in the EU. In theory, health claims may only be used on food defined as "healthy" by a nutrient profile. This nutrient profiling restriction was due to be implemented in 2010 but no model has yet been established. Therefore, permitted health claims can be used as long as the conditions for use of the claim as set out in the respective regulations are met. Once nutrient profiles are established, health claims may only be used on food products deemed "healthy". This Regulation is also applicable in Iceland, Norway and Liechtenstein as members of the European Economic Area. Switzerland amended its foodstuff law based on its bilateral agreements with the EU to include permitted EU health claims.
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 EU School Fruit Scheme, launched in the 2009-2010 school year, merged with the EU School Milk Scheme on 1 August 2017 into one legal framework based on the Regulation on the new School Fruit, Vegetables and Milk Scheme (Regulation EU No 2016/791). The scheme is funded through the EU’s common agricultural policy and supports the distribution of fruit, vegetables and milk and milk products to schools across the EU as part of a wider programme of education about European agriculture and the benefits of healthy eating. It provides financing to Member States based on the number of school children and level of development of the country. The implementation of the programmes is at the discretion of national or regional governments, but to receive funding, they must distribute fruit, vegetables and milk products in schools and implement educational measures, such as farm and market visits, educational material distributed to teachers and interactive games on education and nutrition, and regularly monitor and evaluate implementation. Foods containing added sugars, salt, fat, sweeteners or artificial flavor enhances are exempt from the scheme: as an exception, limited quantities of added sugar, salt and fat are allowed if they are approved by the Member States' health/nutrition authorities. The Member States determine the frequency and duration of the distribution of the food.
European Commission, Directorate-General for Agriculture and Rural Development. Evaluation of the European School Fruit Scheme Final Report. Brussels, 2012
European Court of Auditors. Are the school milk and school fruit schemes effective? Special Report No. 10. Luxemburg, 2011
Decree No. 2011-1227 of 30 September 2011 (arising from Law No. 2010-874 of 27 July 2010 on the modernisation of agriculture and fisheries) regulates the nutritional quality of school meals in France, including the diversity and composition of meals, provision of water, portion sizes and restrictions on salt and sauces outside of prepared dishes. School canteen managers are required to keep record of menus for the previous three months at all times, including detailed information on food purchased from suppliers, and are required to identify clearly on menus seasonal ingredients in the composition of the meal. This follows from Interministerial Circular No. 2001-118 of 25 June 2001 which made recommendations on consuming a balanced diet in schools.
Based on the French Public Health Act of 2004 (Law No. 2004-806, Article 30), vending machines containing drinks and snacks are not allowed in schools since 1 September 2005. Fruit and bottled water must be made available.
Capacci S, Mazzocchi M, Shankar B (2018) Breaking habits: the effect of the french vending machine ban on school snacking and sugar intakes. Journal of Policy Analysis and Management 27(1): 88-111
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.
Since 1 January 2012, France has applied an excise duty to drinks with added sugar and artificial sweeteners, including sodas, fruit drinks, flavoured waters and “light” drinks (Law no 2011-1977). Since 1 July 2018, France has applied an excise tax proportional to the sugar content of sugar sweetened drinks. Official Customs Bulletin No 7212 outlines a table with the tax rates per kilogram of added sugar per hectoliter up to 15kg. For example, a drink with 5g of added sugar per litre is taxed at 0.055 Euro per lire and a drink with 10g of added sugar per litre is taxed at 0.135 Euro per lire. An excise tax is also applied to non-calorically sweetened drinks at a rate of 3 Euro per hectoliter.
Berardi N et al. (2012) The impact of a ‘soda tax’ on prices: Evidence from French micro data. Working Paper No. 415, Banque de France
Etilé F, Lecocq S, Boizot-Szantai, C. The Incidence of Soft-Drink Taxes on Consumer Prices and Welfare: Evidence from the French ”Soda Tax”. PSE Working Papers n°2018- 24. 2018
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.
All TV advertising in France (targeted at children or adults) for processed food and drinks, or food and drinks containing added fats, sweeteners and/or salt, must be accompanied by a message on the principles of dietary education as approved by the National Institute of Health Education. The messages were defined by a 2007 Decree: "For your health, eat at least five fruit and vegetables a day"; "For your health, exercise regularly"; "For your health, avoid eating too many foods that are high in fat, sugar or salt"; "For your health, avoid snacking between meals".
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 2007, as part of the second phase of France’s National Nutrition and Health Programme (PNNS), a standard reference document was developed to enable the signing of voluntary nutrition commitments by members of the food industry (eg producers, food industry companies, distributors and caterers). The standard reference document outlines nine principles used in the approval process for the charters. Commitments within the charters must meet certain criteria and cover the composition and nutritional characteristics of the food product (eg reduced amounts of fat, sugar, salt; increased amounts of fibre) and/or a consumption intervention (eg action on portion sizes or marketing). A committee of volunteer experts from the public sector (eg research institutes, hospitals, universities and public schools) reviews the proposed charters. To date, over 35 companies have made voluntary commitments, which are reviewed and approved by an external committee of experts to ensure they are “significant”. Approved charters of voluntary commitment for nutritional improvement are signed by the food industry and monitored by the Food Quality Observatory (created in 2008).
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.
Since 27 January 2017, France has banned unlimited offers of sweetened beverages for free or at a fixed price in schools, public restaurants and any facility used to teach, accommodate or receive children under the age of 18, eg dormitories, sports facilities, youth prisons (Article L. 3232-9 of the Public Health Act). Sweetened beverages are defined as any (non-alcoholic) drink sweetened with sugar or artificial (caloric and non-caloric) sweeteners, including flavoured carbonated and still beverages, fruit syrups, sports drinks, energy drinks, fruit and vegetable nectars, fruit- and vegetable-based drinks, as well as water-, milk- or cereal-based beverages.
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 (India, US), plates (Australia, Colombia, UK), pagodas (China), spinning top (Venezuela), traditional African house (Benin) and circles (Argentina). Some countries have started to include sustainability criteria in their dietary guidelines (eg Germany in 2013, Finland and Brazil in 2014, Sweden and Qatar in 2015, the Netherlands and UK in 2016). Brazil’s revised dietary guidelines, launched in 2014, present food- and meal-based recommendations that take into account cultural dimensions and promote the consumption of minimally processed food as well as health, wellbeing and sustainable food systems, and recommend avoiding ultra-processed food. Canada’s new food guide, launched in 2019, provides guidance on what to eat, as well as how to eat. This includes recommendations on healthy eating habits that encourage people to cook more often, to be mindful of their eating habits, to use food labels, to cook at home and to eat meals with others. The new food guide is an online suite of resources that provides information targeted to different audiences, including the general public, health professionals and policy makers.
Details on the content of national dietary guidelines can be found on the FAO database on Food-based dietary guidelines.
The French Ministry of Social Affairs and Health and the National Institute of Health Prevention and Education run a healthy living campaign called Eat Move (Manger Bouger) as part of the National Nutrition and Health Programme (PNNS). Launched in 2001 and ongoing, it includes mass media, informational videos, print advertisement and a website that has a range of resources including targeted nutrition education tools and La fabrique à menus (added in 2013), a menu planner with seasonal recipes that are in line with the PNNS nutrition guidelines.
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