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.
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
Two German states have enshrined the voluntary guidelines on quality standards for school meals by the German Nutrition Society (DGE) in law: Berlin implemented the Law for quality improvements of school lunch meals in 2014 in all-day primary schools. The Law sets the DGE quality standards as a minimum requirement which schools have to adhere to, in addition to setting up a lunch meal committee that regularly conducts quality controls and supports the selection of appropriate food suppliers.
The state of Saarland requires all-day primary and secondary schools to provide school meals that are in line with DGE quality standards (Article 8 of the Regulation of all-day primary and secondary schools).
The DGE guidelines recommend that schools provide water and unsweetened herbal or fruit teas, and prohibit drinks that are high in sugar including juices and energy drinks. The guidelines contain a 20-day plan suggesting serving whole grains on at least four days and potato products a maximum of four days; salad, vegetables or legumes each day; fruit at least eight times; dairy products (ideally low-fat) at least eight times; fish at least four times and meat a maximum of eight times; rapeseed oil is the only permitted oil.
The German Nutrition Society (DGE) has set voluntary guidelines on quality standards for school meals in Germany. The guidelines recommend that schools provide water and unsweetened herbal or fruit teas and prohibit drinks that are high in sugar including juices and energy drinks. The guidelines contain a 20-day plan suggesting serving whole grains on at least four days and potato products a maximum of four days; salad, vegetables or legumes each day; fruit at least eight times; dairy products (ideally low-fat) at least eight times; fish at least four times and meat a maximum of eight times; rapeseed oil is the only permitted oil.
Many local school authorities (Schulträger) contractually require food suppliers to adhere to DGE quality standards.
Two German states, Berlin and Saarland, have enshrined the voluntary guidelines in law (see above under Mandatory standards for food available in schools, including restrictions on unhealthy food).
The German Nutrition Society (DGE) developed various voluntary guidelines on quality standards for meals in specific settings as part of IN FORM - Germany’s initiative to promote healthy diets and more exercise. Core elements of the DGE quality standards are criteria for optimal food choices, the frequency of serving various food groups, and menu planning and preparation to optimise the nutrient content of the offered food. In all settings, rapeseed oil is the standard cooking oil, and water as well as unsweetened herbal or fruit teas are the recommended beverages.
For nurseries (age 0–6) (2009, revised in 2014), the guidelines prohibit drinks that are high in sugar, including juice and soft drinks as well as energy drinks. They contain a 20-day lunch plan suggesting serving whole grains on at least four days and potato products a maximum of four days; salad, vegetables or legumes each day; fruit at least eight times; dairy products (ideally low-fat) at least eight times; fish at least four times and meat at a maximum of eight times. To date, around one-third of all nurseries act in accordance with the DGE standard.
For canteens in the workplace, the guidelines (2008, revised in 2014) contain a five-day lunch plan suggesting serving whole grains at least once and potato products not more than once; salad, vegetables or legumes each day; fruit at least twice; dairy products (ideally low-fat) at least twice; fish at least once and meat at a maximum of two days.
For meals in hospitals (2011, revised in 2014), rehabilitation centres (2011, revised in 2014) and care homes for elderly (2009, revised in 2014), the guidelines contain a seven-day meal plan for three meals and according to requirements two additional snacks per day suggesting serving whole grains at least 14 times and potato products a maximum of two times; salad, vegetables or legumes three times each day; fruit two times each day; dairy products (ideally low-fat) at least two times a day; fish at least twice a week and meat at a maximum of three times a week.
For meals on wheels (2010, revised in 2014), a service providing meals for persons aged 65+ living in their own homes, the guidelines contain a seven-day lunch plan suggesting serving whole grains at least once and potato products no more than once; salad, vegetables or legumes each day; fruit three times; dairy products (ideally low-fat) at least three times; fish at least once a week and meat at a maximum of three times a week. The guidelines do not include recommendations for beverages, as they do not form part of the standard meal service (but will be provided upon request).
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.
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
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.
The German national IN-FORM initiative, launched in 2008 by the Ministry of Health and the Ministry of Food and Agriculture, promotes healthy diets and physical activity, and includes provisions to integrate diet and physical activity into training programmes for health professionals. These provisions have not been implemented nationally, but through actions in some states and communities.
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.
In 2007, the voluntary “nutrition licence” programme for elementary school children in Germany was introduced through “IN FORM”, an initiative to promote healthy diets and exercise by the Ministry of Nutrition and Agriculture and the Ministry of Health. Children are taught cooking skills, hygiene rules and the nutrition pyramid in year 3 of elementary school. After taking an oral and written exam, they receive a personalised nutrition licence (“Ernährungs-Führerschein”). As of May 2016, 780,000 pupils have taken part in the programme. With the support of the Ministry of Nutrition and Agriculture, aid infodienst, a German non-profit association, trained 5,000 elementary teachers and 600 trainers to deliver the “nutrition licence” programme. aid infodienst also supplies the teaching material.