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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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.
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In September 2014, the Macedonian Ministry of Education’s Rulebook on nutrition standards and meals in primary schools was implemented, setting limits on permissible salt, sugar and fat levels of food served in primary schools. Kindergartens and holiday camps are subject to the Ministry of Labour and Social Policy’s Rulebook on standards and norms for services provided by institutions caring for children, implemented in January 2014. It contains intake requirements on calories, carbohydrates, protein, fats, vitamins and minerals based on WHO recommendations. The nutrition standards for kindergartens are widely implemented. The implementation of the elementary school nutrition standards is reported to move at a slower pace, mostly because elementary schools use external catering services which take longer to adjust to the nutrient limits.
In September 2016, the Macedonian Ministry of Education implemented the Rulebook on nutrition standards and meals for the students living in student dormitories. The nutrition standards, based on population-based nutrition guidelines of the Ministry of Health and Institute of Public Health, outline specific nutrient levels (for calories, carbohydrates, protein, fats, sugars, vitamins, minerals) which apply to meals served in all university student dormitories in both public and private dormitories in Macedonia. The nutrition standards include recommended food and dishes for individual meals and recommended frequency of certain food categories.
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.
From October 2014 to December 2015 the Macedonian government ran a campaign called Health is a Choice! Healthy Food and Healthy Lifestyle for a Long Life! to raise awareness about the importance of eating healthy food, leading a healthy lifestyle and exercising. The campaign included TV and radio commercials, media advertisements and billboards.