Chronic, non-communicable diseases (NCDs), especially cardiovascular diseases, cancers, obesity and type 2 diabetes mellitus, kill more people every year than any other cause of death1. Four factors in the epidemiology of these diseases – poor diet, physical inactivity, tobacco and alcohol use – are of overwhelming importance to public health.
To educate the public and inform policy-makers about a healthy diet, for many years food-based dietary guidelines (FBDGs) have been globally promoted as an important part of national food and nutrition policies. The Plan of Action endorsed at the 1992 International Conference on Nutrition called on governments to provide to the public ‘qualitative and/or quantitative dietary guidelines relevant for different age groups and lifestyles and appropriate for the country’s population’2. Based on this call, many countries have developed FBDGs for the population and/or subgroups of the population. More recently, the 2004 World Health Organization (WHO) Global Strategy on Diet, Physical Activity and Health3 encouraged governments to provide FBDGs in order to advise national nutrition policy, nutrition education, intersectoral interventions and collaborations. Effective implementation of FBDGs at population level and in policies is needed in order to contribute to halting the current NCD epidemic.
Method
The information in the present paper is based on a systematised literature review of FBDGs which shaped questions to be asked of key informants responsible for their implementation in different countries.Footnote † Research questions were: What is the role of FBDGs? How are they implemented and monitored? What are their successes and barriers to success in promoting diet-related health? Interviews were conducted by email or telephone with key stakeholders and representatives from public and private institutions in four countries, chosen as case studies: Germany, Chile, New Zealand and South Africa. These were chosen to be diverse by level of development (national income) as well as geographical location. For the literature review, electronic health, education and social science databases were searched. The review primarily considered studies published after 1995 and available in English, German or Spanish. The search terms used were: food based dietary guidelines, dietary guidelines (+country name), nutrition guidelines, food pyramid. The search was also performed for the German and Spanish translation of ‘dietary guidelines’. Literature on how to develop FBDGs was not considered. ‘Grey’ literature, e.g. national reports on FBDG implementation and evaluation, was also sought. Unpublished documents received from the interviewees were also reviewed.
Interviews were conducted with one person from four key institutions in each country. The informants came from: the Ministry of Health (nutrition unit), the 5 A Day fruit and vegetable programme, the academic sector and the fruit and vegetable production and trading sector, included as key 5 A Day participants.
Since in Germany the governmental responsibility for nutrition does not lie with the Ministry of Health (BMGS – Bundesministerium für Gesundheit und Soziales) but with the Ministry of Consumer Affairs, Nutrition and Agriculture (BMELV – Bundesministerium für Ernährung, Landwirtschaft und Verbraucherschutz), exceptionally a representative of both ministries was interviewed.
The methodology was approved by the Ethics Committee of City University. Interviews were carried out in August and September 2005. Each interview partner received an invitation to be interviewed. Choice as to whether information was elicited by phone or by email was left to the interviewee’s decision. Questions were prepared for posing by voice or email in English, German or Spanish. Potential interviewees were contacted and followed-up by email, if they did not respond to the initial inquiry within a week. None of the designated interviewees declined to participate. Most chose to answer the research questions via email. Telephone interviews were carried out with three interviewees and answers were recorded by the researcher (I.K.). All interviews were held in the mother tongue of the interviewee and, where necessary, translated into English.
Results
The role of FBDGs
FBDGs emerged for the first time in the late 1960s, in ScandinaviaReference Truswell, Shils, Olson and Shike4. FBDGs are defined by WHO/Food and Agriculture Organization of the United Nations (FAO) as ‘the expression of principles of nutrition education mostly as foods’2. The purpose of the guidelines is to educate the population and to guide national food and nutrition policies as well as the food industry. Dietary guidelines are advocated as a practical manner to reach nutrition goals set for the population, while considering the setting, social, economic and cultural factors as well as the physical and the biological environment.
Following the call of the International Conference on Nutrition, the WHO and FAO organise (sub-) regional training workshops for national government representatives from the health, nutrition and agricultural sectors, in order to support especially medium- and low-income countries in the development of FBDGs (and of national food and nutrition action plans). The WHO nutrition policy database5 monitors the development and implementation of national food and nutrition action plans and if countries have FBDGs. Presently 27 out of 52 countries in the WHO European Region have FBDGs6, as do 22 out of 37 countries in the WHO Western Pacific Region7.
When formulating FBDGs at national levels it is often difficult to separate the scientific from the political process and therefore some countries opt to open the process for a stakeholder discussion or involve all stakeholders from the beginning in the formulation. The government may not be the leader in the dietary guidelines development, but it is important that it oversees the process and publicly endorses the dietary guidelines. DwyerReference Dwyer8 argues that an endorsement from the private sector is also valuable for successful implementation. The development and revision processes of FBDGs have been subject to fierce debates and lobbying from the side of food producers and processorsReference Truswell, Shils, Olson and Shike4, Reference Dwyer8, Reference Lang and Heasman9.
Implementation of FBDGs
To implement FBDGs, the WHO and FAO2 recommend that each country shall formulate a qualitative version for the public and a quantitative version and background material aimed at health professionals and policy-makers. To reach the general public, WHO and FAO suggest the use of a variety of media, so that all age groups can be reached and various levels of literacy are taken into account. In addition, all (government-sponsored) food distribution, food services and nutrition programmes should receive the information about the FBDG, should adopt it and apply it as pioneers. WHO/FAO2 also proposed that process and outcome evaluation should accompany the implementation of FBDGs. The EURODIET report also makes recommendations for the implementation of dietary guidelinesReference Stockley10: first, dietary guidelines can serve as communication tool and second as a ‘springboard’ for other, broader health strategies. Hence, the EURODIET authors make a distinction whether dietary guidelines are promoted per se (e.g. via a leaflet or other material) or if they form part of a wider health promotion/disease prevention strategy at population level. The latter is judged more likely to lead to behavioural changes, while aiming at either a specific target group or a setting or focusing on specific approaches (advocacy, local project, etc.).
In general, not much literature could be identified that documents the implementation of FBDGs at national levels. SchneemanReference Schneeman11 outlines some general challenges to FBDG implementation. These are to:
• increase awareness and motivate behavioural change;
• move from the provision of information to messages targeting behaviour changes;
• address all socio-economic segments in the population;
• maintain integrity of all messages developed;
• translate the FBDG into other languages or dialects.
Much of the literature found in this area comes from the USA, where the responsibility to implement the FBDGs lies with the government and a public–private partnership that was founded especially to implement themReference Guthrie and Smallwood12. Implementation occurs mainly via educational materials and the government-sponsored food programmes for schools and low-income families. All school lunches and breakfasts need to meet the FBDGs and the US Department of Agriculture supports schools to implement them, including nutrition education to motivate schoolchildren to make healthy choices13.
If FBDGs are not put into practice, one could assume that they are not understood. Constraints to put FBDGs into practice are, however, many more than lack of knowledge or misunderstanding of FBDGs. FBDGs are mainly developed taking nutrition and epidemiological evidence into accountReference Kearney and McElhone14, while consumer perceptions and attitudes may not be reflected. FBDGs are rather a ‘top-down’ than a ‘bottom-up’ approach. Consumers are not directly involved in the development and dietary guidelines may figure fairly low on the public agendaReference Stockley10.
Also, food choice is guided by price, taste, convenience and other factorsReference Guthrie and Smallwood12. Additional influences are varying messages given by health professionals, the media and others, and the food preferences of family members, which in particular women may take into account as well as (family) income. Last but not least, ‘healthy foods’ – such as fruit and vegetables – may be perceived as unattractive, not tasty, time-consuming or simply boring (especially for children)Reference Seymour, Fenley, Yaroch, Khan and Serdula15.
All barriers and particular challenges have important implications for the implementation of FBDGs. Consequently, it is equally or even more important to focus on removing the barriers to follow the FBDG than to inform and educate the public about it.
Also, agricultural policies can be seen as a barrier to the implementation of FBDGsReference Lobstein16. The WHO European Office emphasises that ‘food policies in many countries have a production bias in contrast to a health bias’17. It recommends that agriculture policies should be reoriented to focus more on consumer health, while consumers need to be made more aware about how they can meet the FBDG with regional products, in particular locally produced fruit and vegetables. This, however, means running against powerful interests, ready to defend long-established subsidies for certain foods, as in Europe, where the Common Agricultural Policy financially supports the destruction of fruits and vegetables and the removal of orchards in order to maintain a high price.
Four country case studies: implementation, monitoring, successes and barriers
Table 1 gives an overview of the implementation, monitoring, success factors, barriers and the relevance of the FBDG for the national food and nutrition policies in the four casestudy countries.
Comparison of the main characteristics of FBDG development, implementation and monitoring
FBDG – food-based dietary guideline; INTA – National Institute of Food Technology and Nutrition; MINSALUD – Chilean Ministry of Health; DGE – German Nutrition Society (Deutsche Gesellschaft für Ernährung); BMELV – Ministry of Consumer Affairs, Nutrition and Agriculture (Bundesministerium für Ernährung, Landwirtschaft und Verbraucherschutz); AID – ‘info-service consumer protection, food, agriculture’ (Infodienst Verbraucherschutz, Ernährung, Landwirtschaft); BMGS – Ministry of Health (Bundesministerium für Gesundheit und Soziales); BzgA – Federal Centre for Health Education (Bundeszentrale für gesundheitliche Aufklärung); MoH – Ministry of Health; PHO – primary health-care organisation; DHB – district health board; NHF – National Heart Foundation; FNG – Food and Nutrition Guideline; NGO, non-government organisation.
*Based on information from the key informants.
Chile
Chile was the first Latin American country where experts from the National Institute of Food Technology and Nutrition (INTA) and the Ministry of Health (MINSALUD) developed a set of FBDGs in 1997. Health professionals, in particular the nutritionists of the provincial public health services, were trained in using and communicating the FBDG. Pamphlets and other written information were given to health and education professionals, who then passed the information to the public or patients. In addition, health and other community associations received training in using the FBDG. The FBDG is also found on some food products.
In 2004 a review of the dietary guidelines was initiated and many of them reformulated. The new FBDGs are published together with recommendations for physical activity and tobacco control and stress prevention messages18. In 2002 the INTA formally evaluated the dissemination of the FBDG through a survey among the responsible nutritionists of the provincial health services. The number of persons who had participated by then in educational sessions about the FBDG was 36 120. In addition, 10 different manuals for various population groups had been developed at regional level and more than 500 000 leaflets, posters and flyers distributedReference Olivares, Zacarias, Benavides and Boj19. Monitoring also takes place through small-scale studies evaluating consumer education programmesReference Domper, Zacarias and Olivares20 and a survey on knowledge about the FBDG among primary health-care professionals. This survey showed that knowledge of the FBDG by health professionals is low, except for nutritionists. Regarding improvements in FBDG implementation, the private sector and the mass media should be included more in its dissemination. Further, changes are desired in the motivation of the professionals, especially of the nutritionists, as they have a key role in promoting the FBDG.
Germany
In Germany the first set of FBDGs was issued in 1985 (for the Federal Republic of Germany at that time); revised sets were published in 1991 and in 2000. In the 2005 the FBDG was reviewed but not changed, while the accompanying food pyramid was re-shaped. The German Nutrition Society (DGE – Deutsche Gesellschaft für Ernährung) issues the FBDG. The BMELV endorses, promotes and implements the FBDG, also via DGE and the ‘AID info-service consumer protection, food, agriculture’ (AID – Infodienst Verbraucherschutz, Ernährung, Landwirtschaft), both co-financed by the BMELV. The FBDG implementation is seen as a success from a qualitative point of view, since some changes in the dietary behaviour can be seen. However, dietary habits differ according to socio-economic strata: low socio-economic groups have a worse profile. In addition, a high percentage of the adult population is overweight, which indicates that they are not following the FBDG, which could be seen as a failure of these. To improve FBDG promotion, it would be important that all institutions and communicators in the area of nutrition adopt the FBDG and communicate it together, and this way the target groups would be better reached.
New Zealand
In 1985 the New Zealand Ministry of Health (MoH) issued dietary guidelines for the first timeReference Truswell, Shils, Olson and Shike4. These were then revised and reissued in 1991 as the food and nutrition guideline (FNG) for adults (i.e. the term ‘food-based dietary guidelines’ is not used in New Zealand). In addition, the MoH also published an FNG for all main groups along the life course: toddlers, children, adolescents, pregnant women, breast-feeding women and older peopleReference Baghurst21. A background paper for health professionals and a pamphlet for lay persons are issued for all FNGs. The FNG for adults was revised in 2000, which for the first time included a public consultation. In 2003 the current set was published. The FNGs are implemented and all costs for it borne by the MoH through their publication on the internet and in hard copy. The food industry also reproduces the FNG22.
In 1998, the MoH commissioned a formal evaluation of the written health education materials (booklets) for children, adolescents and older persons from the mid-1990 through focus groups discussions and key informant interviews. Neither among the older people nor among the parents and children/adolescents had many seen the booklets. Some of the adolescents found the materials unappealing and outdated. Parents found explications too complicated. Older people, however, found the booklets informative. Many participants made concrete suggestions on how to improve the materialsReference Cameron and Brinsdon23, Reference Trustin and McCracken24. Today the development of health education materials always includes focus group discussions with consumers.
The following success factors were highlighted:
• the MoH has a good system of disseminating the FNGs widely through mailings, newsletters and conference presentations;
• all material is free of charge, available online and in hard copy;
• the education sector uses the FNGs and familiarises children and the community with the guidelines.
Important barriers mentioned were the following:
• the FNG materials are not much distributed beyond the health sector, e.g. they are not available in public meeting or community places;
• consumer awareness is limited since the FNGs are not disseminated through mass media;
• knowledge does not equal behaviour change – even if people know the FNG, they do not change their behaviour;
• cost and availability of healthy foods limits adherence for certain population groups;
• cultural issues.
South Africa
Until the recent development of the FBDG in South Africa, nutrition education was carried out ad hoc Reference Love, Maunder, Green, Ross, Smale-Lovely and Charlton25. Between 1997 and 2001 a multidisciplinary group developed the current FBDG intended for all persons over the age of 7 years without special dietary needs. The implementation lies with the national and provincial Departments of Health (DoH), which developed explanatory teaching and education materials26. Dietitians and other health professionals were trained to communicate the FBDG. Despite this, there seems to be a lack of trained personnel, especially at community level. For example, the strategic plan of the integrated nutrition policy of the Kwazulu-Natal Province27 includes nutrition education as a focus area, but points out that nutrition advisers are lacking. The plan does not mention the FBDG as a tool or a benchmark for knowledge, while it aims to measure changes in knowledge and attitudes. This suggests that communication of the FBDG even within the governmental structure could be improved. While FBDGs are seen as an important part of nutrition policy, food insecurity is still a main problem. Thus the FBDG can only be part of a larger strategy focused on combating hunger and deficiencies, but also encouraging self-sufficiency and economic sustainability. Therefore it would be important that, for example, the national Integrated Nutrition Programme, the Agricultural Policies for Household Food Security and the Poverty Alleviation Programme are consistent with the FBDG.
Discussion
FBDGs are mainly implemented via written/electronic information provided through the health and/or education sector but a broader approach to include them into wider health promotion strategies, as recommended by EURODIETReference Stockley10, is not seen. This ‘traditional’ mode of FBDG dissemination per se, the lack of funds, and the challenge to reach the low-income population and to overcome poverty are the main barriers identified to successful implementation. When suggesting changes, the informants concurred that more stakeholders should be involved to better reach consumers. Notably, environmental or policy changes to complement FBDG implementation were not listed. Positive changes towards a wider approach are the ‘Healthy Eating – Healthy Action’ Strategy in New Zealand28, which includes the promotion of environmental changes and calls on a variety of stakeholders to participate, or the new Chilean publication18 which combines the FBDG with advice on physical activity, tobacco and mental well-being. However, while nutrition education and information are important, a pamphlet alone cannot workReference Gibney, Wolmarans, Gibney, Margets, Kearney and Arab29. Focusing on nutrition information alone may increase health inequity, if only certain parts of the population are reachedReference Stockley10. Thus, important lessons learnt are to emphasise ‘reaching the hard to reach’, work with many stakeholders and add complementary environmental changes.
Evaluation of FBDG implementation is a weakness in all four countries. Chile is the only country that performed a survey to estimate the population reached. ChileReference Yañez, Olivares, Torres and Guevara30 and New ZealandReference Cameron and Brinsdon23, Reference Trustin and McCracken24 conducted focus group discussions to evaluate their understandings of their FBDG, but there seems to be no coherent evaluation plan in any of the four countries examined. This finding is confirmed by Lachat et al. Reference Lachat, Van Camp, De Henauw, Matthys, Larondelle and Remaut-De Winter31, who found that while nutrition monitoring and surveillance is carried out in several countries, food and nutrition policies are not evaluated. An open question here is what indicators would be needed. Through national dietary surveys or sales data the dietary intake is measured, but it may take a long time to see changes and a direct relationship to FBDG promotion would be hard to establish. Hence, intermediate indicators, such as understanding the message or increased availability and accessibility of ‘eat more’ foods, should be used as well.
FBDGs give positive and negative messages regarding a total diet. The ‘bad news’ needs to be part of the nutrition information given to the population as well as at the policy level. Policy-makers should support e.g. fruit and vegetable promotion, but they should also focus on the ‘eat less’/’instead of’ messages e.g. through controlling the marketing of foods high in sugars, salt and/or fats to children.
Another issue that requires some reflection is conflict of interest, which may be present within the government (agriculture vs. health) or between FBGD promoters and parts of the food industry. Since consumer research showedReference Domper, Zacarias and Olivares20, Reference Geiger32 that the pyramid is known because it is on the packages of foods, it is important to ensure that the food processing industry uses the official FBDG. Thus, to ensure ‘buy-in’ to the FBDG from all sectors is important, while it will be a challenge to overcome conflict of interest and avoid undue influences on FBDG formulation.
All in all, rapid improvements in FBDG implementation are needed in order to make a contribution to halting the global epidemics of obesity and other nutrition-related NCDs. At the same time, it is clear that FBDGs have a foothold in the policy and public health nutrition world. From the present study, a number of recommendations can be suggested to consolidate and improve on that status.
Emerging recommendations
The following recommendations correspond to the issues concerning FBDG implementation discussed in the four case studies and are derived from the interviews or inspired by the literature review3, Reference Stockley10, 33 and addressed to specific stakeholders.
Monitoring of FBDG implementation
National governments should evaluate FBDG implementation regularly, using intermediate indicators and identifying barriers to success. At regional and global level the WHO and FAO could coordinate a common mode of monitoring to help assess the contribution of all stakeholders to FBDG implementation. Food and health non-government organisations (NGOs) could provide a valuable ‘watchdog’ function to ensure that government conducts such monitoring regularly.
Successes and factors in FBDG implementation
Multistakeholder involvement in promoting and implementing FBDGs at national level is important but national governments should endorse the FBDG and lead its implementation, highlighting its value in training not just for health professionals but also for non-health professionals who influence food availability and dietary habits, such as kindergarten and school teachers, caterers and administrators of health and social services. The food and catering industry should use the official, national FBDG and make those foods recommended as ‘eat more’ readily available in worksite, school and hospital cafeterias, restaurants and fast-food chains and improve the nutritional quality of processed foods to fit with the FBDG through product reformulation. NGOs should form inter-sectoral alliances to promote and endorse the official/national guidelines. At global level WHO/FAO should continue to support FBDG development where not existing and subsequent implementation and monitoring, while identifying best practices.
Changes in FBDG implementation
FBDGs need to be promoted through the various mass media, often the most important source of information for the public, especially in lower socio-economic groups. The multistakeholder approach could also be used when developing or revising FBDGs at national level and when implementing the FBDG to ensure consistency of message. This focus on information should be accompanied by (and not be used as a substitute for) continued environmental interventions and other sustainable changes.
FBDGs as part of wider food and health policies
The FBDG should form the bedrock for governmental health strategies and in particular be used to align wider agriculture, food and nutrition policies. In turn, these should support FBDG implementation. Bodies such as national food and nutrition councils should be a source of advice on health-centred policy change and implementationReference Lang, Rayner, Rayner, Barling and Millstone34. School food policies, for example, should require meals and snacks offered to comply with the FBDG, including local supply networks. Thus FBDGs could become a policy and organising tool as well as a scientific tool.
