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 21 February 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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*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
Producers and retailers are required by law to provide a list of the nutrient content of pre-packaged food products (with limited exceptions), even in the absence of a nutrition or health claim. The rules define which nutrients must be listed and on what basis (eg per 100g/per serving).
Huang L et al. (2014) A systematic review of the prevalence of nutrition labels and completeness of nutrient declarations on pre-packaged foods in China. Journal of Public Health 37(4), 649-658
Nutrient lists on pre-packaged food must, by law, include the trans fat content of the food. The rules generally define how the trans fat content must be listed, and on what basis (eg per 100g/100ml or per serving). If the trans fat content falls below a certain threshold, it may be listed as 0g (eg less than 0.5g per serving, or less than 0.3g per 100g of food product). Chile requires mandatory trans fat labelling only once the total fat content per serving exceeds 3g.
Doell D et al. (2012) Updated estimate of trans fat intake by the US population. Food Additives and Contaminants 29(6), 861-874
Van Camp et al. (2012) Changes in fat contents of US snack foods in response to mandatory trans fat labelling. Public Health Nutrition 15(6), 1130-1137
Lee JH et al. (2010) Trans Fatty Acids Content and Fatty Acid Profiles in Selected Food Products from Korea between 2005 and 2008. Journal of Food Science 75(7), C647-C652
Ricciuto L et al. (2008) A comparison of the fat composition and prices of margarines between 2002 and 2006, when new Canadian labelling regulations came into effect. Public Health Nutrition 12(8), 1270-1275
Friesen R, Innis SM (2006) Trans Fatty Acids in Human Milk in Canada Declined with the Introduction of Trans Fat Food Labeling. The Journal of Nutrition 136(10), 2558-2561
In effect since 1 January 2017, Ontario’s Healthy Menu Choices Act, 2015 (passed in May 2015 as part of the Making Healthier Choices Act, 2015 (Bill 45) and accompanied by Ontario Regulation 50/16) requires food service premises that are part of a chain of 20 or more food service premises in Ontario (as well as certain cafeteria-style food service premises) to display calories for “standard food items” on menus, labels and display tags. Regulated food service premises include restaurants, quick-service restaurants, convenience stores, grocery stores, movie theatres, public-facing cafeterias, food trucks and others. “Standard food items” are restaurant-type food or drink items (eg ready-to-eat items) that are sold or offered for sale in servings that are standardised for portion and content. Menus include paper menus, menu boards, electronic menus, drive-through menus, online menus or menu applications, advertisements and promotional flyers. Food service premises must also display information on daily caloric requirements. Ontario’s 36 public health units are responsible for implementation of the Act. The Ministry of Health and Long-Term Care developed an implementation guide, fact sheets and a frequently asked questions document to facilitate and streamline implementation.
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.
School fruit and vegetable programmes operate at the province level in British Columbia, Manitoba and Northern Ontario:
− British Columbia’s School Fruit & Vegetable Nutritional Program, launched in 2005 and administered by the British Columbia Agriculture in the Classroom Foundation, provides fresh local fruit or vegetable snacks to schools every other week, 13 times in the school year. In 2013, the programme expanded to deliver milk to students in kindergarten to grade two. It is administered by the British Columbia Agriculture in the Classroom Foundation, and funded by the British Columbia Ministry of Health in partnership with the Ministries of Agriculture and Education.
− Ontario’s Ministry of Health and Long-Term Care launched the Northern Fruit and Vegetable Program (NFVP) in Northern Ontario in 2006, in cooperation with the Ontario Fruit and Vegetable Growers’ Association and the Ontario Ministry of Agriculture, Food and Rural Affairs. Elementary and intermediate school-aged children receive fruit and vegetable snacks at no cost, in combination with healthy eating and physical activity education, twice per week from January to June. NFVP is currently delivered in three regions of Northern Ontario, in partnership with the local health units, school boards, and elementary and intermediate schools.
− Manitoba’s Vegetable & Fruit Snack Program, launched in 2008, is funded by the Province of Manitoba and the Public Health Agency of Canada; the number of times pupils receive fruit and vegetable snacks per week depends on each school’s way of implementation.
In 2013, the Federal, Provincial and Territorial Group on Nutrition (FPTGN), a working group consisting of representatives from all Canadian provinces and territories, released a Guidance Document for the development of Nutrient Criteria for Foods and Beverages in Schools. The Guidance contains nutritional guidelines on food served in schools, classing food products into four groups – vegetables and fruit, grain products, milk and alternatives, meat and alternatives – and two categories – Choose Most Often and Choose Sometimes. The Guidelines suggest maximum levels for fat, sugar and salt, with the reference quantities being largely based on Health Canada’s Canada Food Guide. The Guidance is not mandatory, but is intended to guide the provinces and territories in their development of new and revision of existing school nutrition policies, and to support the food industry in developing and reformulating products sold in and to schools.
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.
*Private insurance providers also offer private subsidy schemes. For example, South Africa’s largest private health insurer, Discovery Health, runs the cash back rebate programme "Vitality", in which healthier items purchased in food shops receive a 10% discount.
Launched on 1 April 2011, Nutrition North Canada (NNC) is a government of Canada subsidy programme that helps provide northerners in isolated communities with improved access to perishable, nutritious food. NNC provides a retail-based subsidy that enables local retailers and registered suppliers to access and lower the cost of perishable healthy foods like meat, fish, eggs, milk and bread, as well as fruit and vegetables, all of which must be transported by air to these isolated communities. NNC also subsidises commercially processed country or traditional foods such as Arctic char, muskox, and caribou. NNC has two subsidy levels: level 1, which is the higher subsidy, is granted to foods that are deemed the most perishable and most nutritious; while level 2, the lower subsidy, is applied to other staple food items.
Eligibility is based on isolation factors and focuses on communities that lack year-round surface access (no permanent road, rail or marine access) requiring goods to be flown in. Effective 1 October 2016, 121 northern communities had full access to the NNC subsidy. Four criteria inform subsidy rates, which vary across communities: 1) geographical distance from the supply centre to the isolated community, 2) distance flown, 3) population according to the census, and 4) minimum wage.
Residents in eligible communities can purchase subsidised food from registered northern retailers. Individuals, local restaurants and social institutions can also access the subsidy by ordering eligible items directly from registered suppliers. Retailers and suppliers are responsible for passing on the full subsidy to consumers and participate in regular compliance reviews as part of their agreement with the department of indigenous and northern affairs Canada. In order to increase programme transparency, on 1 April 2016, NNC implemented a mandatory point-of-sale system allowing customers to clearly see the application of the NNC subsidy on their grocery receipts.
Galloway T (2017) Canada’s northern food subsidy Nutrition North Canada: a comprehensive program evaluation. International Journal of Circumpolar Health 76(1), 1279451
Galloway T (2014) Is the Nutrition North Canada retail subsidy program meeting the goal of making nutritious and perishable food more accessible and affordable in the North? Can J Public Health 105(5): e395-397
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.
Since 1978, Section 248 of Quebec’s Consumer Protection Act bans any commercial advertising directed at children under 13 on TV, radio, print, internet, mobile phones and signage as well as through the use of promotional items. The ban is applicable, among others, to food and beverage marketing. Section 249 of the Act specifies the three criteria used to determine if a commercial message is directed at children under 13: whether the promoted product is intended for children and/or appeals to them specifically; whether the advertisement’s presentation is appealing to children; and whether the time and place of the advertisement is such that children are exposed to it. Exemptions exist for advertising in children’s magazines, at children’s entertainment events, in store windows and on-pack advertisement if they meet certain criteria (eg the advertisement must not exaggerate the product or directly entice a child to purchase it).
Potvin Kent M, Dubois L, Wanless A (2012) A Nutritional Comparison of Foods and Beverages Marketed to Children in Two Advertising Policy Environments. Obesity 20(9), 1829-1837
Dhar T, Baylis K (2011) Fast-Food Consumption and the Ban on Advertising Targeting Children: The Quebec Experience. Journal of Marketing Research 48(5), 799-813
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 July 2010, a multi-stakeholder Sodium Working Group, established by Health Canada, agreed a Sodium Reduction Strategy for Canada. The Strategy set an interim goal of reducing daily sodium intake from 3,400mg to 2,300mg by 2016. The multi-staged strategy included recommendations in the areas of education, voluntary reduction of sodium levels in processed food products and food sold in food service establishments, research, and monitoring and evaluation. Health Canada established voluntary sodium reduction targets for 94 processed food categories following extensive consultation with the food industry and encouraged the food industry to achieve these targets by the end of 2016.
Added February 2018: Health Canada (2018) Sodium reduction in processed foods in Canada: An evaluation of progress toward voluntary targets from 2012 to 2016
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.
In March 2009, the Ministry of Healthy Living and Sport of British Columbia passed the Public Health Impediments (BC Trans Fat) Regulation, effective since September 2009. Under the Regulation, food service establishments are not permitted to use margarines and oils with a trans fat content exceeding 2%, and other food with a trans fat content of above 5%. Food exempt from the restriction are pre-packaged food products with a nutrition facts table required under the Canadian Food and Drugs Act that are sold or offered directly to the consumer without any alteration to the nutritional contents, and food that only contains naturally occurring trans fats. Food service establishments must also keep documentation on site on the trans fat content of the food they use. In case of violations, operators can be fined $230 for exceeding the prescribed trans fat content and $115 for failing to provide adequate documentation upon request. Food service establishments are defined in the Food Premises Regulation (B.C. Reg. 210/99) as premises on which food is processed, served, and consumed immediately (article 1.1).
Heart & Stroke Foundation of BC & Yukon and ActNowBC (2012) Measuring Up: An Evaluation of the BC Trans Fat Initiative. Vancouver, June 2010
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.
New countries added February 2018: 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.
There are two public campaigns on healthy eating ongoing in Canada: the Nutrition Facts Education Campaign (Phase I with a focus on % Daily Value 2010-2014 and Phase II with a focus on Serving Size since 2015) and the Eat Well Campaign (since September 2012). They aim to improve the understanding of healthy eating, including reading the Eating Well with Canada’s Food Guide, reading nutrition labels (in particular the % Daily Value), the importance of reducing sodium intake and improving food skills to maintain a healthy weight. The campaigns are managed by Health Canada’s Office of Nutrition Policy and Promotion and involve public private partnerships with various stakeholders, including food manufacturers, grocery retailers, produce marketing associations, health NGOs and health professional organisations, as well as provinces and territories.
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
In 2010, the Canadian government launched a Nutrition Facts Education Campaign with the industry trade organisation Food & Consumer Products of Canada (FCPC). The ongoing multi-media initiative aims to improve understanding and use of nutrition information on labels.