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
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.
In August 2010, the Mexican Ministries of Education and Health issued a set of mandatory food and beverage guidelines for elementary schools for roll-out in 2011–14. They were developed under the framework of the National Agreement for Healthy Nutrition. The guidelines promote the daily intake in schools of healthy food, such as fruit, vegetables and water; ban sodas; limit the availability of other soft drinks, whole milk, salty and sweet snacks, and desserts that comply with nutritional criteria to a maximum of two days per week; and prohibit completely products that do not comply with the nutritional criteria. The Guidelines were updated in 2014. The revised Guidelines extend the standards to secondary schools, include recommendations for food brought into schools from home, and increase the stringency of some of the nutrient criteria.
In order to support efforts of the Mexican government to reduce obesity, Liconsa, the government-owned company that purchases and distributes subsidised milk to low-income households, switched two-thirds of its milk supply to low-fat milk in 2013.
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.
In December 2013, the Mexican legislature passed two new taxes as part of the National Strategy for the Prevention and Control of Overweight, Obesity and Diabetes (Estrategia Nacional Para Un Mexico Sin Obesidad). They entered into force on 1 January 2014. An excise duty of 1 peso (around $0.05) per litre applies to sugary drinks. Sugary drinks are defined under the law as all drinks with added sugar, excluding milks or yoghurts. Preliminary price monitoring indicates that the price of sugary drinks has increased by around 10%. The revenue from the sugary drink tax should be allocated to fund programmes addressing malnutrition, obesity and obesity-related chronic diseases, as well as access to drinking water (6th transitory article, Federal Law on Income for the Fiscal Year 2017); however, the revenue is currently being allocated to the general budget. An ad valorem excise duty of 8% applies to food with high caloric density, defined as equal to or more than 275 calories per 100g. The food product categories that are affected by the tax include chips and snacks, confectionery, chocolate and cacao based products, puddings, peanut and hazelnut butters.
In effect since 1 January 2011, a 25% tax is applied to energy drinks. Energy drinks were added to the Special Tax on Production and Services Law (Ley del Impuesto Especial sobre Producción y Servicios) by Decree on 19 November 2010. The Law defines energy drinks as non-alcoholic beverages with >20mg per 100ml of caffeine and mixed with stimulants (eg taurine). The Law also applies to concentrates, powders and syrups used to prepare energy drinks.
Colchero MA et al. (2017) In Mexico, Evidence Of Sustained Consumer Response Two Years After Implementing A Sugar-Sweetened Beverage Tax. Health Affairs 36(3), 564-571
Added February 2018: Taillie L S et al. (2017) Do high vs. low purchasers respond differently to a nonessential energy-dense food tax? Two-year evaluation of Mexico's 8% nonessential food tax. Preventive medicine, 105, S37-S42
Batis C et al. (2016) First-Year Evaluation of Mexico’s Tax on Nonessential Energy-Dense Foods: An Observational Study. PLoS Medicine 13(7): e1002057
Added February 2018: Colchero M et al. (2016) Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. British Medical Journal, 352, h6704
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.
In February 2014, the Mexican Ministry of Health issued an Order restricting the advertising of food and sweetened beverages, defined according to a nutrient profiling model. The restrictions apply to TV programmes classified as “A” within the times of 2.30–7.30pm on weekdays and 7:00am–7.30pm on weekends, where over 35% of the audience are under age 13. Advertising for this food is also restricted in films classified as “A”. Implementation began on 15 July 2014 for sweetened drinks, potato chips, chocolates and confectionary, and was expected to be extended to other food covered by the nutrient profiling model in January 2015.
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 2012, the Mexican Health Secretariat signed an agreement on voluntary salt reduction in bread with the Mexican National Chamber of the Bread Industry (CANAINPA), the Mexican National Association of Supermarkets and Department Stores (ANTAD) and Bimbo SA (largest Mexican-owned baking company). ANTAD, CANAINPA and Bimbo pledge to reduce the salt content of sliced bread and bolillo (similar to a baguette) by 10% within five years. In 2013, the Ministry of Health announced a national target for salt reduction of 5g salt/person/day by 2020, consistent with the regional target.
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 2013 in Mexico City, the Less Salt, More Health initiative was launched. It is a voluntary agreement between city government and the trade group representing restaurants to encourage restaurants to provide salt shakers only if guests ask for them. In April 2014, it was announced that 2,438 restaurants had voluntarily joined the initiative. Employers in these sectors supported its implementation for the benefits involved for the health of the population.
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.
Mexico developed a set of Beverage Guidelines for Healthy Hydration in 2008.
As part of the Mexican National Strategy on the Prevention and Control of Overweight, Obesity and Diabetes (La Estrategia Para Un Mexico Sin Obesidad), the Presidency and Secretary of Health launched a national health promotion campaign focusing on the prevention of non-communicable diseases, Check, Monitor and Move Yourself (Chécate, Mídete, Muévate). The objective of the campaign is to foster a culture of taking care of personal health, promote exercise and discourage the consumption of high-calorie food. The campaign uses a variety of media channels, including television, radio, cinema, billboards, advertisements on public transport and social media. The Mexican Social Security Institute and the Safety and Social Services Institute for State Workers are co-sponsors. The campaign launched in October 2013 and is expected to run until 2018.
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 Mexican Integrated Nutrition Strategy (EsIAN), first piloted in 2008 and since rolled out nationally, includes individual counselling to pregnant women and mothers of children under 5, and the distribution of micronutrient supplements. It promotes breastfeeding and appropriate complementary feeding, as well as linear growth.
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 Mexico, the General Law on Education (Ley General de Educación) of 1993, last amended in 2016, establishes that schools must provide nutrition education alongside minimum standards for physical activity and sports, with the aim of promoting a culture of healthy eating.