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
A Notification to the Ministry of Public Health (2007) issued by the Thai Food and Drug Administration requires five categories of snack food to carry a Guideline Daily Allowance (GDA) label. The label includes text aimed to help consumers understand the GDA and requires a warning label that reads "Should consume in small amounts and exercise for better health”.
In August 2016, the voluntary Healthier Choices logo was launched in Thailand, a front-of-pack labelling scheme to help consumers identify healthier food choices (Notification of the Ministry of Public Health No. 373, B.E.2559 2016, Re: The Display of Nutrition Symbol on Food Label, 12 February 2016). The logo was developed in collaboration between the National Food Commission, the Ministry of Health's Food and Drug Administration, the Health Promotion Foundation and Mahidol University. The Healthier Choices logo is owned by the Thai Food and Drug Administration, and its use is managed by the Nutrition Promotion Foundation of Mahidol University. The logo can be applied to beverages, sauces and condiments, dairy products, ready-to-eat meals, instant food and snacks; it is intended to eventually cover all food products. To be eligible for the logo, fish sauce must not contain more than 6g of sodium per 100ml, and soy sauce not more than 5g sodium per 100ml. Beverages must not contain more than 6g of sugar per 100ml if they are sold in single-serving containers; in beverages sold in containers that exceed 150% of a single serving, sugar must not exceed 18g per container. All other food must not exceed 500kcal and has to reach at least 20 points out of an achievable 40 points on the required nutrient content. The point system contains minimum and maximum levels of total fat, saturated fat, total sugar, protein, sodium, calcium fibre and iron in six categories, ranging from 0 (worst) to 5 (best).
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 2008, the Thai Department of Health, in collaboration with the Ministry of Education’s Office of the Basic Education Commission (OBEC), announced a voluntary ban of soda and sugary packaged snacks in elementary and secondary schools under OBEC. It has been implemented by the majority of schools under OBEC.
The voluntary Thai School Lunch Programme was implemented in 1999, recommending schools to provide meals and snacks in line with the nutrient standards of the Thai Recommended Daily Intake (RDI) (last amended 2003). Three RDIs exist for different age groups: 3–5 years (1,200kcal), 6–12 years (1,550kcal) and 13–18 years (2,000kcal). School meals and snacks should make up 40% of the RDI, and recommend a distribution ratio of 55–60% carbohydrates, 10–15% protein and 25–30% fat. In addition, the RDIs set maximum levels of protein, fat, total carbohydrate and cholesterol, and contain recommended levels of vitamins (A, B1, B2, C), folate and calcium. The guidelines are intended to prevent both undernutrition and overweight/obesity. In 2013, the budget per lunch per pupil was increased from 13 Thai Baht (ca. $0.4) to 20 Thai Baht (ca. $0.6) to increase the quality of school lunches. Due to a lack of monitoring and evaluation capacity of the ministries in charge of the programme (Ministry of Education, Ministry of Public Health, Ministry of Interior), it is unclear how widely the RDIs are implemented.
Since 2012, restaurants and food stores in public hospitals are encouraged to comply with the Department of Health’s Healthy Food Menu policy, which includes the Healthy Menu and the Fatless Belly Menu. The Healthy Menu requires the dish to be cooked using vegetable oil and providing protein (in the form of meat, nuts, or eggs), carbohydrates (rice or noodles), various vegetables and fresh fruit. To comply with the Fatless Belly Menu, the dish should not exceed 400kcal, 15g of fat, 2g of sugar and 600mg of sodium, and it should consist of 50% vegetables, 25% low-fat meat and 25% rice or a starchy carbohydrate.
In 2000, the Ministry of Public Health, in collaboration with the Ministry of Education, introduced the voluntary Childcare Centre Standard. Childcare centres are encouraged to comply with nutrition guidelines for children aged 1–3 years and 4–5 years (last updated 2013); the latest survey, conducted in 2014, showed that 61.4% of childcare centres across Thailand met the Standard. The Standard prohibits sugar-sweetened beverages, meat high in fat, the use of salty seasonings (such as fish and soy sauce) and sugar in dishes, and snacks high in sugar and salt, including a ban to bring such snacks to the centres. They include recommendations on portion size for underweight, normal and overweight children as well as the frequency of food groups and meals. In addition, childcare centres have to comply with the Thai Recommended Daily Intake (RDI) (last amended 2003) for 3–5 year olds which are based on 1,200kcal/day and recommend a distribution ratio of 55–60% carbohydrates, 10–15% protein and 25–30% fat. The RDI sets maximum levels of protein, fat, total carbohydrate, and cholesterol, and contains recommended levels of vitamins (A, B1, B2, C), folate and calcium. The Standard and RDI are intended to prevent both undernutrition and overweight/obesity.
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.
Added February 2018: On 16 September 2017, the Excise Tax B.E. 2560 (2017) went into effect in Thailand introducing an excise sugar tax on certain beverages. An ad valorem rate is applied to the following beverages: artificial mineral water, soda water, and carbonated soft drinks without sugar or other sweeteners and without flavour; mineral water and carbonated soft drinks with added sugar or other sweeteners of flavours (14%); fruit and vegetable juices (10%). An additional specific tax on sugar is added to the ad valorem tax starting at 0.10 baht (about $0.0031) per litre for drinks containing over 6 grams to 8 grams; 0.30 baht (about $0.0095) per litre for drinks containing 8 grams to 10 grams; 0.50 baht (about $0.015) per litre for drinks containing 10 grams of sugar to 14 grams and 1 baht (about $0.031) per litre for drinks containing over 14 grams per 100ml of sugar. The sugar tax increases every two years and by the year 2023 onwards the tax will be 1 baht per litre for drinks containing 6 to 8 grams; 3 baht (about $0.095) for drinks from 8 grams to 10 grams; 5 baht (about $0.15) per litre for drinks over 10 grams.
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.
Added February 2018: Thailand’s Control of Marketing Promotion of Infant and Young Child Food Act (B.E. 2560), launched in 2017, bans all advertising of food for infants (eg breastmilk substitutes) and complementary food for infants. Food for young children cannot be advertised if it is linked to or cross-promoting breastmilk substitutes. It is prohibited to use infants or young children in advertisements. The Act outlines that labels on food for infants must be significantly different from food for young children and other foods. Penalties exist for violating the advertising components of this Act, including up to one-year imprisonment.
Governments have stated they support the implementation of "pledges" developed by food companies that restrict advertising of food (varies by company) to children under 12 through specified communications channels (typically TV, radio and internet). (See Yale Rudd Center for Food and Obesity's database on Pledges on Food Marketing to Children Worldwide).
Schermbeck RM, Powell LM (2015) Nutrition Recommendations and the Children’s Food and Beverage Advertising Initiative’s 2014 Approved Food and Beverage Product List. Preventing Chronic Disease 12:140472
Powell LM et al. (2011) Trends in the Nutritional Content of TV Food Advertisements Seen by Children in the US: Analyses by Age, Food Categories and Companies. Archives of Pediatrics and Adolescent Medicine 165(12), 1078-1086
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 2015, the Ministry of Public Health, in partnership with the Thai Health Promotion Foundation, Thai sugar producers and Thai hotels, implemented a voluntary policy to reduce the size of sugar packets from 6–8g to 4g.
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.
*Civil society organisations have also developed public awareness campaigns on unhealthy food. For example, Cancer Council Victoria in Australia has a social marketing team that runs campaigns related to cancer prevention, including on diet and obesity. In January 2013, it launched the Rethink Your Sugary Drink campaign on YouTube and social media focused on the amount of sugar in soft drinks. In Mexico, the civil society network Alianza por la Salud Alimentaria ran a public campaign against soft drinks in May–August 2013. A series of adverts were posted on buses, billboards and in the subway showing 12 heaped spoonfuls of sugar next to a bottle of soda. The adverts asked "Would you eat 12 spoonfuls of sugar? Why do you drink soda?”
In Thailand, the Sweet Enough Network was established in 2003 by a group of dentists, paediatricians and public health workers in the Ministry of Public Health’s Dental Health Division to endorse regulations to reduce added sugar in food products and raise awareness of the risk associated with excess sugar consumption. They have a logo and mascot, which is promoted through books, games and videos.
The Low Salt Network in Thailand is funded by the Thai Health Promotion Foundation. In 2014, it collaborated with the Ministry of Public Health on a Low Salt Week involving a mass media campaign on public television and cable networks.
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.
Diet and Physical Activity Clinics are available in Thai Ministry of Health-run hospitals, focused on evaluating health status and developing individual weight-loss plans.