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
EU Regulation 1169/2011 on the Provision of Food Information to Consumers, passed in 2011, requires a list of the nutrient content of most pre-packaged food to be provided on the back of the pack from 13 December 2016. This Regulation is also applicable in Iceland, Norway and Liechtenstein as members of the European Economic Area. In Switzerland, nutrient content labelling is only mandatory for products bearing nutrient or health claims or sold to the EU (but most manufacturers already label nutrient content on their food products voluntarily).
EU Regulation 1169/2011 on the Provision of Food Information to Consumers, passed in 2011, permits EU Member States to develop voluntary guidelines for front of pack nutrition information, to be used in addition to the mandatory nutrition information on the back of pack. Information on energy value, fat, saturated fat, sugar and salt content is permitted. Different styles of presentation (eg % Guideline Daily Allowances or traffic lights) are permitted. This Regulation is also applicable in Iceland, Norway and Liechtenstein as members of the European Economic Area and Switzerland based on its bilateral agreements with the EU.
National legislation regarding the compulsory use of warning labels on high-salt food in Finland has been in place since 1993. The legislation is applied to all the food categories that make a substantial contribution to the salt intake of the Finnish population. Food that is high in salt is required to carry a "high salt content" warning if the salt content is more than 1.1% in bread, 2% in sausages, 2.2% in cold meat cuts, 2% in fish products, 1.4% in cheese, 1.2% in ready to eat meals, and 1.4% in breakfast cereals or crisp bread. These limits were last updated in December 2016 and since then also apply to unpackaged cheese, sausages, and other meat products, where the information must be communicated in writing at the retail outlet in a readily accessibly manner close to the unpacked food.
A heart symbol system was introduced in 2000 by the Finnish Heart Foundation and the Finnish Diabetes Foundation. The heart symbol indicates that a product is a better choice regarding sodium and salt content compared with another product in the same food category. The heart symbol system is acknowledged by the Finnish national authorities, and the National Nutrition Council recommends consumers to use products bearing the heart symbol.
Regulation 1924/2006 establishes EU-wide rules on the use of specified nutrient content and comparative claims (ie levels of fat for a low fat claim). As of January 2010, only nutrition claims as listed in the Regulation’s annex are permitted. In theory, these nutrition claims may only be used on food defined as "healthy" by a nutrient profile. This nutrient profiling restriction was due to be implemented in 2010 but no model has yet been established. Therefore, permitted nutrition claims can be used as long as the conditions for use of the claim as set out in the annex are met. Once nutrient profiles are established, nutrition claims may only be used on food products deemed "healthy", though two notable exceptions will apply: nutrition claims referring to the reduction of fat, saturated fats, trans fats, sugars and salt/sodium will be allowed without reference to a profile for the specific nutrient, provided the claims comply with the conditions of the Regulation; and a nutrition claim may be used even if a single nutrient exceeds the nutrient profile as long as a statement in relation to this nutrient appears on the label in close proximity to, on the same side and with the same prominence, as the claim (the statement must read: 'High [name of nutrient] content'). This Regulation is also applicable in Iceland, Norway and Liechtenstein as members of the European Economic Area; Switzerland amended its foodstuff law based on its bilateral agreements with the EU to include permitted EU nutrient claims.
Regulation 1924/2006 (applicable as of July 2007) establishes EU-wide rules on the use of health claims (claims on nutrient function, disease risk reduction and children’s health). Companies may only use health claims that are substantiated and authorised by the European Commission and Member States (various regulations authorising health claims to date). The European Food Safety Authority is responsible for verifying the scientific substantiation of claims; it has done so for claims currently in use and continues to do so for claims that are proposed and applied for by companies that want to use health claims in the EU. In theory, health claims may only be used on food defined as "healthy" by a nutrient profile. This nutrient profiling restriction was due to be implemented in 2010 but no model has yet been established. Therefore, permitted health claims can be used as long as the conditions for use of the claim as set out in the respective regulations are met. Once nutrient profiles are established, health claims may only be used on food products deemed "healthy". This Regulation is also applicable in Iceland, Norway and Liechtenstein as members of the European Economic Area; Switzerland amended its foodstuff law based on its bilateral agreements with the EU to include permitted EU health claims.
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 2017, the Finnish National Nutrition Council updated their nutrition recommendations for school meals replacing the recommendations from 2008. The updated recommendations are based on Health from food – Finnish nutrition guidelines (2014) and Eating together – food recommendations for families with children (2016). The recommendations provide a basic plate model for individual energy expenditure. Food and nutrient recommendations for salt, fibre, fat, starch, and fat content are outlined for all of the components of the basic plate model. The recommendations state that drinks available at school meals should include fat-free milk/milk drinks and buttermilk, fortified with vitamin D. Other liquid dairy products and fermented milk products should be fat-free or low-fat products with a maximum fat content of 1%. Cheese products with a fat content of at most 17% and a maximum salt content of 1.2% should be selected. Fresh water should be available as the primary beverage at meals and must be available as the primary beverage to everybody during the whole school day. No soft drinks, energy drinks or any other acidified beverages or beverages with added sugar are served at school.
The Finnish Act on Early Childhood Education and Care, Section 2b (8.5.2015/580), Section 6 (8.5.2015/280) and Basic Education Act, Section 31(13.6.2003/477) outline that school-age children shall be provided with healthy and necessary nutrition that fulfills their nutritional needs and provided a meal free of charge on every school day. Children at kindergarten/childcare are entitled to a meal each day and low-income populations are provided with a free meal.
In 2009, legislation required products entitled to EU subsidies under the School Milk Scheme to meet nutritional criteria, including maximum levels of salt content. The criteria are set jointly by the Finnish National Nutrition Council and KELA, the Social Insurance Institution of Finland. In August 2017, the legislation was amended so that only fat-free milk and fat-free sour cream are subsidised, and cheese was removed from the subsidy.
The Finnish government Decree 564/2003 on supporting meals at universities requires meals to meet specific nutritional criteria in order to qualify for government subsidies. Nutrition recommendations were first published in 2003, revised in 2008 and updated in 2011. The Finnish National Nutrition Council and KELA, the Social Insurance Institution of Finland, jointly set the updated recommendations. They include compulsory meal components, nutritional criteria for all meal components (total fat, saturated fat, salt, fibre), consumer advice and guidance for healthy choices, rotation of menus, number of meals that have to meet the criteria for nutritional quality and criteria adherence guidelines. The updated nutrition recommendations came into effect on 1 January 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.
Finland imposed excise taxes on non-alcoholic beverages and confectionery for most of the 20th century for revenue-raising purposes. The excise duty on confectionery was removed in 2000, re-introduced in 2011 and removed again in January 2017. In 2014, the tax rate was 0.95 euros per kg by weight for confectionery and ice cream, 0.22 euros per litre for beverages with more than 0.5% sugar and 0.11 euros per litre for other non-alcoholic beverages. The tax on candy and ice cream was removed on 1 January 2017. Currently an excise tax is levied on non-alcoholic beverages. Producers with an annual production volume of less than 50,000 litres are exempted from the tax.
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.
The Finnish Consumer Protection Act (1978, last updated 2016) regulates all marketing targeting consumers, including food marketing to children. The Consumer Ombudsman’s Guidelines: Children and Foodstuffs Marketing (2004, developed in cooperation with the National Public Health Institute) set out how to apply the Consumer Protection Act. The Guidelines specify that the purpose of food advertisements must be explicit, that the way of presenting cannot be misleading and that advertising practices should not encourage unhealthy dietary habits in children. They also advise to take special care when using marketing techniques with a special appeal to children. Neither the Consumer Protection Act nor the Guidelines define what unhealthy dietary habits and marketing techniques with a special appeal to children are. Whether food marketing to children violates these requirements is decided on a case-by-case basis by the Consumer Ombudsman and the Market Court (the court that hears marketing cases based on the Consumer Protection Act). Considerations regarding the age-appropriateness of marketing are also made on a case-by-case basis, independent of the general definition of a child being a person below the age of 18 under Finnish law. The Guidelines, which are not legally binding, were developed taking into consideration the Market Court’s case law, and contain examples of cases where marketing was found to violate the Consumer Protection Act. Examples are competitions that a child can only participate in if the product is bought; using collectible toys; giving the impression that buying the advertised food will make the child more popular; and masking advertisement as a story. During the past decade, the Consumer Ombudsman has not had cause to take any case concerning food marketing to children to the Market Court, and has instead successfully collaborated with industry to align marketing practices with the Guidelines.
Policies within this category aim to harness the whole food system, and the sectors which influence it, to ensure coherence with healthy eating. This is because the food system, and the policies that affect it, influence our food environment.
What our food industry produces is in part a response to incentives in the supply chain. Sectors outside of health influence our ability to take policy action. Likewise, if governments implement policies contained in NOURISHING, they have repercussions upstream for the actors and activities in food systems. This wider relationship to the food supply chain presents an opportunity to support all the policies in NOURISHING with actions in the food supply chain.
The Finnish National Nutrition Council is an inter-governmental expert body under the Ministry of Agriculture and Forestry with advisory, coordinating and monitoring functions. It is composed of representatives elected for three-year terms from government authorities dealing with nutrition, food safety, health promotion, catering, food industry, trade and agriculture.
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.
In 2009, the Finnish National Nutrition Council developed recommendations for beverages for children and adolescents, adults and older people that split beverages into three categories: drink daily (eg water), you can also drink daily (eg a glass of fruit juice) and drink only infrequently (eg soft drinks). Recommendations differ by age category.
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.
In Finland, nutrition guidance by public health nurses is provided free of charge on a mandatory basis as part of antenatal care, and during appointments at child health clinics post-partum. Nutrition counselling is tailored to the family’s needs and targets both parents. It is based on the 2016 Food Recommendations for Families with Children developed by the Finnish National Institute for Health and Welfare.
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.
Education is a key part of awareness raising on health issues in Finland, and compulsory classes in health education and home economics are part of basic education. Home economics includes food preparation, meal planning (taking nutritional recommendations into account) and how to interpret food labelling and assess the reliability of different types of nutrition information.