A snapshot of food-based dietary guidelines implementation in selected countries
Introduction
Food-based dietary guidelines (FBDGs) are a country's recommendations to their people on what constitutes a healthy diet. FBDGs include, among other tools, a set of science-based easily-understood messages for the general public, often accompanied by an image/graphic (FAO 2020). The FBDGs development process includes a situation analysis, which ensures that FBDGs respond to the country context. Recent papers have highlighted the need for this process to be more systematic and transparent in order to ensure that FBDGs are informed by the best available evidence and pertinent contextual factors, better manage conflicts of interest and improve stakeholder participation (Blake et al., 2018; Zeraatkar et al., 2019). Some countries include recommendations on meal options, eating modes/food practises, food safety, hygiene and physical activity in their FBDGs, while a few have incorporated environmental sustainability aspects into theirs (Gonzalez Fischer and Garnett, 2016). Recently, there has been renewed interest in the potential of FBDGs to address the multiple sustainability challenges associated with diets and food systems,1 through recommendations that better support both human and environmental wellbeing (Ahmed et al., 2019; Springmann et al., 2020; UNEP, 2019). FBDGs are among the strategies used in system-oriented approaches that look for solutions across sectors and at different scales for food systems transformation (Brouwer et al., 2020).
FAO maintains a repository that catalogues FBDG made available by countries (FAO et al., 2020). While national FBDGs are available from 94 countries, not many low and middle income countries have them. In 2020 only 2 out of 29 low income countries (LICs) and 14 out of 50 lower-middle-income countries (LMICs) had FBDGs available on the repository (FAO et al., 2020) compared with 34 out of 56 upper-middle-income countries (UMICs) and 44 out of 83 high-income-countries (HICs) according to the World Bank classification of countries (World Bank, 2020). Nonetheless, several recent global reports and/organizations have increasingly recognized the need for countries to develop FBDGs, and implement them to inform coherent actions across food systems, covering actors and institutions from production to consumption (FAO, 2016; Global Panel 2017; Wijesinha-Bettoni et al., 2017). For this reason, experts recommend that FBDGs go beyond their common use in food and nutrition education programmes to be used by sectors such as agriculture, health, food security and nutrition to guide their relevant policies and programmes in order to contribute to the achievement of sustainable healthy diets.
Despite this potential, many factors impede the effectiveness of FBDGs in improving diets and the health of the general population. Such factors include lack of political support, non-participation of stakeholders and conflict with market forces during FBDG development and implementation, and lack of published research on evaluation of their effectiveness (Brown et al., 2011; Mozaffarian et al., 2018; Palma and Jetter, 2012). Although a degree of consumer awareness and understanding of FBDGs is evident in the literature reviewed, it is important to note that awareness and knowledge do not automatically translate into action (Bechthold et al., 2017; Brown et al., 2011; Smitasiri and Uauy, 2007). In addition to knowledge, motivation, skills and opportunities for choosing the proper action are needed (Ölander and Thøgersen, 1995). Therefore, the concurrent development of people's capacities and the provision of a supportive environment are essential in this context (Brown et al., 2011; FAO, 2016; Kwasnicka et al., 2016).
Adding to the above difficulties, the concept of FBDGs “implementation” has been ambiguously interpreted in published papers. A number of terms encountered in the literature, such as implementation, dissemination, socialization of messages, creation of community consciousness, promotion and communication, were sometimes used interchangeably in the same text, or taken to mean different things by different authors (EUFIC 2009; Keller and Lang, 2008; Usfar and Fahmida, 2011). The European Food Information Council (EUFIC), for example, refers to “communicative efforts” to “inform the public on the FBDG messages” when referring to “Implementing FBDGs” (EUFIC, 2009). Many published papers use the term “implementation” to refer to simple dissemination activities. By contrast, the EURODIET report has suggested that FBDGs should be implemented both as a communication tool and as a ‘springboard to planning, implementing, and evaluating public health nutrition strategies’ (Sjöström and Stockley, 2001), giving a much broader meaning to the term “implementation”.
For this study we defined “dissemination” as referring to activities that aim to inform the public about the FBDG messages using different channels (e.g. videos, songs, websites, social media etc. and print materials (e.g. leaflets, posters etc.). “Implementation” was defined as referring to comprehensive strategies and actions that embed FBDGs in national policies and programmes, and apply and activate them in different sectors (e.g. health, agriculture, education etc.) and settings (e.g. schools, communities, workplaces).
In order for FBDGs to be effective in influencing food practices in the long term, a pre-requisite is that they are well implemented (EFSA, 2010). At present, very little documentation, mainly limited to HICs, is available on how countries actually implement FBDGs. Similarly, details of monitoring and evaluation (M&E) of implementation, as well as guidance on implementation are scarce (Bechthold et al., 2017; Brown et al., 2011; Bush, 2003; Keller and Lang, 2008; Smitasiri and Uauy, 2007; WHO, 2013). Given the increased interest and demand for FBDGs, documenting the processes/strategies used for FBDGs implementation is critically important. We conducted this study to help fill some of the existing knowledge gaps regarding FBDGs implementation by conducting a survey of key informants together with a review of literature.
Section snippets
Desk review of literature
A desk review of the available literature was conducted in two steps as part of the study. At the planning stage, the literature was consulted to help frame the survey, design the questionnaire and get an idea of sectors/settings where FBDGS were being implemented. Key scientific databases such as Web of Science, Pubmed and Scopus were searched together with grey literature to identify policies and programmes guided by FBDGs. Articles were selected based on their abstracts, mainly limited to
Results
Responses were received from 27 countries out of the 36 countries contacted (75% response rate for countries). The responding countries corresponded to one LIC, three LMICs, 10 UMICs and 13 HICs. Of the 41 individual respondents, 26 were employed by the national authority responsible for FBDG development, generally the Ministry of Health (MoH). Others worked for the Ministry of Agriculture (MoA), Ministry of Education (MoE), Ministry of Food and Environment, Ministry of Agriculture and
Discussion
The current study identified several examples of FBDGs implementation spanning various sectors and settings. The majority of activities were led by health and education sectors, in line with findings from the previous FAO study in Latin America and the Caribbean (FAO, 2014). This could be explained by the fact that in many countries the FBGDs development process has traditionally been carried out by health and nutrition experts, who go on to use the FBDGs in their work. The involvement and
Conclusion
This study provides a snapshot of FBDG implementation in the surveyed countries, which shows that FBDGs are generally not utilized to their full potential. For FBDGs to be used more effectively, sectors other than nutrition and health need to see their value and be involved in their development and implementation. The FBDGs development process should lean on a wider base of inputs that come from the different sectors that have an impact on diets and healthy eating. Therefore, having a food
Funding
This work was carried out under the regular programme of work of the Food and Agriculture Organization.
Contributions
RW-B and AK were involved in all stages of the study, including the analysis and drafting of the manuscript. RW-B and AK prepared the manuscript with inputs from YH and FH. AK prepared the survey in electronic format, collated the responses, and followed up where further clarifications were needed. AK and RW-B analysed the data. All other authors made important contributions to the conceptualization and design of the study, helped to identify key informants, reviewed the survey questionnaire
Disclaimer
The views expressed in this information product are those of the authors and do not necessarily reflect the views or policies of FAO.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
We are very grateful to all those who participated in the key informant survey, and in some cases, continued to communicate with us to provide further details and clarifications. We thank the two anonymous reviewers and the editor for their comments, which helped to improve the article.
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