The Development of Food Based Dietary Guidelines

FBDG express the principles of nutrition education in terms of the food and food choices available to the population rather than in terms of specific nutrients or food components. Scientifically, these guidelines are based on the association between dietary patterns and the risk of diet-related diseases and incorporate recommendations that address major diet-related public health issues. In addition to communicating scientific knowledge about the association between food, dietary patterns, and health, development of FBDG provides an opportunity to strengthen consensus among various government and non-government organizations on important nutrition recommendations to be incorporated into educational programs. In addition, by expressing scientific principles in terms of food, FBDG recognize the consumer awareness of food rather than nutrients and emphasize to consumers the importance of meeting nutrient needs with foods. Thus, both the content of the FBDG and the process of development are important.

Researchers often focus their studies on a specific nutrient or food component that may alter the risk of developing a disease. These studies are reviewed in the development of FBDG, but the information must be reorientated from a nutrient-based focus to a food recommendation by addressing the questions in Table 1. As indicated by these questions, the process is driven by the identification of diet-related public health issues and the development of food-based strategies that are relevant to the target population.

The process for developing FBDG is based on building consensus among various sectors and groups involved in public health. Table 2 provides a general outline of the steps in the process, which can be adapted to the specific needs of a country or region. The goal is to have a set of guiding principles for food-based recommendations that lay out the overall policy agreed by various agencies and groups.

The product of the working group is likely to be a document that outlines recommendations and includes background information on the rationale for the guidelines as well as guidance on implementing the recommendations. The guidelines from three countries are shown in Table 3 as an example of the types of message developed during this process. In all cases, the messages are accompanied by a document containing background information. Table 4 presents common themes emerging from the FBDG that have been developed in a variety of countries. Based on foods available and cultural practices, the types of fruits, vegetables, and whole grains and the specific types of food that are emphasized as sources of protein, calcium, or unsaturated fatty acids may vary. In

Table 1 Reorientating from nutrients and food components to foods

What are the important public health issues for the population? Do they have diet-related factors?

Health statistics will indicate the major causes of morbidity and mortality in a population. Diet-related diseases include nutritional-deficiency diseases and noncommunicable diseases such as obesity, type 2 diabetes, certain types of cancer, and cardiovascular disease. It is important to determine whether nutrition is the primary cause of the disease or secondary to some other more prevalent problem (e.g., smoking, infectious agents)

What are the target nutrients linked to the major public health issues? Are there related nutrients or other factors?

In many nutrition-related problems several nutrients or food factors may interact to cause the nutritional problem. For example, the fat content of the diet affects absorption of fat-soluble vitamins, obesity can be related to either excess energy intake or inadequate expenditure, multiple factors contribute to adequate bone formation, folic acid can mask vitamin B12 deficiencies, etc. Simply increasing the intake of a target nutrient and ignoring these other factors may not address the problem adequately

What foods are high in the nutrient(s) or consumed in sufficient quantity to be a significant source of the nutrient(s)?

Using both food-composition databases and food-consumption data, foods that are good sources of the nutrient and foods that are consumed in sufficient quantity to meet the target intake can be identified. Likewise, dietary patterns that lower the risk for the public health problem and are associated with adequate intake of the nutrient can be identified

What is likely to be acceptable by the target audience?

For nutrition interventions to achieve success, recommendations must target food choices that can be integrated into the diet based on cost and acceptability of the foods

How do diet strategies integrate with other food policies?

Economic, agricultural, and trade analysis is useful to determine which diet strategies are sustainable

Table 2 Steps in the development of food-based dietary guidelines

1. Develop support from key government agencies

The successful implementation of FBDG will depend on support from key ministries such as health, agriculture, education, sports, and recreation. Building consensus among these agencies will result in consistent messages regarding diet, health, and lifestyle for the public. Examples of support include technical support for data analysis or a Secretariat to maintain and coordinate activities

2. Form a working group of experts

The working group should include diverse expertise in areas such as public health, nutrition, food science, agriculture, and behavioral sciences

3. Solicit public comment and input

The expert panel needs to gather and evaluate scientific information to determine the guidelines that are most relevant to the target population. This information can be obtained from the scientific literature. In addition, professional groups may have important information to submit to the panel for consideration. Solicitation of information is consistent with an open process; however, the panel is responsible for evaluating the relevance of the information submitted

4. Review and identify key public health issues and evaluate the diet-health relationships of concern for the population, determine the critical health, food, and nutrition issues to be targeted in the FBDG, and define the purpose, target groups, and content of the FBDG

Even if data are limited, it is important for the working group to identify the key public health issues. This step may be especially important in countries in which both under-nutrition and over-nutrition are of concern. Identification of the public health issues allows the working group to address the questions in Table 1

5. Develop and draft the main messages for the FBDG

The working group will need to decide whether the draft document will be targeted primarily at health professionals, and hence may be more technical, or will be targeted toward the general public. In developing the main messages, they may identify consumer-orientated materials, such as a food guide that will be useful in communicating the FBDG to the public

6. Assess the cultural and economic appropriateness and credibility of the messages as perceived by the target groups

Through focus groups or other types of consumer testing the effectiveness of the FBDG can be assessed. This information can be used to revise the guidelines before developing the final draft

7. Release and implement the FBDG

It is valuable to have government leaders from key ministries involved in the release and implementation of the FBDG so that there is a commitment to integrate the guidelines into departmental policies. In addition, the implementation can require development of educational materials for different target groups as well as public-private partnerships to aid in dissemination of the messages to the public

8. Monitoring and revision

Monitoring can be used to assess the impact and implementation of the FBDG. In addition, monitoring data are useful for making appropriate revisions and updates to the guidelines on a periodic basis

FBDG, food-based dietary guidelines.

Table 3 Dietary-guideline messages from three countries

China

Thailand

Aim for fitness

Aim for a healthy weight Be physically active each day

Build a healthy base

Let the pyramid guide your food choices

Choose a variety of grains daily, especially whole grains Choose a variety of fruits and vegetables daily Keep food safe to eat

Choose sensibly

Choose a diet low in saturated fat and cholesterol and moderate in total fat Choose beverages and foods to moderate your intake of sugars If you drink alcoholic beverages, do so in moderation

Eat a variety of foods, with cereals as the staple Consume plenty of vegetables, fruits, and tubers

Consume milk, beans, or diary or bean products every day

Consume appropriate amounts of fish, poultry, eggs, and lean meat; reduce fatty meat and animal fat in the diet

Balance food intake with physical activity to maintain a healthy body weight Choose a light diet that is also low in salt If you drink alcoholic beverages, do so in limited amounts

Avoid unsanitary and spoiled foods

Eat a variety of foods from each of the five food groups, and maintain proper body weight

Eat adequate amount of rice or alternative carbohydrate sources

Eat plenty of vegetables and fruits regularly

Eat fish, lean meats, eggs, legumes, and pulses regularly

Drink milk in appropriate quality and quantity for one's age Eat a diet containing the appropriate amounts of fat Avoid sweet and salty foods Eat clean and safe food Avoid or reduce the consumption of alcoholic beverages

Table 4 Common themes for food-based dietary guidelines

Foods or behaviors that are encouraged

Cautionary messages

Energy balance

Includes physical activity Encouraging a healthful variety of foods

Fruits and vegetables Use of whole grains Protein-based foods Foods that are calcium sources Sources of unsaturated fatty acids Safe food handling

Saturated fatty acids and trans fatty acids Energy balance Total energy from fat Consumption of foods high in added sugar Use of salt and salty foods Alcohol all countries concerns about the increasing incidence of obesity have placed greater focus on energy balance, in terms of both food selection and physical activity. As a part of their effort to support the development of FBDG, the FAO launched a public information initiative for consumers entitled 'get the best from your food'. This initiative promoted four simple principles (Table 5) that can be adapted for educational programs in a variety of settings.

Most countries that have developed FBDG have also developed a food guide to accompany the messages in the guidelines. The food guide is typically a simple graphic illustration of food choices and dietary patterns. The food guides that accompany the FBDG shown in Table 4 are illustrated in Figure 1. Criteria for a food guide should include representation of foods common to the population, consistency with the FBDG, use of simple graphics that are meaningful to the target population, and developing a food pattern that meets the nutrient requirements of the population. Although a simple graphic is useful for visual communication, it should be clear that proper use of the food guide depends on understanding the more complete information in the FBDG.

Table 5 Food and Agriculture Organization initiative: get the best from your food

Key concept

Enjoy a variety of food

Eat to meet your needs

Protect the quality and safety of your food

Keep active and stay fit

Recognizing the importance of food in understanding nutrient requirements, nutrient and non-nutrient interactions, and diet-health relationships Importance of energy balance and different needs across the life cycle

Recognizing the importance of food and water sanitation, especially in developing countries Importance of physical activity in maintaining well-being

Food-guide pyramid

A guide to daily food choices

Fats, oils, and sweets group Use sparingly

Milk, yoghurt, and cheese group 2-3 servings

Milk, yoghurt, and cheese group 2-3 servings

Meat, poultry, fish, dry beans, eggs, and nuts group 2-3 servings

Fruit group 2-4 servings

Meat, poultry, fish, dry beans, eggs, and nuts group 2-3 servings

Fruit group 2-4 servings

Bread, cereal, rice, and pasta group 6-11 servings

Fats and Oils, 25 g

Milk and Milk Products, 100 g Bean and Bean Products, 50 g

Meat and Poultry, 50-100 g Fish and Shrimp, 50 g Eggs, 25-50 g

Vegetables, 400-500 g Fruits, 100-200 g

Cereals 300-500 g

Fats and Oils, 25 g

Milk and Milk Products, 100 g Bean and Bean Products, 50 g

Meat and Poultry, 50-100 g Fish and Shrimp, 50 g Eggs, 25-50 g

Vegetables, 400-500 g Fruits, 100-200 g

Cereals 300-500 g

Figure 1 The food guides that accompany the FBDG in (A) the USA, (B) China, and (C) Thailand.

Figure 1 Continued.

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