Chapter four - Development and implementation of food-based dietary guidelines
This chapter provides guidance on how a country can develop and implement FBDG. This guidance is provided in two major parts; the first part concerns development of the guidelines, and the second part gives advice on how the guidelines can be used to improve dietary practices.
In preparing FBDG, countries should keep in mind that guidelines are always subject to change, and that many factors have to be taken into account in preparing them. Many different sources of information should be reviewed and considered before FBDG can be developed, and countries should base their review on the available local, regional or international information. As additional scientific information on the effects of the guidelines becomes available, further consideration might be needed for changes or adjustments to FBDG. Also, in the review process leading to these guidelines, a wealth of food, nutrient and health information should be reviewed and synthesized, and this may lead to additional recommendations to policy-makers and technical experts which will supplement the FBDG.
In developing guidelines, countries may wish to set high goals such as a greatly improved food supply, and a healthy and well-nourished total population. FBDG are an important part of achieving these goals, but the guidelines should be practical, dynamic, flexible, and based on the existing situation and what can be achieved in the short-to-medium-term towards reaching long-term goals. The guidelines will be an important part of a country's overall plans to reach these goals, especially national plans of action to improve nutrition which countries have or are preparing in response to the World Declaration and Plan of Action for Nutrition, and other major agriculture, health and education policies and plans.
The consultation recommended that to prepare FBDG an interdisciplinary working group would be needed. In order to begin the process, policy-makers such as the ministers of agriculture and health should be made aware of the beneficial uses of dietary advice with regard to food supply planning, better health status, reduced health care costs, and improved work, growth and learning capacity for different population groups.
Groups of concerned individuals, and others working in the areas of health, agriculture, education and communication, need to take actions to increase awareness of the importance of developing and implementing FBDG so that government policy-makers will appreciate the value of this work as a part of overall nutrition improvement activities. Appropriate briefing papers, seminars and information to the public using various communication channels may all be helpful in encouraging the formation of a national working group to prepare FBDG.
In countries with agencies concerned with policies affecting food and nutrition, there may already be dietary guidelines, largely expressed in the technical terms of nutritional science. Such recommendations, e.g. "no more than 10% of energy as saturated fatty acids (12:0 to 16:0)" tend to be meaningless or confusing to the majority of people who have not made a special study of nutritional biochemistry and who do not have their own set of food tables. In order to make dietary guidelines more practical and better understood and increase their impact on food habits, they need to be translated from nutrient-based dietary guidelines into FBDG.
The process may be initiated due to criticisms that current nutrient-based dietary guidelines are impractical and ineffective. Such concerns may be expressed by consumer groups, journalists, sociologists or any people concerned with nutrition education, who may persuade the most concerned government ministries (e.g. health, education and agriculture) to set up a working group to develop FBDG. Realization of the need for dietary guidelines may originate in the health sector (e.g. ministry of health) because of the drain on resources of increasing morbidity from NCD, some of which are diet-related.
Countries with limited resources, and where there are few professional nutritionists, may not yet have dietary guidelines. In such cases the guidelines that would be particularly helpful will take into account both traditional food habits and changing practices where imported and newly produced foods have become common.
Some guidelines may already be part of national policies, aimed at improving nutrition, some of which are supported by outside funding from FAO, UNICEF and/or WHO, e.g. national plans of action for nutrition, iodine deficiency disorders (IDD) control and breast-feeding programmes. Governments in general have looked kindly on dietary guidelines because they are not costly to prepare, do not require imported machinery or expensive staff, and aim to reduce expenditure on NCD.
Someone, inside or outside government agencies, has to start the process, generate some enthusiasm among a few other key players and press the appropriate ministry to set up a working group. The food sector has usually accepted and even welcomed dietary guidelines because they reduce confusion about nutritional goals and help with forward planning.
Some countries may seek technical help to develop guidelines by asking FAO or WHO to provide a temporary advisor with appropriate experience to assist in the work. When neighbouring or similar countries have already produced dietary guidelines, these can be utilized and adapted to form part of the basis of the new guidelines. However, in using guidelines from other countries it is important that they be modified for suitability, acceptability, compatibility and to fit the disease problems, and food preferences and availability of each country.
In all countries, developed or developing, when the decision is taken to form a national working group it is important to ensure representation of all major groups, including senior representatives from the ministries of agriculture, health and education and from the nutritional science and food science sectors of academia, consumer groups and other pertinent nongovernmental organizations, and the food industry. Having broad representation on the working group is important to ensure that all points of view will be considered, and to provide communications with, and feedback from, all concerned sectors. FBDG should be based on the realities in each country and on what can be achieved over time. Obtaining the information needed, whether scientific, sociological, technical or trade-related, can only be done using a broad approach.
When the working group is formed it will have to organize and carry out a wide variety of work which will lead to FBDG. The box below illustrates the tasks to be performed, and the following sections of this chapter give more detail about this work.
SUGGESTED STEPS FOR DEVELOPING FBDG
1. Working group should be formed including representatives of agriculture, health, food science, nutritional science, consumers, food industry, communications and anthropology.
2. Appropriate technical focal points provide material on nutrition-related diseases and on food availability and food intake patterns in the country. Members of the working group are invited to suggest nutritional objectives.
3. Working group identifies, through full discussion, a set of major nutrition-related health problems for which dietary guidelines could tee useful. Working group also evaluates the general food production and supply situation by considering current practices, subsidies and other governmental policies and problems, to see if FBDG can be implemented under the present situation.
4. Set of draft "food-based guidelines" formulated.
5. Background/back-up statements for each "food-based guidelines" are prepared, and each statement is circulated to all working group members.
6. Working group or committee meets again and each background statement is critically reviewed and revised. Wording of guideline statements is pilot-tested with consumer groups) revised as needed and carefully checked.
7. Background statements are finalized, synthesized and sent to interest groups in the country for comment (possibly also to international advisers for comment).
8. Working group meets again to consider changes in view of the comments received.
9. Working group secretary puts together draft of final report; working group concludes draft, adopts, publishes and disseminates final report and implementation begins.
The issues which should be considered in the process of developing FBDG are presented in this section. The steps and actions presented are not itemized in order of priority, thereby allowing flexibility for adaptation by individual countries. Some activities described in each step could run simultaneously. The guideline development working group should coordinate all the following steps. The working group should consult as extensively as possible in order to ensure a successful outcome.
1. Review diet-related health patterns/diseases/mortality
Which conditions are causing concern!
Are these conditions related to diet and nutrition! (see Annex 3 for details)
1.1 Identify the nutrition problems of public health significance, e.g. overnutrition, undernutrition.
Use information on anthropometry and biochemical indicators, where available.
1.2 Estimate the magnitude and severity of these problems. Look at morbidity and mortality rates as well as costs and trends.
1.3 Distinguish age-groups and specific population groups which are affected by the different problems.
1.4 Try to conclude likelihood, magnitude, severity, order of priority, cost-benefits of diet-related diseases in order to initiate priority listing.
Descriptions of most of the health indicators, their use and cut-off points as well as their global distribution can be found in the following WHO documents and publications:
Reports of the Health for All Monitoring and Evaluation system (1)
Physical Status: the Use and Interpretation of Anthropometry (2)
Maternal Anthropometry and Pregnancy Outcomes (3)
The Global Database on Child Growth (4)
The Worldwide Magnitude of Protein-Energy Malnutrition: an Overview from the WHO Global Database on Child Growth (5)
Treatment of Severe Protein-Energy Malnutrition (6)
Protein-Energy Malnutrition: WHO/UNICEF Policy Paper (7)
Management of Nutrition Emergencies in Large Populations (8)
Physical Status: the Use and interpretation of Anthropometry in Adolescence (9)
Issues in the Assessment of Nutritional Status Using Anthropometry (10)
An Evaluation of Infant Growth (11)
A Field Guide for Rapid Assessment of Nutritional Status in Emergencies (12)
Global data base on breast-feeding (13)
Indicators for assessing IDD and their control through salt iodization (14)
Indicators and strategies for iron deficiency and anaemia programmes (15)
Indicators for assessing vitamin A deficiency and their application in monitoring and evaluating intervention programmes (16)
MONICA - manual (17)
Prevention of Diabetes Mellitus (18)
National Cancer Control Programmes - Policies and Managerial Guidelines (1 9)
Other sources of diet-related health data include:
Local health statistics data (mortality and morbidity), Nutrition surveillance data.
National Plan of Action on Child Development, National Plan of Action for Nutrition.
Special studies by universities, research organizations, government agencies, food manufacturers, etc.
2. Review food consumption patterns
2.1 Examine food intake patterns including changes or trends over time. If information on food consumption patterns is not available:
Is there need for a food/nutrition data collection or survey?
If so, what method should be used (see Chapter 3 for details on methodology).
Other information that might be used would be food balance sheets, household expenditure surveys, etc. (see Chapter 3 for details on methods of data collection and use of such information).
2.2 Distinguish food intake patterns for population subgroups, e.g. infants, young children, pregnant/lactating women, the elderly, ethnic groups, etc.
2.3 Identify food preferences and other factors influencing food consumption patterns, e.g. culture, tradition, religious prohibitions, taboos, etc.
2.4 Identify desirable traditional or other current food patterns and practices that could be reinforced
2.5 Assess food availability throughout the country, taking into account:
household food production
overall production/availability - how much is used for people (versus animals)
Sources of local food data include the following:
FAO national food balance sheet
FAO Nutrition country profiles (104 countries)
National Household Expenditure surveys.
Additional sources of useful data include the country reports from the International Conference on Nutrition (ICN) and various multi-country risk factor studies, such as INTERHEALTH (20), INTERSALT (21) etc.
3. Draw conclusions on likely magnitude of linkages between diet and health/disease; verify the degree to which the problem is diet-related.
3.1 Evaluate nutrient and/or food intakes in comparison to available reference values (see Annex 3).
3.2 Note dietary deficits, excesses, imbalances and interactions, etc. in defined groups.
3.3 Evaluate nutrient and/or food intakes in comparison to established food-nutrientdisease relationships (see Annex 3).
3.4 Identify priority diet-related diseases to be addressed, taking into account internal and/or external concerns, e.g. hypertension might be a priority concern in the country (internal concern), while donor funds might be available for IDD programmes (external concern).
3.5 Determine desirable and attainable nutrient intake levels.
3.6 Decide on methodology for converting nutrient guidelines to "food-based guidelines. (see Chapter 2).
4. Take account of national and population frameworks which affect the occurrence and prevention of problems.
FBDG should be consistent with relevant national policies for improved food supplies and nutrition.
4.1 Health policies and priorities.
Health policies affect nutrition through their influence on the sociocultural and physical environment and the demographic situation. An important aspect of health policy is the need to reduce the disparities in health and nutritional status and the inequities in access to health and nutrition services. The vulnerable population groups, such as urban slum dwellers, childbearing women, refugees, displaced persons, etc., are particularly at risk of malnutrition, and directing health policies and programmes to meet their needs could significantly protect and promote their nutritional well-being.
4.2 Agriculture policies and sustainable production.
Agricultural policies have an impact on nutrition, the level and stability of food production, and frequently the income of nutritionally at-risk households, food prices, women's labour demands and time allocation, and the nutrient content of foods. Increasing the production of traditional food crops, such as roots and tubers, pulses and legumes by small producers would directly improve food supplies for nutritionally vulnerable groups.
4.3 Environmental realities and food safety concerns.
Nutritional well-being ultimately depends on society's capacity to manage the interaction between human activities and the physical and biological environment in ways that safeguard and promote health and do not threaten the integrity of natural systems. The physical environment has a major influence on human health not only through soil, water, air and climate, but also through its interaction with the biological environment.
4.4 Education and social policies including welfare.
Education policies play a key role in promoting healthy diets and lifestyles. While the content and emphasis of educational messages vary according to lifestyle, culture and access to natural or processed foods, the goal of nutrition education is the same: to preserve health-enhancing dietary behaviours contributing to good health. In addition, social policies such as housing have an effect on health and nutrition where inadequate shelter, poor ventilation, lack of facilities for solid-waste disposal, air and noise pollution and over-crowding have negative consequences for any health and nutrition situation.
4.5 Development, women's development and population policies.
The implications of population policies on nutrition are significant, particularly in food-deficit countries where rapid population growth and urbanization continue. As with environmental issues, addressing population concerns is fundamental to improving nutrition. In addition, considering the relatively poor state of maternal health and the important role women play in family welfare and often in food production, strong policies in favour of maternal health services, including family planning, are important.
4.6 Other policies related to food supplies and nutrition.
Macroeconomic policies, for example relating to exchange rates, wages, prices and foreign trade, are an interesting example of how the nutritional status of different population groups may be affected. Macroeconomic policies can adversely affect nutrition if they discriminate against the food and agriculture sector and rural areas, and against the poor and vulnerable groups, or if they curtail social services, such as health, education, targeted food subsidies, etc., for example in developing countries undergoing structural adjustment.
4.7 Adverse effects (consider how the change in food pattern being advocated will affect the total diet).
5. Determine which health condition (good or bad), disease pattern, nutrient deficiency or excess or imbalance, dietary practice, food supply and marketing practice, etc. warrants the necessity of FBDG to change food consumption behaviour, and determine which food groups are of primary interest (see Chapter 3 for details on-how to convert from nutrients to food).
5.1 Consultation with all interested parties on priority list developed after steps 1-4 above and modify as needed.
6. Define content and target groups for the FBDG
QUESTIONS TO BE CONSIDERED IN DEVELOPING FBDG
1. Is a single set of dietary guidelines needed or are multiple sets required, e.g. for urban and rural populations?
2. Are these guidelines to include children, infants and other vulnerable groups?
3. Are the guidelines compatible with the potential for the food supply (agricultural production, fisheries potential, minimizing imports) ?
4. Are the guidelines environmentally sustainable?
5. Should the guidelines be written in different languages used in the country?
6. How many food groups are needed. How will they be named?
7. Should branded, packaged foods be included in our food groups?
8. How should different cuisines and religious food laws be accommodated?
9. How should the wide range of nutrients between individual foods in food groups be accommodated?
10. How can we allow for the wide range of energy requirements between different subgroups and individuals?
11. How can we express recommendations on specific food components e.g. protein, fats, fibres, salt and sugars in the food groups?
12. Should we include water and other drinks in the dietary guidelines?
13. Should dietary guidelines address issues of food and water safety and sanitation, including safety of complementary foods for young children?
14. Should the dietary guidelines address weight, exercise and other lifestyle factors?
7. Define the purpose/goals/targets of guidelines
When drawing up guidelines, consider the following:
7.1 The target groups selected and the broad strategy adopted may have a major influence on the form and content of the guidelines as well as the mode of dissemination.
7.2 The context in which the dietary guidelines are going to be used. They are part of general advice about health which include statements that relate to other lifestyle factors, such as exercise, smoking, etc.
7.3 Include a statement such as: "These guidelines provide advice to the general healthy population about food choices, so that their usual diet contributes to a healthy lifestyle, and is consistent with reduced risk for development of diet-related diseases".
7.4 Guidelines should address the total diet and not just individual foods or the foundation, or core diet, only.
7.5 Identify to which groups the guidelines apply (usually adults, but specific guidelines may be targeted to other special groups, such as infants and young children).
7.6 Emphasize that the guidelines are to be used as a complete set and no one guideline is to be used in isolation.
7.7 It is optional how guidelines are ordered, but be sure that the order is clear and country-specific. Priority may differ between different subgroups and may change with time.
7.8 See that FBDG are consistent with nutritional reference values (see Annex 3).
1. Draft guidelines
1.1 Select drafting group (see above concerning working group or committee formation).
1.2 Allocate responsibility for preparing a statement on the rationale and justification for each guideline.
1.3 Circulate draft to relevant groups including:
health sector professionals
agriculture sector professionals
1.4 Review guidelines, taking into account feedback from all interested parties. This review process can include seminars, meetings, etc.
2. Formative evaluation of the guideline
Formative evaluation for wording of dietary guideline statements, etc. to ensure that the wording, content, etc. are appropriate for the general public. Ideally this requires the services of a nutrition educator and/or communication expert (see Section 4.4 Implementation).
3. Publishing and implementation of the guideline (see section 4.4 Implementation).
Dietary guidelines have become an almost universal tool in food and nutrition policy development and nutrition education. Merely having a set of dietary guidelines, however, will not guarantee an effective nutrition policy or that the population will follow their advice. Attention should be given to communicating dietary guideline information effectively to the public. In fact, a suggestion might be to produce two dietary guideline documents, one of a more quantitative nature for policy-makers and health professionals and another more qualitative in nature for the general public. It is difficult for one dietary guideline document to serve two independent purposes well, i.e. public policy and nutrition education.
The purpose of this section is to describe the important factors to consider in the process of implementing a dietary guideline for the general public. Some of the major issues in this process are summarized in the accompanying box.
As emphasized throughout/his report, the FBDG should be scientifically sound. However, there are a number of other factors that should be considered as well. To make the dietary guidelines meaningful to the general public, they should be short, simple, clear, memorable, culturally appropriate and communicated well in a variety of media. Ideally, they should be multimedia and multisectoral, address all relevant community groups and ages, and complement existing community programmes. Important content issues are listed below.
The dietary guidelines should be practical for the general public to implement or else they will not be used. That is, the recommended foods or food groups should be affordable, widely available, and accessible to most people in the country taking into account geographical variation. In addition, the guidelines should be flexible, that is suitable for people of different ages (youth to old age), energy requirements (sedentary to active), and in some cases physiological states (e.g. pregnancy and lactation).
POINTS TO BE CONSIDERED IN IMPLEMENTING FBDG
1. How to classify and express mixed dishes.
2. How to list and show branded and packaged food products.
3. Which foods to give as examples in pictures.
4. Should the advice be expressed as change from the present consumption or in some absolute way?
5. Should amount be expressed in servings? grams? cups? or "eat most, eat moderately, eat least"?
6. Be sure to have backup definitions for professionals of the words used to express amounts and ratios of food groups.
7. How should food groups be named, e.g. "cereals", "fibre foods", "starchy foods"? It is recommended that generic food names be used and not components/nutrients found in the group.
8. Make sure the artistic expression for any visual material is culturally acceptable.
9. Make sure materials are appropriate for different educational levels (e.g. primary school, educated adults).
10. Decide where to put all foods that are available in the country. Avoid confusion about which group a particular food belongs to.
11. Encourage broad funding support for implementing the official guidelines.
Dietary guidelines will fail if they are not understood by the general public. Reading level of the document and advice should be kept to a 5th or 6th grade level (or 4-5 years of primary education) whenever possible, in industrialized countries. In many other countries, much lower levels of literacy should be assumed or even non-literacy. In addition, the terminology should represent both everyday usage and scientific meaning, which can be problematic. For example, the public may misinterpret words such as "fat" (thinking it is only visible fats in foods or not including oil), or "too much", or "moderation", or "avoid too much" and "eat less of" (22). If the public does not understand the dietary guidelines, they will either dismiss them or misapply the advice due to misconceptions (see table).
Percentage of women and men who held misconception themes in common at interview I
Change amount by switching to oil or margarine
Fat clogs arteries
Saturated fat has more fat and/or calories than unsaturated
Fat is not a nutrient
Saturated fat has more cholesterol than unsaturated
Saturated fat is less efficiently used than unsaturated
Cholesterol is found in fatty foods
Cholesterol is needed in diet
Cholesterol is found in plant foods
Cholesterol is fat or a component of fat
Decrease dietary fat to decrease dietary cholesterol
Fish and chicken are low in cholesterol
Adapted from: Misconceptions about Fats and Cholesterol: Implications for Dietary Guidelines by GW Auld, CL Achterberg, VM Getty and JG Durrwachter. Ecology of Food and Nutrition 33, pp. 15-25, 1994.
If food groups are incorporated into the dietary guidelines, the groupings should make sense to the general public. Many food groups in the past have been organized according to nutritionists' schemes, e.g. energy foods, bodybuilding foods and protective foods (2 3), but the public may not think that some of the foods grouped together "belong" together, such as seaweed and mango or rice and sugar. Therefore, food groupings in dietary guidelines or accompanying educational materials should complement the food classification systems used by the target population.
Similarly, visuals that illustrate the dietary guidelines should be readily understood. Concrete illustrations are preferable to abstract visuals (24). For example, the interlocking hexagons used in the US in several versions of their dietary guideline brochures were not understood or remembered by consumers (25-28). Recently the Food Guide Pyramid (29) has become a popular teaching tool and is better understood by the public.
In summary, comprehension of the guidelines by the public is critical to dietary guideline success. Field-testing of this factor should be a requirement before dietary guideline release.
Dietary guidelines will fail if the public finds them culturally unacceptable. The most important factors influencing acceptability are the current food habits and specific food recommendations or examples incorporated into a set of guidelines (30). For example, guidelines or food group illustrations that promote meat among vegetarian populations will be rejected. Food recommendations that violate religious prohibitions or propose radical changes in current practices will be rejected. Recommendations for small changes and familiar foods will be better accepted. Portion sizes, number of recommended servings, and traditional food preparation techniques should also be considered. In terms of presentation, dialect or language, illustrations (e.g. race or ethnicity of illustrated models) and colour choice (e.g. colours that represent certain political parties or other associations) can also affect the acceptability of a set of recommendations.
The communication channel may also be more culturally acceptable, or less so. Therefore, the choice of who conveys the message (are they credible?) and how they deliver the message (is it readily accessible and accepted?) should also be considered in a cultural context. Variations in educational level and rural versus urban needs may need to be addressed as well. Again, evaluation and revision of dietary guidelines among the intended users are essential to meet cultural acceptability.
Who should be involved in the implementation process?
The food-based dietary guideline working group should recognize the multifactoral nature of the implementation process and should adopt a cooperative partnership with several experts involved in the promotion of better nutrition and health. Communications experts can be called upon to produce the message in an appropriate and appealing form and to devise effective means of conveying it to the general population. Nutritionists should verify the content of the messages to ensure their correctness and validity.
Priority in disseminating the information should be directed to ongoing food distribution, food service and nutritional programmes. Such programmes may be sponsored or supervised by nongovernmental organizations, by the public sector or by private enterprises. Nevertheless, such programmes should be encouraged to incorporate the proposed guidelines and to spearhead their immediate and practical application.
The working group should also seek the participation of educators, health professionals, social workers, extension agents, nurses and others in disseminating the information to the masses of the people. Nutrition or health oriented associations may also be requested to participate.
Key persons and trainers concerned with the dissemination process should be encouraged to acquire the background information necessary for interpreting the messages. Workshops and seminars can be designed to sensitize and educate those key persons to fully comprehend the broad concepts and specific messages presented by the guidelines.
Process of translating dietary guidelines into messages/slogans
This section describes how to translate the draft of dietary guidelines into a list that is functional for the public. Brochures, posters and 10-, 30-, and 60-second "sound-bites" for radio and television can also be produced. It should be understood that this process involves many revisions of the dietary guideline statements.
Are multiple versions needed?
In general, countries are encouraged to limit the number of dietary guideline sets to one or as few as possible. Multiple sets may increase public confusion and communication efforts will be more complicated and costly. However, in some countries, there may be distinct populations with such different food beliefs, food patterns and health outcomes that multiple sets are needed. Other countries might consider separate guides for infants and young children or for pregnant and lactating women. If a country does not have any guidelines, it is suggested that only one set be developed at first. Any additional sets that are needed can be added a later time.
Testing dietary guidelines
Taking careful account of the scientific content, practicality, simplicity and cultural acceptability, food-based dietary guidelines can then be drafted. It has been suggested that the working memory deals successfully with no more than 7(±2) concepts (31). Therefore, a maximum of seven messages should be given in a single dietary guideline for practical learning and implementation purposes.
Then pilot test this draft. First, validity or credibility should be checked with nutritionists as well as representative users, for example, school teachers, community leaders and the general public. They can be merely asked to read the set and use a checklist to rate credibility, meaning, affordability, acceptability, etc. The guideline set can be revised accordingly. The mock-ups of the set can be made for proposed distribution to the public (for example in the form of a brochure or poster). Artists and communication experts need to work in concert with nutrition experts to ensure this version is accurate es well as appealing. In other words, the goal for this set is to draw the public's attention to the guidelines and effectively communicate their content.
These can then be tested with members of the general public, using focus groups to determine the appropriateness and cultural acceptability of the content and the visual presentation. Focus groups should be conducted with 815 people per group and enough groups conducted to yield a fair representation of the variability of the population by region, religion and/ or education. This procedure does not require scientific sampling. Rather, three focus groups per region may be sufficient. See Andrien for further "how-to" information (32,33).
The next step is to conduct a more in-depth evaluation of consumers' understanding of the guidelines. Brochures, posters, or sound-bites can be given to representative individuals to read or listen to (as appropriate). Then an individual interview should be conducted to ascertain how that individual interprets the words and advice given in the guidelines (see next page). Consumers can also be asked how they would apply this advice in their own lives. Between 10-20 interviews should be conducted with each special audience group (32,33). The interviews need to be transcribed (by hand, if necessary) for analysis. Analysis procedures are qualitative and should focus on the identification of misconceptions that are common across the data set. Unique, singular misconceptions cannot be dealt with. The materials should again be revised based on this input. This step may need to be repeated several times to ensure the revisions are properly understood by the target audience(s).
Finally, content validity should be rechecked by context experts to ensure that the final statements are still consistent with the science behind their development.
These materials, products and messages may then be promoted and broadcast throughout the country in a variety of settings including the educational system, private organizations, health care systems, etc. These products can also be given to school educators to develop programmatic materials and curricula based on the dietary guidelines.
Translation of guidelines into educational materials
Educational materials and programmes can be developed to support the dietary guidelines and documents published in each country. The purpose of these materials is to further explain and elaborate the content, application and implications of the guidelines in people's everyday lives. For example, instructional materials can address, in detail, issues such as serving size, traditional foods, and packaged and branded versus home-produced foods. Food fortification, designer and functional foods; hard-to-place foods including mixed dishes; imported foods; and different cuisines, languages and dialects, as well as how to adapt the advice to different ages, physiological needs and special audiences, can be addressed as well (see Annex 5). For example, a single set of dietary guidelines could be translated into a variety of languages, and food lists and illustrations made to match each cuisine to each language. Relevant discussion about food preparation techniques could also included.
In translating FBDG messages into educational materials, all concerned stakeholders should be involved. Industry representatives, religious and community leaders, dietitians, health care workers, consumer representatives, teachers, extension workers and other educators should be encouraged to develop and/or implement educational materials and programmes. Partnerships among these groups should be promoted to maximize the reach of the programmes and quality of the materials.
A multi-media approach to education is encouraged. When the same message is communicated and reinforced by a variety of media, and by spokespersons in a variety of settings, the impact is likely to be greater. Therefore, the educational packages should ideally include poster and print materials, other visuals and hands-on activities that individuals can either perform alone (e.g. a shelf inventory of home food supplies) or in a group setting. In either case, people will learn best if they have the opportunity to practice the application, preferably with supervision and feedback on their performance. Lesson plans should be included for group settings. If a regional or national mass media campaign is being conducted, the educational materials and media should of course be coordinated with it. For example, a dietary guideline curriculum and learning activities should already be in place and taught in local schools when a national radio campaign begins.
The more time given to nutrition education, the more people will learn. Dramatic increases in learning and application can be noted when cumulative instruction increases from 15 minutes to 2 hours to 15 hours per year. However, learning will be maximized in any one session in 20 minutes, especially with youngsters. Educational sessions should not last beyond 60 minutes for any audience, because attention will be lost and learning efficiency and effectiveness will decline. It is worth noting too that many secondary teachers are reluctant to add nutrition to the curriculum because of time constraints, which may be overcome with better curricula (see below).
A curriculum is a planned, sequential set of lessons, where each lesson ideally builds on the knowledge given in the previous lesson. Nutrition education in the past has often erred because it is repetitive. For example, in the USA children are often taught the basic food groups in the first, third, fifth, eighth and twelfth years of school (aged about 6, 8, 10, 13 and 17 years). By their exposure, they are bored by the instruction and pay no attention. Rather, the approach should be to order all the relevant concepts from simple to complex and teach them sequentially, matching the level taught to the students' understanding (whatever their age). For example, third-year students may be able to learn only a set of food group names and some of the foods in each. Fifth-year students may learn the number of recommended servings and serving size. Older students may be able to learn something about the nutrients in each food group and thereby learn the rationale for the groups, but only if they have already mastered the simpler information.
Most educational programmes require teacher training or "train-the-trainer" preparatory programmes to ensure proper implementation and instruction. These should be planned for in the material development phase as well.
The effectiveness of mass media and message campaigns as well as educational programmes needs to be evaluated to determine reach, frequency and impact. Two major types of evaluation are discussed.
The purpose of process evaluation is to assess how a message or programme was disseminated or implemented in the field. This information puts the results of outcome evaluation into context and informs project managers and policy-makers why a programme does or does not work. These results can then be used to modify or adjust the campaign to improve outcomes. It poses questions such as how many messages were broadcast, how often, at what time, to whom and by whom. It may also assess message acceptability and credibility to the target audience. For educational programmes, process evaluations typically ask how many lessons were taught, in what order, to whom, who taught the lessons and how much time was spent on each. The most important question in any process evaluation is "whether the communication campaign or educational programme was implemented as it was designed and intended".
Process evaluations are generally conducted by survey (personal interview, telephone or mail survey) at one or more points during the implementation phase. Focus groups can also be used. Sample sizes are relatively small but it is important to try to sample a full range of responses, e.g. in each participating region. If conducted early in the campaign or programme the results can be used to make adjustments. If conducted late in a campaign or programme, the results can be used in designing the next effort.
The purpose of an outcome evaluation is to assess the results or impact of the campaign or programme at its completion. In terms of communications campaigns it is usual to measure awareness, knowledge change, attitude change and, if appropriate, behaviour or practice. Sample sizes should be enough to detect statistical changes. Behaviour should not be the only outcome measure, especially if the change in behaviour sought is large relative to the effort made in the campaign. For example, it may be unrealistic to expect women to change breast-feeding practices on the basis of one radio message per day, but realistic for one message per day to increase awareness and discussion of the issue within a community.
Evaluation methodologies rely primarily on surveys. Open-ended questions have the advantage of capturing answers in the respondent's own vocabulary, but the data may be more difficult to analyse. Close-ended questions (e.g. multiple-choice, yes/no, questions) are easier to analyse, but their validity may be questioned. It is beyond the scope of this report to describe how to construct such surveys, but some expertise is required to produce quality results. Therefore, training or consultation in this area is highly recommended if the expertise is not already available.
Other methodologies should not be overlooked. Focus groups as described earlier may also be used. In addition, changes in household food production, commercial production, consumption trends, and dietary intake can also be monitored and evaluated to determine programme impact (see Chapter 4 for more elaborate description of these methodologies).
Health outcomes including biochemical indicators may be appropriate to assess some dietary guideline programmes in some circumstances (see section 1.4 in this chapter).
Overall, the final results should be interpreted in context. That is, the dietary guidelines are but a piece of the puzzle in achieving more positive diet, health and production practices.
Part 1: General nutrition/health: overall reaction to guidelines
1.1 Do you consider yourself healthy now!
What does it mean to you to be healthy?
What do you do to keep yourself healthy?
Does what you eat have anything to do with being healthy? In what ways?
Probe for: excess/deficiency; preventive/therapeutic; short/long-term effects.
Part II: Responses to individual guidelines
2.1 How do you define variety?
2.2 How do you know if there is variety in your diet?
2.3 Are there any negative consequences if you don't?
If yes, what are they?
Now I want to ask for your reaction to four different terms related to weight.
3.1 First, what is meant by desirable weight?
How is that different from ideal weight?
What about reasonable weight?
And finally, what about healthy weight?
Which term do you find most meaningful? Why!
3.2 If people do not maintain their desirable/ideal/reasonable/healthy weight, what might happen in terms of their health!
NOTE: For 3.2, 3.3 and 3.4, use the term the respondent identified above as the most meaningful.
3.3 How do you know what you should weigh?
4.1 What does the statement "Avoid too much fat, saturated fat, and cholesterol" mean to you?
4.2 Are there any differences in your mind between fat, saturated fat and cholesterol?
If yes, what are the differences?
In what ways are they the same?
4.3 How much fat (dietary) is too much?
What about saturated fat?
What about cholesterol?
If respondent has no answer, ask for an opinion, or what he/she thinks.
[NOTE: From questions 4.3 on, separate these questions if the respondent made a distinction between the three. If not, leave them "lumped" together.]
4.4 How would you know if you were consuming too much fat/saturated fat/ cholesterol?
4.5 How would you decrease the amount of fat/saturated fat/cholesterol in your diet?
4.6 What could happen to a person's health if too much fat/saturated fat/ cholesterol were not avoided?
Now we will talk about the guidance concerning starch and fibre.
Let's begin with fibre.
5.1 What do you consider fibre to be?
What are some foods that contain fibre?
5.2 What do you consider an adequate amount of fibre?
How would you know if you were getting an adequate amount?
5.3 Are there any health benefits to eating an adequate amount of fibre? If yes, what are they?
Are there negative consequencies if a person does not consume an adequate amount of fibre? If yes, what are they?
5.4 What do you consider starch to be?
What are some foods that contain starch?
5.5 What do you consider an adequate amount of starch?
How would you know if you were getting an adequate amount?
5.6 Are there any hearth benefits to eating an adequate amount of starch? If yes, what are they?
Are there negative consequences if a person does not consume an adequate amount of starch? If yes, what are they?
5.7 Why do you think these two items were paired together in one recommendation?
6.1 When I say the word "sugar", what comes to mind!
If you were reading a food label, how would you identify sugar?
6.2 How do you know if you are eating too much?
How much is too much?
Adapted from: Evaluation of 'Nutrition and Your Health: Dietary Guidelines for Americans" Part II: A Men's Sample, FNS Contract No. 53-3198-8-024 by CL Achterberg, MA Pugh Ozgun, J McCoy, VM Getty, April, 1991.
1. Review the document Development and Implementation of FBDG on a periodic basis in the light of the experience of agencies who use the document to guide their activities.
2. FAO and WHO should, to the extent possible, assist governments in developing, implementing and monitoring FBDG.
3. FAO and WHO should continue to encourage relevant research and disseminate information on the development and implementation of FBDG to promote cost-effective approaches for improving nutrition and health status.
4. The 1974 FAO/WHO recommended intakes need to be revised and updated. A number of other FAO, WHO or FAO/WHO documents, which provide nutrition recommendations, should also be updated to reflect current scientific evidence. A list of these documents is provided in Chapter 2.
5. FAO is encouraged to assist in further developing, updating and disseminating food composition data for countries and regions.
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