B.O. SCHNEEMAN
Barbara O. Schneeman is Professor of Nutrition, Department of Nutrition, University of California, Davis CA, United States.1
Food-based dietary guidelines (FBDG) are an integral component of nutrition policy and provide a mechanism to link policies related to food, nutrition and health promotion. As an educational tool for the public, FBDG express nutrition principles in terms of food and dietary patterns that promote health and lower risk for nutrition-related diseases. As a policy tool they provide a means to coordinate nutrition-related programmes as well as to evaluate the adequacy of the food supply in meeting the nutritional needs of the population.
In 1995 FAO and the World Health Organization (WHO) sponsored an Expert Consultation on the Preparation and Use of Food-Based Dietary Guidelines in Cyprus2 (WHO, 1998). This consultation was an outcome of the 1992 International Conference on Nutrition held in Rome by FAO and WHO. Governments were advised about the process for developing FBDG that are relevant to their country's population. The consultation sought to learn from the experiences of various governments and organizations that had developed FBDG and to recommend ways that would help all regions of the world to improve or begin this process. Since then FAO, in conjunction with the International Life Sciences Institute (ILSI), has sponsored workshops in different regions to encourage governments to initiate such a process. In 2000, the processes in Thailand and the Philippines were reviewed to determine the usefulness of the recommendations of the 1995 consultation.
In Thailand, participants in the FBDG process at the Institute of Nutrition at Mahidol University, the Division of Nutrition in the Department of Health, and Ramathibodi Hospital were interviewed. In Manila, interviews were conducted at the Food and Nutrition Research Institute of the Department of Science and Technology, the Department of Health, the FAO office, the University of the Philippines in Los Baños, the National Nutrition Council of the Department of Agriculture and the Nutrition Center of the Philippines. The interviews focused on the process of developing FBDG, on what worked well, what could work better and plans for the future.
Three key principles were identified at the Cyprus workshop:
The experience of both Thailand and the Philippines illustrates how important these key principles are in the process.
In both countries six factors were identified as important and necessary in providing input to the formation of a set of FBDG. These are described below.
To determine the relevant diet-related public health issues, food consumption and public health data gathered within each country were examined. In addition, data from other countries, such as approaches towards developing FBDG or health and food consumption statistics, were reviewed by the working groups. These country data were examined to determine what could be learned from the experience of others, even though guidelines from other regions were not subsequently adopted.
The working groups recognized that there were limitations in the data available, but felt strongly that this was not reason enough to abandon the process. In their view it was important to start somewhere: one outcome of the process would then be to highlight the need for relevant data. They also emphasized the importance of determining what was of greatest relevance to their own country, rather than simply taking advice from other regions that might be questionably relevant to their own circumstances.
Experts in nutrition, public health, education and food science served on the working groups. This expertise ensured that scientific data were reviewed and debated in terms of relevance to each country's current situation and population needs. There was some involvement from the agriculture sector and both Thailand and the Philippines plan follow-up activities that will more fully engage agriculture experts in the implementation of the FBDG.
The working groups recognized the need for research on the messages being developed. They conducted studies with target audiences to assess interpretation of the guidelines during their formation. For example, in Thailand survey research was used to develop a food guide to accompany the guidelines. This guide provides information about appropriate quantities of food or portion sizes. Focus groups were used to determine the most appropriate symbol for the food guide. Studies on nutritional guidelines by the Philippine Information Agency illustrated the importance of expressing nutritional information in terms of foods that are understood by the target audience. For example, the original messages about vegetable oil were not clear to consumers since they did not recognize oil as coming from typical vegetables (such as cabbage or greens). Oil was seen as being for consumption (edible oil) or for engines (motor oil). In both countries data were used to improve the message and better target consumers with useful information.
Data limitations should not be a reason to avoid formulating guidelines... it is important to start somewhere and to highlight the need for more data
The importance of core food-based messages in the guidelines was recognized and provided an opportunity to integrate the guidelines into other health programmes affecting nutrition and health. In Thailand, for example, the message, "Drink milk in appropriate quality and quantity for one's age", is consistent with a programme in schools to provide milk for each child. In the Philippines, the message on breastfeeding recognizes that society as a whole, and not just nursing mothers, needs to ensure that infants can be breastfed. Likewise, messages were included on lifestyle factors such as physical activity, alcohol consumption and smoking that impact overall nutrition and health status. Inclusion of these recommendations meant more integrated messages for target audiences and also ensured that consumers recognized the complexity of issues that affect health and well-being.
The two main public health issues in these regions are undernutrition, including inadequacy of total food intake and micronutrient deficiencies, and an emerging pattern of chronic disease associated with excess intake and/or more sedentary lifestyles. Both working groups made every effort to make sure that the food-based approaches recommended would address each of these concerns. Guidelines relevant to the public health needs of the population were of obvious value and provided motivation to extend their use to many sectors, such as rural health workers, schoolteachers, community educators, hospital nutritionists and food companies that had an impact on nutrition and health.
Both sets of guidelines were personalized. In Thailand a self-evaluation was included, which guided an individual through the key messages, thereby enabling the working group to assess what changes were needed for the guidelines to be followed effectively. This self-evaluation meant that a potential reader examined the guidelines from a different aspect and did not simply read the messages. It also gave health care workers ideas as to how they might probe for practical actions in implementing the guidelines. The Philippine guidelines contained frequently asked questions and an action plan. Both approaches sought to make the guidelines more practical and to stimulate action.
The working groups indicated that the process for development of FBDG was as important as the substance itself and identified five items as key factors discussed in the following sections.
The working groups stated that a Secretariat in a government agency is an essential component for success for several reasons. The Secretariat is a visible commitment of the government to the development of food and nutrition policies based on FBDG. Comments on FBDG from public and private organizations can be submitted through the Secretariat, guaranteeing extensive input and participation in the process. The Secretariat can also gather data and background information as well as identify research needs. This data/information-gathering role ensures that the working group has ready access to information for decision-making. Finally, if the Secretariat is a government agency or interagency governmental unit, it can coordinate the dissemination of the guidelines and their integration into government policy.
It has been stated that the Secretariat is a visible sign of government commitment to the process and outcome of developing FBDG. This commitment needs to continue beyond completion of the experts' work and ensure that the effort be ratified through the appropriate agencies. In Thailand and the Philippines, such endorsement was visible through high-level government officials' participation in the release of the guidelines. In Thailand, the Prime Minister and Minister of Health participated actively in the process. In the Philippines, each agency head signed an endorsement of the nutritional guidelines and the Ministers of Health and of Agriculture participated in the release of the document. In both cases, the involvement of high-level public officials helped bring media attention and hence publicity to the content of the guidelines. The participation of and endorsement by key government officials in the guidelines indicated that they would be integrated into policy development. Besides the governments, lead universities also included the guidelines in their curriculum and extension programmes. Again, because of their involvement in the process, these educational institutions disseminated the guidelines and integrated them into their nutrition programmes.
Interviewees in both countries emphasized the importance of consensus building as a part of the process of developing FBDG. Since the guidelines evolved over a year or more and group members worked together on the interpretation of data and in gathering information, commitment was integrated into the process and its outcome. The comments about consensus building strongly suggested that the mechanism to develop consensus as a part of the process was as important as the guidelines themselves. Without consensus among the relevant agencies it would be difficult to incorporate the guidelines into government policy and programmes. Moreover, the links forged and the spirit of collaboration built up throughout the development process created a positive environment for future action.
Linked to consensus building, the process of developing FBDG is multisectoral, involving several government ministries as well as the academic and private sector, all of which have a certain influence on dietary patterns in each country. As the agencies looked towards the future steps in the process, they recognized the value of this multisectoral approach and realized that an even more extensive network might be needed to achieve successful implementation. The process builds up gradually. At the beginning, the need to be multisectoral and the choice of participants might not be obvious but, as the process advances, the corresponding need for additional partners becomes more evident.
In both Thailand and the Philippines it took more than a year to develop FBDG and each country is engaged in additional projects for the implementation and dissemination of the guidelines. This length of time was essential for building consensus. Although there may be advantages in developing a set of guidelines rapidly with a small well-qualified group, debates over appropriate wording, analysis of data and the gathering of new information build a sense of ownership in the guidelines and focuses their relevance for the target population. The length of time dedicated to the process also provided an opportunity to determine what other health-related polices should be integrated with FBDG. The iterative nature of the process helped to both build consensus and commitment to its outcome, while the inclusion of evaluative stages in the development of FBDG reinforced the concept of assessment and revision according to practical experience as to what worked well and what could work better in communicating with the public. In the working groups, comments were made about the evaluation of the current guidelines with the aim of obtaining new information to improve the recommendations and target them more effectively. The concept of a learning process was reinforced.
Generally, the process and its outcome achieved a high level of satisfaction, particularly in producing a final document that was relevant to the health of each country's population. This motivated adoption of the guidelines in existing public health programmes and stimulated discussions on the new programmes needed. Because of the consensus-building process, the document was seen to be valuable in influencing public policy. It was noted that the food-based approach highlighted the importance of agricultural policies addressing the food needs of the population. Without FBDG, export and related economic policies are the primary incentives for agricultural policies. In most countries, several government agencies are responsible for nutritional questions and although it is challenging to liaise and collaborate with these multiple agencies, the process itself created a platform for coordination and consensus building around the most important public health issues related to nutrition.
Efforts to target at-risk and low-income households are needed to ensure that guidelines are used effectively
The guidelines help to define and support the research agenda in nutrition. Using country-specific data for the process creates a new and important need for data in policy formation. Participants in the process are able to determine what data are essential, new types of data that are needed and, most important, are able to justify the important role of government agencies and/or universities in gathering data that can be used to monitor nutrition and public health issues. The working groups were concerned that the data available were sufficient. However, as noted earlier, lack of data should not be used as a reason to impede the development of FBDG in a country. Recommendations were made to use available data and utilize resources from similar regions. An outcome of the process has been to identify needed improvements in nutrition monitoring data. Because government agencies were involved in the process, all information can be incorporated into future work plans, although it is clear that the mere identification of data needed does not guarantee new government investments in nutrition monitoring. However, the process illustrates the use of such data for sound policy development.
In both Thailand and the Philippines the nutrition expertise in the academic community has developed considerably over the past 20 years. This capacity-building is most evident at the Institute of Nutrition at Mahidol University and at the University of the Philippines, Los Baños, although in both countries capacity-building extends beyond these two institutions. Graduate training programmes as well as working relationships with government agencies are an important means of building overall capacity for addressing nutrition issues and policies. This capacity-building has strengthened the ability of these countries to develop science-based approaches for the development of FBDG.
Different types of educational approches and message development are needed when implementing the food-based dietary guidelines
While the overwhelming response to the development of FBDG was positive, several concerns were raised by the groups interviewed. One main concern, voiced explicitly by the Philippine focus group, was to ensure that the guidelines were relevant for low-income families. Some participants perceived the guidelines to be mainly for the financially secure or wealthy and that the recommendations were too expensive for many at-risk, low-income individuals to follow. While such perceptions may be incorrect, efforts will be needed to target these populations appropriately and to ensure in both countries that all groups are able to use the guidelines effectively to improve nutritional status.
The recognition of the need for different types of educational approaches and message development is being incorporated into the implementation phase of FBDG and future activities. For example, in Thailand a workshop was planned to discuss the guidelines with various sectors, including rural health workers, schoolteachers, community educators, hospital nutritionists and food companies to test and further develop a manual on the use and dissemination of the guidelines. The outcome of this workshop will be development of appropriate strategies for targeting nutrition and health messages to different groups.
A related challenge was how to incorporate FBDG into plans for food security. Nutrition has frequently been integrated into poverty relief and the assumption made that as the economy develops, nutritional status will improve. However, emerging data suggest that improvement in nutritional status is not simply an outcome of poverty relief but the result of programmes designed to improve food security (Bloom and Canning, 2000). Some would even argue that food security is a prerequisite for alleviating poverty in a region, yet nutrition relief programmes have to justify their existence and demonstrate that there will be a return on the investment.
Food-based dietary guidelines for the Thai population
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Food-based dietary guidelines for the Philippine population
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It is a positive step to see the guidelines used by non-government agencies to promote good nutrition and health. However, there is concern about maintaining the integrity of the message. Industry groups or specific interest groups might use only subsets of the guidelines to highlight a message relevant to their own product or agenda. Private, non-governmental organizations have developed their own food guides, often developed from those available in other countries. While positive in terms of promoting the content of the guidelines, they raise the question of whether there will be confusion between the various models and food guides. Some effort is being made to address these concerns. For example, in the Philippines there is a review of proposed uses by non-government groups and, to date, approval has only been given to those groups who publicize all the guidelines with the icons developed by the government. The United States Food Guide Pyramid reinforces the importance of this concern. The United States Department of Agriculture (USDA) developed the pyramid with a set of criteria and a research protocol (Welsh, Davis and Shaw, 1993). Several groups have subsequently made modifications to the pyramid and published various versions (e.g. the Mediterranean, the Asian and the Californian). The criteria for these versions are unlikely to follow those of the USDA food guide yet the discrepancies are not well understood and assumed by some to be a part of the government educational materials because of their similar guise.
While considerable interest exists in evaluation of the process and the impact of the guidelines, additional resources are necessary. Mechanisms for evaluation are important to support the ongoing nature of the process.
In the working groups, concerns were raised about translation of the guidelines into the various dialects used in the country. In the Philippines this issue is especially critical, as well over 50 dialects are used, most of which are unique and distinctive from each other. It is important that the guidelines be in the major dialects for use at the community level and that the validity of the translation is monitored.
The release of the guidelines was planned specifically to achieve considerable high-level support and media coverage. Likewise, communication plans are being developed and there is strong interest in developing relevant, ongoing communication strategies. Although awareness of the messages appears to be high, putting them into practice does not automatically follow. In reviewing the process, there may be a need to focus on using the content of the guidelines to develop messages that promote action. An example from the United States was the development of the "It's all about you" campaign to promote the dietary guidelines. The messages were developed from consumer focus groups and focused on specific actions to help the public follow the guidelines.
In Thailand and the Philippines it was clear that the effort to develop FBDG is positive, engenders a feeling of participants' involvement in the recommendations and builds consensus. Concerns were directed more at the continuation of the collaboration and the recognition that new efforts would be needed for behaviour change. Involving key leaders with knowledge of the process developed in Cyprus helped to foster planning a multisectoral process and began with identification of the most relevant public health issues for each country's population.
Experiences shared between countries in implementing a process are an excellent way to expand and improve upon the recommendations from the Cyprus expert consultation. The experience of Thailand and the Philippines stresses certain principles that are important for success and illustrates that the process can be adapted to meet the needs of a particular region or country. Although Thailand and the Philippines differ in the way that they developed their activities and organization to develop FBDG, there are also common overlapping areas. These are use of country specific data, a multisectoral approach, use of an extensive expertise base, focus on relevance to local groups, identification of the major public health issues, connecting with related public health messages/programmes, engaging in a learning process, and recognition from the government of the need for guidelines and a commitment to coordinate the effort.
references
Bloom, D.E. & Canning, D. 2000. The health and wealth of nations. Science, 287: 1207-1209.
WHO. 1998. Preparation and use of food-based dietary guidelines. WHO Technical Report Series No. 880, Geneva, World Health Organization/FAO.
Working Group on Food-Based Dietary Guideline for Thai. Food-based dietary guideline for Thai. Distributed by the Institute of Nutrition, Mahidol University and the Division of Nutrition, Department of Health, Ministry of Public Health, Thailand.
Department of Science and Technology. 2000. Nutritional guidelines for Filipinos. Revised edition. Distributed by the Food and Nutrition Research Institute, Department of Science and Technology, Manila, the Philippines.
Welsh, S.O., Davis, C. & Shaw, A. 1993. USDA's food guide, background and development. Miscellaneous Publication No. 1514. United States Department of Agriculture. Washington, DC, US Government Printing Office.
1 This article is based on the author's work as an FAO consultant.
2 Editor's note: see Food, Nutrition and Agriculture, No. 19. FAO, 1997.
