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Nutrition 31 (2015) 908 – 915 Contents lists available at ScienceDirect Nutrition journal homepage:

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Nutrition journal homepage: www.nutritionjrnl.com Review European food-based dietary guidelines: A comparison

Review

European food-based dietary guidelines: A comparison and update

Concetta Montagnese B.Sc., Ph.D. a , b , * , Lidia Santarpia M.D., Ph.D. a , Margherita Buonifacio Dietitian a , Arturo Nardelli Dietitian a , Anna Rita Caldara Senior Dietitian a , Eufemia Silvestri Senior Dietitian a , Franco Contaldo M.D. a , Fabrizio Pasanisi M.D., Ph.D. a

Contaldo M.D. a , Fabrizio Pasanisi M.D., Ph.D. a a Interuniversity Center for Obesity and Eating

a Interuniversity Center for Obesity and Eating Disorders, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy b CEINGE Biotecnologie Avanzate, Naples, Italy

article info

Article history:

Received 6 November 2014 Accepted 9 January 2015

Keywords:

FBDGs Dietary guidelines European countries Healthy diet Noncommunicable diseases

abstract

Objectives: The aim of this study was to review and update information about food-based dietary guidelines (FBDGs) used by European countries. Methods: FBDGs from 34 European countries were collected and their pictorial representations, food groupings, and associated messages of healthy eating and behavior were compared. Results: FBDGs from 34 European countries were collected, representing 64% (34 of 53) of all European countries; 74% (28 of 34) are European Union members. Of these FBDGs, 67% (23 of 34) adopt the pyramid as a food guide illustration, and classify foods into ve or six groups. The main food groups are grains, vegetables, fruits, and vegetables and fruits as a uni ed group. Some dif- ferences include the modality of food classi cation. Despite dietary pattern results from geographic conditions and cultural (ethnic) heritages, most nutritional key points are similar among the different European FBDGs: In particular, the basic message is to consume adequate amounts of grains, vegetables, and fruits with moderate intake of fats, sugars, meats, caloric beverages, and salt. Other healthy behaviors are frequently but not always indicated. Conclusions: FBDGs still seem insuf cient as far as ethnic peculiarities, agreement on how to group foods, and subgroup population nutritional requirements.

2015 Elsevier Inc. All rights reserved.

Introduction

Food and nutrition play a key role in the prevention and treatment of some of the most common chronic non- communicable diseases (NCDs) such as obesity, cardiovascular disease (CVD), diabetes, and some types of cancer. It is well known that these diseases derive, at least in part, from an excessive intake of some nutrients and a shortage of others, in particular of certain micronutrients [1,2] . Consumers often are confused by the information and advice continuously offered by different sources on nutrition and healthy lifestyles and some- times even by the details on food labels about composition in

CM and LS contributed equally to this study. The authors have no con icts of interest to declare. * Corresponding author. Tel.: þ 39 081 373 7887; fax: þ 39 081 373 7808. E-mail address: montagnese@ceinge.unina.it (C. Montagnese).

0899-9007/ 2015 Elsevier Inc. All rights reserved.

nutrients (carbohydrates, fat, protein, vitamins, and minerals). In order to spread simple and understandable nutritional infor- mation, scienti c societies such as the Food and Agricultural Organization (FAO) and the World Health Organization (WHO) have produced and updated food-based dietary guidelines (FBDGs) since 1996 [3 5] . FBDGs were conceived to provide general indications of what a population should eat in terms of foods rather than of nutrients. They are written in an easy-to-understand language with illustrations, and address public health concerns, such as chronic NCDs, by providing a basic framework for use when planning meals or daily menus, to achieve a healthy balanced diet. The aim of this study was to collect all the available national FBDGs from European countries identi ed according to WHO European-Member-States classi cation. The collected FBDGs were compared according to their pictorial representation, message on healthy eating, variety of food grouping (including

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beverages), and eventually the recommended quantities for each food group. Finally, other healthy lifestyle suggestions were considered.

Materials and methods

FBDGs from European countries identi ed according to the WHO European- Member-States classi cation and divided into eight geographic subregions to facilitate comparative analysis were collected ( Appendix A ). Sources of infor- mation were the Internet, the FAO website, embassies, and National Ministries of Health. Countries with < 100 000 inhabitants (WHO website, 2012) were excluded. Data concerned the format of the FBDGs, additional texts such as lea ets, booklets providing further information and advice on the types and quantities to be consumed for each food group, as well as additional tips that also could include uids, alcohol, physical activity, and body weight advice as well as individual healthy behaviors. After collecting data, FBDGs were compared ac- cording to graphic patterns, foods pictured, and food grouping composition. Other speci c integrative recommendations on the type of beverage consumed, salt intake, healthy lifestyle (physical activity), and other healthy behavior items were also considered.

Results

WHO identi es 53 European countries, divided into eight geographic subregions; 28 countries are federated as the Euro- pean Union (EU) for a total population of 904,168,000. Of cial FBDGs, such as any supportive dietary-related information, were requested from the 53 European countries. Andorra, Monaco, and San Marino states were excluded from the analysis due to a population rate < 100 000 inhabitants. We were unable to obtain of cial data from 16 countries, most of which did not belong to the EU ( Appendix A ). Therefore, nal data analysis regarded 34 European countries for a total of 746,440,000 European citizens (83% of the entire European population according to WHO criteria).

Geographic distribution of studied countries

Data from all western, northern, southern and eastern Euro- pean (Slovakia excluded) and Baltic country subregions were collected ( Appendix A ). No subregion data were available for countries of the Central Asian Republics; few data were obtained from southeastern European countries (data available only for Albania, Croatia, and Slovenia) and Commonwealth of Indepen- dent States (only Russian Federation). In conclusion, data on 64% (34 of 53) of European countries food guides were available; for 32 countries, information was exhaustive (as FBDG formats and various supportive information: Web pages, lea ets, and book- lets). For Lithuania, no graphics were obtained, whereas for the Moldavian Republic only a graphical representation was available.

EU countries

Twenty-eight of 34 (82%) European countries recruited in the study were of cial members of the EU. We obtained complete data for 26 of them. We were unable to obtain of cial informa- tion for Cyprus (southern Europe) and Slovakia (central-eastern Europe), the two remaining states members of the EU.

Languages

Sixteen of the 34 countries had data and supportive infor- mation (Web pages, lea ets, and booklets) both in English and in the local language, whereas data were available only in the local language for the remaining 17 countries. Finally, Swiss FBDGs

were available both in the local German language and in Italian, due to the different regional cultural settings.

Food guide illustration shapes

As far as shapes of food guide illustrations ( Table 1 ), most European countries (97%) had a visual aid with exception of Lithuania, which lacked a FBDGs graphical representation. The pyramid was the most frequently (67%) adopted food guide illustration. Foods representing the largest portions of a recommended healthy diet are at the base of the pyramid, whereas foods to be eaten more sparingly are at the top. Germany uses a three-dimensional food pyramid that combines quantitative advice (nutrition circle) with qualitative advice on food consumption in a single model ( Fig. 1 A). The four faces of the pyramid provide a qualitative classi cation of food primarily based on energy density and nutrient content, as well as other nutritional physiological criteria: foods of plant origin, foods of animal origin, dietary fats and oils, and bever- ages. Colors on the left side of the pyramid indicate the nutri- tional value of foods and give advice on the amount to be consumed. The base of the three-dimensional food pyramid is the Deutsche Gesellschaft für Ernährung (DGE; German Nutrition Society) nutrition circle in which the size of each segment is a measure of the quantity of food in the daily plan [6,7] . Plant-based foods, milk, and dairy products occupy a much larger proportion of the circle than other animal-based foods. Fats are reduced to a very small proportion of the whole and water lls the center. Eight of the 33 (24%) countries used a circle as a food guide pictorial representation. The circle is divided into different sec- tions, each representing a food group; the area of the food sec- tion is proportional to the recommended amount. The Swedish circle ( Fig. 1 B), despite emphasis on cereals consumption, is divided in equal sections: Consequently no information on the recommended quantity for each food group is present.

Table 1 Food guide shapes used in European FBDGs

 

Pyramid (n ¼ 22)

Circle (n ¼ 7)

Others * (n ¼ 3)

No food guide graphic (n ¼ 1)

Albania

Denmark

France

Lithuania

Austria

Iceland

Hungary

Belgium

The Netherlands

Turkey

Bulgaria

Norway

Croatia

Portugal

Czech Republic

Sweden

Estonia

United Kingdom

Germany y

Greece

Ireland

Israel

Italy

Latvia

Luxembourg

Malta

Moldovan Republic

Poland

Romania

Russian Federation

Slovenia

Spain

Switzerland

FBDG, food-based dietary guideline * Other food guide forms included the house for Hungary, four-leaf clover for Turkey, and stairs for France.

y Germany is de ned as a three-dimensional pyramid even if it combines circle and pyramid models.

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910 C. Montagnese et al. / Nutrition 31 (2015) 908 – 915 Fig. 1. German, Swedish,

Fig. 1. German, Swedish, Hungarian, French, and Turkish food-based dietary guidelines. (A) Three-dimensional German pyramid; (B) Swedish circle; (C) Hungarian house; (D) French stairs; (E) Turkish four-leaf clover.

Other food guides included a house for Hungary, a four-leaf clover for Turkey, and stairs for France ( Fig. 1 C E, respec- tively). In the Hungarian house, each part represents a food group, with a size proportional to the quantity suggested in the diet. The ground and rst oors are two rectangles with the same area (representing the main food groups consisting in cereals, vegetables, and fruits); the roof is up of two different-sized triangles indicating meat to be consumed more than milk; the chimney depicts foods to eat more sparingly (sugars and fats). In the Turkish four-leaf clover, the upper leaf contains milk and dairy products. As Turkish people consume small quantities of these products, the upper leaf was chosen to emphasize their nutritional importance. The right leaf of the clover contains meat, eggs, and legumes; the bottom right leaf includes vegetables and fruits and the left leaf bread and cereals. In the French stairs, foods to be consumed in higher amounts are at the top, whereas those to be consumed in small quantities are at the bottom. French guidelines also are shown in a table containing recommendations on the amount of each of the six food groups and on salt and uids to be consumed. The table also contains recommendations on physical activity.

Only Bulgaria and Turkey provided a rationale on the form chosen to represent their FBDGs: Bulgaria adopted the pyramid because its shape provides a simple message on the propor- tionality of foods to eat daily. Turkey used the four-leaf clover to symbolize happiness; heart-shaped leaves indicate that eating habits are essential to prevent CVDs.

Additional information

Although FBDG graphical presentations are designed to stand on their own, some additional text is often added. The text can be part of the graphic to indicate the names of the food groups (e.g., United Kingdom plate), or names of the foods within the group (e.g., German 3-D pyramid), or indicate the recommended number of servings (e.g., Irish pyramid). Alternatively, the text can be an attached lea et or a detailed booklet. For 58% of FBDGs, the visual aid is accompanied by a list of diet tips. Some FBDGs also include advice on a varied diet, healthy body mass index (BMI), water or alcoholic beverage intake or emphasize cultural and social messages (e.g., enjoy your meals ; start your day with breakfast ; make mealtime a social time ; enjoy meals with all members of the family ; eat a variety of foods every

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Table 2 Foods represented (%) in the available European FBDG graphics *

Food pictures

%

Fruit Bread Fish Vegetables Milk, yogurt Potatoes Pasta Red meat Rice Fats (butter, others) Eggs Legumes Oils Poultry Sweets and sugars Noncaloric beverages (caf e, tea, water, etc.) Nuts Caloric beverages Breakfast cereals Salad snacks Sausages Canned tuna Alcoholic beverages Sweet snacks Salt

100

100

100

100

97

97

93

90

90

87

87

83

80

77

70

60

48

43

43

37

31

31

10

10

3

FBDG, food-based dietary guideline * Lithuania (no FBDG graphic), Hungary and Italy (no food pictured in FBDG graphic) were excluded from the analysis.

designed with a different color to emphasize the difference in terms of nutrient and energy (and servings) amount. Regarding the frequencies of food pictures represented in the FBDGs ( Table 2 ), fruit, vegetables, sh, and bread were reported in all of the guidelines, whereas alcohol and sweet snacks were represented in only 10% and salt in only 3%. Both manufactured/ packaged and fresh foods were represented in all countries. Most foods were shown as manufactured: yogurt, cheese, butter, sweets, salty snacks, sugared drinks, canned legumes and sh, pasta, rice and breakfast cereals; milk and oil were reported in bottles.

Food grouping

According to the Glossario di Alimentazione e NutrizioneUmana by the Federazione delle Societ a Italiane di Nutrizione, a food group is de ned as a category into which different foods may be placed according to their similar origin of production, similar nutritional properties, similar marketing characteristics, or all three. The largest number of countries classi ed foods into 5 or 6 groups (eight and nine countries, respectively), whereas some countries recommended choosing foods among 7 groups (seven countries), 8 (four countries) or 4 (three countries). Norway proposes 10 food groups and Greece 12. We were unable to obtain any graphic formats or information about food groups for Lithuania. Among the 50 different food groups identi ed, the most frequently represented were grains, vegetables, fruits, vegetables and fruits, protein rich foods, dairy foods, alternate proteins rich foods, fat-rich foods, sugar-rich foods, and bever- ages. Fruits and vegetables are grouped together in 22 FBDGs possibly because of their similar production and relatively close nutritional value, and split in 9 countries; their consumption is always strongly encouraged. The Norway FBDG groups fruits and vegetables with berries, whereas Estonia and Sweden use the de nition fruit and berries, indicating the importance of berry

day ). Twelve of 33 (39%) FBDGs are accompanied by physical activity recommendations. Occasionally, there is advice on food hygiene. Twelve countries (Turkey, Bulgaria, Hungary, Luxembourg, Latvia, Spain, Italy, the Netherlands, Ireland, Slovenia, Russian Federation, and Belgium) contain additional text on food safety (e.g., Foods must be protected against bacterial and chemical contaminations ; Buy your food from reliable sources only ). Moreover, ve of these (Turkey, Slovenia, Russian Federation, Ireland, and Bulgaria) give advice on how to prepare and store foods safely and three of them (Italy, Spain, and the Netherlands) have additional text on how to treat and store different food groups either cooked or raw, and on suggested refrigerator and freezer temperature. Recommendations and advice on healthier cooking methods are present in 13 countries. Eight countries (Slovenia, Russian Federation, Portugal, Albania, Latvia, Ireland, Belgium, Estonia) recommend choosing healthy cooking methods to reduce the amount of added fat (e.g., Steaming, grilling, baking and boiling are healthier than frying ). Five countries (Italy, Spain, Bulgaria, Germany, and Luxembourg) include advice on healthy cooking not only to reduce added fat, but also to preserve natural taste and food quality, and to avoid the formation of harmful substances (e.g., preferably cook food on low heat, if possible for a short time, using small amount of water and fat ). Some FBDGs encourage consumers to check labels on foods. Norway, Sweden, and Denmark use the keyhole as a joint nutrition label for healthier food products. The keyhole is a common label used in these countries to draw attention to healthier foods. It was inspired by the Swedish keyhole estab- lished in 1989 by the Swedish National Food Agency and com- bines a food circle and a pyramid. The keyhole is a food label that identi es the healthiest foods in a food group. Foods labeled with this symbol contain less fat, sugars, and salt and more bers than foods of the same group. With this system, consumers can easily identify healthier foods. The keyhole is optional and food pro- ducers are responsible for ensuring that foods exhibiting the symbol conform to the Danish Veterinary and Food Adminis- trations regulations. Finally, 49% of countries (Iceland, Belgium, Spain, Italy, Romania, Denmark, the Netherlands, Norway, Estonia, Ireland, Turkey, United Kingdom, Bulgaria, Finland, Slovenia, Russian Federation, and Malta) present additional text with information on foods (e.g., margarines, bakery, etc.) containing trans-fatty acids and the risk for CVDs.

Foods pictured in the graphics

Food pictures were designed to be part of the FBDG graphics in most countries. Some countries such as Portugal, Estonia, United Kingdom, Croatia, Latvia, and Sweden provide a wide variety of colored fruit, vegetables, and cereals. On the other hand, the Finnish circle represents a single meal: a plate divided in three parts, with each being a single dish (potatoes, sh, and vegetables). Interestingly, this representation provides quanti- tative information: Half of the meal could provide an equal amount of cereals and proteins and the other half only vegeta- bles. Along with the plate, a glass of milk, a piece of fruit, and a slice of whole bread with butter represent a complete balanced meal. No food pictures were represented in the Italian pyramid and in the Hungarian house only food names for each food group are designed as part of the graphic. Furthermore, for the Italian and Hungarian FBDG graphics, each food group name was

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consumption in these countries. Fats and sugars are reported as a unique food group in 10 FBDGs, whereas in 20 of 30 (67%) countries they are considered as two different food groups. Eighteen of 30 (60%) countries grouped salty snacks with sugar or fats and sugar-rich foods. Milk and dairy products were in a separate food group for 23 FBDGs and grouped with animal proteins in 4 countries (Estonia, Latvia, Israel, and Switzerland). Potatoes are grouped as grains in 15 FBDGs, vegetables in 4 countries (Albania, Switzerland, France, and Luxembourg), root vegetables in Sweden and as a separate group in Greece. Le- gumes are grouped with protein-rich foods in 9 FBDGs, with grains in Albania, Switzerland, France, and Luxembourg, with vegetables and potatoes in Sweden, with vegetables and fruits in Turkey, separately in Portugal and classi ed as an alternative protein source in Greece where they are grouped with olives and nuts. Some countries grouped nuts in the protein group (Estonia, Latvia, Ireland, Bulgaria, Spain, and Malta) due to their valued protein content. Other countries (Switzerland, Estonia, and Israel) place them in the fat and oil group because of their high fat content; others in the fat and sugar group (Albania) or sugar group (Croatia), because of their high energy content; or with legumes and olives (Greece). Additional groups also contributed to mark differences among countries: Spain and Germany include in their FBDGs a sausage and fat beef meat and meat, sausages, sh and eggs group, respectively. Most countries considered the beverage group as a separate group of noncaloric uids. Caloric bever- ages are placed in the sugar group (11 countries) or fats and sugar group (6 countries), whereas Switzerland and Luxembourg group alcoholic beverages with sugar. Italy and Austria are the unique countries that consider alcoholic uids and caloric uids (fruit juices and soft drinks) as separate groups, respectively.

Food groups quantitative recommendations

Twenty-nine of 33 (63%; 26 EU members states), have both an FBDG format and additional text to furnish accessory informa- tion and advice on the type and quantity of foods to be consumed. Recommendations and advice are given as text positioned close to the graphic, either on a simple lea et or on a larger booklet. The Spanish food pyramid suggests daily con- sumption of cereals, potatoes, fruits, vegetables, olive oil, milk, dairy, and protein-rich foods. Occasional consumption is sug- gested for sausage and beef meat, fat, and sugar. The Israel food pyramid advises to vary on a daily basis for high-fat foods, protein-rich foods, fruits and vegetables, and grains and to eat sparingly sweets, snacks, and sweetened drinks. The Irish pyr- amid suggests the use the food pyramid to plan your healthy food choices and indicates the number of daily servings for each food group. Only fried foods are limited to one to two portions per week. United Kingdom, Belgium, Romania, and France recommend a daily serving for main food groups, whereas Belgium suggests a weekly portion only for the protein group. The Greek pyramid recommends daily consumption for cereals, vegetables, fruits, olive oil, milk, and dairy; weekly consumption for sh, poultry, olives, pulses, nuts, potatoes, and eggs; and monthly consumption for red meats. Italian FBDGs report two different pyramids both for daily and weekly servings. Detailed data on serving sizes are available only for 15 countries (45%; Germany, Portugal, Italy, Spain, Hungary, Swe- den, Turkey, Bulgaria, Albania, Latvia, Czech Republic, Austria, Switzerland, Ireland, Belgium); for this reason we cannot compare data on quantitative food recommendations in terms of nutrient intakes.

Beverage recommendations

Beverage recommendations are present in 27 (79%) countries.

A uid group can be included in the graphic format (e.g. a

separate group for water, tea, or coffee) to recommend a daily consumption of uids. Twenty-two countries (79%) recommend

a daily consumption of 1.5 L of water. Spain, Ireland, and

Estonia indicate the daily consumption of 1 L of water. Greece and Israel recommend drinking plenty of water (no quantitative information provided). Nineteen of the 34 countries (56%) recommend moderate consumption of caloric beverages (e.g., soft drinks, drinks with added sugar). Seventeen FBDGs include recommendations on alcohol consumption, some providing quantitative information by sex. Six countries (Romania, Norway, Denmark, Hungary, Greece, and Finland) recommend consuming 1 unit/d for women and 2 units/d for men; three countries (United Kingdom, Italy, and France) recommend consuming 2 units/d for women and 3 units/d for men. Switzerland, Estonia, Malta, L uxembourg, Germany, Spain, Iceland, Turkey, Portugal, and Belgium do not give quantitative information but advise moderate alcohol consumption. Poland guidelines recommend avoiding alcohol. Three countries recommend consuming 20 (Russian Federation) or 10 g (Albania and Slovenia) of alcohol daily. Most countries consider beverages as a separate group of noncaloric uids. Eleven countries place caloric beverages in the sugar group,six countries in the fat and sugar group; Switzerland and L uxembourg group alcoholic beverages with sugar. Italy is the unique country that considers alcoholics as a separate group and Austria is the only country that considers caloric uids (fruit juices and soft drinks) in separate groups.

Salt intake

Recommendations on salt intake are present in 29 (85%) FBDGs: Seven countries recommend a limited or moderate daily salt intake, whereas the other 22 de ne a quantitative information recommending 5 g/d (Latvia, Bulgaria, Czech Republic, Turkey, Norway, Malta, and Portugal) or 6 g/d sodium chloride (Austria, Ireland, Albania, France, United Kingdom, Italy, the Netherlands, Denmark, Slovenia, Russian Federation, Estonia, and Belgium). Finland and Iceland recommended a daily salt intake according to sex: 6 g for women and 7 g for men ( Appendix B ).

Lifestyle, physical activity, and other healthy behaviors

FBDGs include recommendations on lifestyle and other

healthy behaviors, such as maintaining a healthy body weight and preventing obesity (76%); to eat a variety of foods, preferably vegetables rather than animal products (82%); to eat in enjoyable surroundings for a better taste and avor perception of foods (48%); to have a healthy breakfast (52%); to eat at regular in- tervals (breakfast, lunch, dinner, and two minor intermediate meals) or simply to eat at regular times (54%); and to have some breaks or snacks and to consume fresh fruit and vegetables, whole cereal products or low-fat yogurt (33%). Thirty-three FBDGs (99.9%) include physical activity as a part

of the format or as a key topic in the supportive information.

Moderate daily physical activity is needed to maintain body mass

within the recommended range (BMI 20 25 kg/m 2 ) and to reduce the risk for chronic diseases such as CVDs, stroke, and type 2 diabetes.

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Albania, Switzerland, and United Kingdom include recom- mendation to stop smoking.

FBDGs for speci c subgroups of the population

Some FBDGs include dietary guidelines for speci c popula- tion subgroups. Fifteen countries (44%; France, Italy, Norway, Luxembourg, Sweden, Albania, Denmark, Turkey, Estonia, Ireland, Romania, United Kingdom, Spain, the Netherlands, and Iceland) provide advice on improving the nutritional status of pregnant and breast-feeding women. Malta provides advice only for breast-feeding women. Italy and Albania include advice for women in menopause. Speci c recommendations regarding children (59%: Italy, Ireland, United Kingdom, Estonia, the Netherlands, Switzerland, Albania, Norway, Belgium, Croatia, Turkey, Sweden, Romania, Spain, Latvia, Hungary, Iceland, Denmark, Finland, and France), adolescents (50%: Ireland, Ice- land, Italy, Sweden, Croatia, Norway, Switzerland, Romania, United Kingdom, France, Albania, Malta, Belgium, Estonia, Denmark, Latvia, and Finland), and the elderly (47%: Spain, Ice- land, Luxembourg, Italy, Romania, Croatia, Estonia, Albania, Switzerland, Ireland, France, United Kingdom, Malta, Belgium, Denmark, and Latvia) are included. United Kingdom FBDGs include speci c dietary guidelines for Asians: taking a daily 10 mg vitamin D supplement if they rarely get outdoors or are housebound, if they wear clothes that cover all their body when outdoors or eat no meat or oily sh.

Discussion

Governments are struggling with the growing social and economic consequences of an alarming increase in NCDs, in particular obesity and its comorbidities. Public health policies and research focused on strategies to improve nutrition and physical activity are therefore necessary to prevent nutritional excess and/or de cit and inactivity consequences [2,8,9] . After World War II, food-based advice focused on the issue of ensuring adequate intake of both macronutrients (proteins, carbohy- drates, and fats) and micronutrients (vitamins and minerals), often using a system of food grouping [5] , which privileged the consumption of meat and dairy products. However, during the 1970s, dietitians became particularly concerned with the over- consumption of fats, essentially saturated fats, sugar, and the lack of ber in the diet. As a result, advice in developed countries tended to become more nutrient-based, with emphasis on increasing consumption of vegetable foods, thus a higher variety in menu selection. In the European Food Safety Authority (EFSA) Scienti c Report, seven steps for the development of FBDGs were identi ed, the most important being identifying the relationship between diet and health, identifying country-speci c diet-re- lated problems, and identifying food consumption patterns [10] . To reach the public, FBDG messages must be short and clear, easily remembered, largely comprehensible, and culturally acceptable to dietary habits, lifestyle, and so on. In some cases, the de nition of FBDG is not suitable, for example, in the case of advice on foods containing calcium, fat, or proteins; also in these cases, the terms FBDGs were used according to the latest EFSA revision [11] , to simplify the messages in the manuscript. In fact, according to the EFSA, FBDGs should be practical, that is, the foods recommended in it must be affordable, accessible, and varied so that they suit different population groups. Visual ma- terials also must be clear and comprehensible. This does not seem to be the case for the three-dimensional German food pyramid, which blends the two graphical representations: The

German nutrition circle to provide quantitative FBDGs for adults and the three-dimensional food pyramid with four tri- angle sides that illustrate qualitative recommendations for an adequate choice within the major food groups [6,7] . The three-dimensional food pyramid was developed by the DGE as a complement to the DGE nutrition circle. It was intended as a new graphic model for the implementation of nutrition recommen- dations. It is clear that experts struggled to add as many features as possible, obtaining comprehensive but chaotic information not easily intelligible by common people. The German Agency for Consumer Information (AID) published a simpler and easier to understand food pyramid that is frequently used in nutritional education for children [12] . The multidisciplinary approach to FBDG increases the likeli- hood of addressing national health problems, and creates greater awareness and acceptance of guidelines among populations [13 15] . Key strategies for an effective message are to identify speci c nutrient gaps and feasible intakes and to encourage typical food consumption and proper choice ranges. FBDG communication messages should be practical and short, comprehensible, and culturally acceptable to ensure a broad uptake by the public. The latter can be enhanced by means of repeated, targeted communications via diverse media channels. Monitoring changes in food composition, consumption patterns, and public health status will help to evaluate FBDG effectiveness and make appropriate adjustments. Updates are essential to adapt the guidelines to the evolving scienti c knowledge on the relationships between food, nutrition, and health and to change food habits and lifestyles. Today, nearly all European countries have developed FBDGs based on the principle of providing guidance for a healthy balanced diet that will help to prevent CVDs, metabolic diseases, and cancer. FBDGs are more common in western than in eastern European countries, in particular, in Baltic countries, central, southern, and northern European countries. Guidelines collected in this research represent 64% of all European countries (34 of 53); 74% (28) are members of the EU. The Russian Federation, Albania, and Slovakia adopted countrywide integrated NCD intervention dietary guidelines [16] , whereas Finland adopted Nordic Recommendations as their own of cial FBDGs. Three countries (Andorra, Monaco, and San Marino) with < 100,000 inhabitants were excluded from the analysis due to the little representativeness of their population. Unfortunately, only 34 of the remaining 50 countries provided their of cial FBDGs and/or supportive dietary-related informa- tion. In conclusion, data examined derived from 34 European countries, for a total of 746,440,000 European citizens (83% of the entire European population classi ed according to WHO criteria). This study updates the information already collected in a previous review published by EFSA in 2009 [11] . In the present revision, information on 10 more countries (Iceland, Israel, Luxembourg, Malta, Moldavian Republic, Norway, Russian Federation, Romania, Slovenia, and Portugal) was added. Furthermore, data on Albania, Austria, Croatia, Estonia, and Italy, already described in the European Food Information Council (EUFIC) 2009, was updated. Unfortunately, no information for the Former Yugoslav Republics of Macedonia and Serbia were available either in our review or in EUFIC guidelines. Data sour- ces are detailed in Appendix C . The pyramid graphic proved to be one of the most effective and ef cient methods for practical nutritional communication and in particular for conveying messages of moderation, pro- portionality, and variety in food guidelines. Translating nutri- tion advice into a colorful pyramid seems to be an outstanding

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way to illustrate what foods con gure a healthy diet. Instantly, the shape suggests that some foods are good and should be eaten more often, and that others should be eaten only occa- sionally. The layers represent major food groups that contribute to the total diet. On the other hand, some authors previously criticized the pyramid because it gives the impression of being counterintuitive in displaying what is best at the bottom of the pyramid and what is worst at the top [17 20] . Evaluation of the guidelines effectiveness, for example by assessing the impact of the graphical representation and/or messages on people s behavior, is necessary to improve communication strategy. Despite European FBDGs being developed by different experts for each country and for use in different cultures, many similarities exist between them. Common recommendations include eating plenty of fruits, vegetables, and complex car- bohydrates, and choosing foods that are lower in saturated fat, salt, and sugar. Unfortunately, data on serving sizes were available for only 15 countries. For this reason, food group recommendations could not be compared in terms of nutrient intakes: In fact, when information on serving sizes was indi- rectly obtained through speci c calculations, the data was unreliable. The use of food groups, as in food pyramids and circles, en- sures the inclusion of all basic foods and gives positive messages about what to eat as well as some qualifying information to help people to avoid eating too much of certain foods. Foods cate- gories are similar in most countries but there is still poor agreement on how to group foods. Some grouping differences were due to the different emphasis given to food nutritional properties or to local preferences in their consumption, cooking preparation. For example, some countries have a unique pro- tein-rich foods group that combines meat, milk and dairy products, sh, legumes, and nuts; some others categorize these foods in different groups. Potatoes and legumes are not unani- mously grouped, in some cases they are grouped together possibly due to local foods habits. Legumes and nuts are both of vegetable origin and healthy, but their caloric content is remarkable thus, they have to be eaten with moderation. Furthermore, they represent the main source of alternate pro- teins (non-animal protein) that derive from high-calorie food, their consumption should be encouraged, replacing and not integrating animal foods. Finally, to avoid essential amino acid de ciency, diets need to be widely varied. Fat- and sugar-rich foods are considered as a group in 10 FBDGs, whereas in 20 FBDGs they are considered individually. The combination of these two types of foods is justi ed for their high-caloric content and not according to nutrient composition. Manufactured fats and sugars are grouped together because their regular con- sumption is potentially unhealthy for the presence of simple sugars and saturated/hydrogenated fats. In this case, their grouping was made according to their main characteristics and not their nutrient composition. In our opinion, a more accurate distinction between fresh and processed (canned) foods is necessary as these types of foods require the addiction to unhealthy nutrients such as salts and sugars, and other additives. The graphic representation helps to simplify FBDG messages and to better illustrate pro- portions of different foods with similar characteristics to be included in a balanced diet. Graphic formats provide a consumer-friendly framework so that if foods from the main groups are eaten each day, an important rst step is taken to- ward achieving a healthy diet, without speci c nutrient knowledge. One of the earliest ways to group foods was based on their origin, as plant- or animal-based foods, a classi cation

familiar to most people. Most of the graphic in FBDGs further divides animal-based foods into two separate groups: the meat-related group, which includes sh, eggs, pulses, and in some cases improperly also nuts (e.g., Spain and Austria), generally giving relevance to their contribution to iron intake, and the milk and dairy products group, which is particularly important for calcium intake. The inclusion of alternative non- animal foods in these groups is important for vegetarians. Similarly, plant-based foods are usually subdivided into ce- reals (improperly including potatoes, which are root vegetables containing carbohydrates), which provide a fat-free, carbohy- drate-rich source of energy and certain types of bers and fruits and vegetables, important for vitamin C as well as other micronutrients and protective elements. Foods containing sugar, added sugar in particular, featured as a separate group in some schemes but are mostly combined with fats and oils in a fatty and sugary food category that includes confectionery, bakery products, and soft drinks. This group always receives a small proportion of the total daily intake to indicate that these foods should be eaten in smaller amounts than the other groups, which form the basis of a healthy diet. The revised version of Italian pyramid has no pictures to represent foods but different colors address suggested foods. The new colors are appreciated, but we believe that images allow a more immediate and sharper message. Ultimately, recommen- dations are made on drinking enough uids, controlling alcohol intake, body weight, and other aspects of lifestyle, such as getting enough physical activity and eating regular meals. Occasionally, advice on food hygiene and social/relational aspects of eating is also considered. Generally, European FBDGs report only rough suggestions to limit consumption of caloric and alcoholic beverages as well as salty foods and salt intake. It is interesting that the new WHO recommendations suggest decreasing sugar consumption to < 10% of daily caloric intake. The American Heart Association (AHA) also suggests limiting added sugars to < 6 teaspoons (100 kcal/d) for women and 9 teaspoons (150 kcal/d) for men [22] . Additionally, both the WHO and the AHA highlighted that the suggested limits on daily intake also include all hidden sugars added to food by the manufacturers [21,23] . Twenty-ve of 35 countries (Latvia, Switzerland, Turkey, Hungary, Slovenia, Russian Federation, Spain, Belgium, Czech Republic, the Netherlands, Denmark, Romania, Luxembourg, France, Norway, Iceland, Greece, United Kingdom, Ireland, Malta, Bulgaria, Finland, Italy, Estonia, and Portugal) have additional text with information regarding the relationship between the consumption of re ned sugar and sugar-added foods and several diseases. More emphasis should be given to minority ethnic commu- nities; likewise some subgroups of the total population that today represent a clear prevention target such as adolescents, pregnant women, and the geriatric population. This review demonstrates that there is still little agreement in what consti- tutes a healthy diet and in how to group foods across Europe. There is a remarkable dif culty in food classi cation, which varies more according to local food habits and ethnicity than nutritional value; for example, in some areas potatoes, which are root vegetables containing carbohydrates, are grouped as cereals. We do not know the exact reason for this, and we can only speculate that it could depend on its culinary use or on the similar content in carbohydrates for potatoes and grains. To our knowledge, in literature, no differences in healthy indexes have been described according to the different food practices of the populations evaluated.

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Conclusions

Dietary guidelines, like any system designed to provide in- dications of what is or is not healthy, should be regularly revised according to continuous ethnic, social, and cultural modi cations and should represent a relevant, but not unique, effort to improve prevention of chronic NCDs in various populations.

Acknowledgments

The authors acknowledge the Austrian, Danish, Estonian, Finnish, German, Icelandic, Israelite, Lithuanian, Dutch, Lux- embourgish, Maltese, Norwegian, and Swedish embassies for the information received.

Supplementary data

Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.nut.2015.01.002 .

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