Food Based Dietary Guidelines (FBDGs)

By Mark L Wahlqvist, MD and Antigone Kouris-Blazos, PhD

Food based Dietary Guidelines (FBDGs) are new. Although the idea is based on the familiar idea of dietary guidelines, FBDGs depart from them in important ways. Current Dietary Guidelines (DGs) are essentially nutrient-based (fat, alcohol, salt, sugar, calcium, iron), but expressed as food groups. As a result, this may create confusion about the term "Food-Based" since most existing guidelines around the world also mention foods, e.g. eat more vegetables, cereals. However, FBDGs are a more integrated way of describing the human diet, because they go beyond addressing "foods" simply as "food groups": they address food production (agriculture), preparation (cuisine), processing (food industry) and development (novel/functional foods). They address traditional foods and dishes, and most importantly cuisine, making such guidelines more practical and user-friendly at the individual level. To develop a plan for re-orientation from nutrients to foods, a WHO work group met in Cyprus on 2-7 March 1995.³ At this meeting the concept and philosophy behind FBDGs were born and encompassed in the "Cyprus declaration". Conclusions of the "Cyprus declaration" are:

à FBDGs should be developed in cultural contexts, recognizing the social, economic and environmental aspects of foods and eating patterns.

à Public health issues should determine the relevance of DGs, e.g. FBDGs can be culturally specific, relate to particular public health concerns and acknowledge excess, deficiency or a combination of these errors in food intake.

à FBDGs need to reflect food patterns rather than numeric goals,

à FBDGs need to be positive and encourage enjoyment of appropriate dietary intakes.

à Various diets and food patterns can be consistent with good health.

à a broad socio-cultural approach to food and health, with sensitivity to food traditions/beliefs

à major advances in food science which allow an appreciation of food component complexity and its implications for human biology

à scientific studies which show that food patterns (like variety, traditionality and acculturation), and not simply nutrient intakes, are predictive of health outcomes and are amenable to useful change in their own right

à the ability to handle large data bases of food intakes, health outcomes and trends in those variables with time - the new discipline of nutrition information applied to nutritional epidemiology

à and an appreciation of the ecological implications of dietary guidelines.

1. Food pattern: Assessing the health outcomes of adherence to a particular food pattern with a favourable health relationship is one way of evaluating the nutritional soundness of an envisaged DG approach. This is most likely to be a traditional food pattern of people with longevity, low morbidity and low prenatal and infant mortality rates (e.g. Scandinavian, Japanese, Mediterranean), through traditional or through cultural adaptation. Negative effects following changes in dietary patterns also indicate food patterns to be avoided. Tracking health indices in populations in accordance with food intake has so far, been the most valuable evidence on which to base FBDGs.

2. Food Variety Indices: While the value of increased food variety in either ensuring essential nutrient adequacy or decreasing the risk of food toxicity (adverse health factors in food are generally diluted where varied foods are eaten) has been understood for some time, measuring food variety as a predictor of health outcome is a relatively recent approach. Enough evidence is available to justify its inclusion in the methodologies for development of FBDGs as a technique to reduce morbidity and mortality while awaiting further scientific studies on how it operates. To increase food variety, FBDGs can promote healthy traditional foods/dishes from the local cuisine as well as from other cuisines (if available). Similarly, healthy modern, novel and functional foods will be introduced and-promoted.

3. Recommended Nutrient Intakes (RNIs): FBDGs should be structured to enable the population to meet RNIs that are critical for diet related public health problems.

4. Use of nutrient densities in establishing and evaluating FBDGs: Using nutrient densities to evaluate dietary quality involves expressing existing RNI values provided by the diet. The conditions for this model are that if a diet provides for the energy needs of individuals it will also satisfy the RNIs for all essential nutrients. This approach permits the simplification of age and gender RNI figures. If these figures are expressed per 1000 kcal the values differ minimally. Individuals within a family group usually form the basic unit for food consumption. Thus, if there is enough food at the family or household level, all members can consume a diet with the recommended nutrient densities and meet their specific RNIs. The problem of intrafamily food distribution needs to be considered in establishing general FBDGs and those specifically addressing the needs of vulnerable groups.

FBDGs allow the principles of nutrition education to be expressed mostly as foods and culture-specific dishes (qualitative and quantitative) in order to make the guidelines as practical as possible. They are intended for use by individual members of the general public. They can largely avoid technical terms of nutritional science. FBDGs can also take into account the positive and negative nutritional effects which follow changes in dietary patterns (e.g. changes to traditional diets during migration and acculturation to mainstream diet) where there is evidence that some food patterns should be avoided or encouraged. Even though they focus on diet, groups responsible for developing FBDGs are encouraged to integrate these messages with other policies related to health (e.g., smoking, physical activity, alcohol consumption). WHO and FAO have now applied the Food-based Dietary Guidelines framework to the nutritional and health needs of populations in the Western Pacific Region⁴ and in older adults.⁵

The principles of FBDGs:

1. Encourage a variety of low-energy dense foods (at least 20 biologically distinct foods per week drawn from all food groups).

2. Emphasize healthy traditional dishes which are vegetable and legume based and where meat and nuts are used as condiments (i.e. small servings of nutritious but energy dense foods are combined with larger servings of low energy dense foods), Encourage consumption of available protective foods (fish, garlic, onion, cruciferous and leafy vegetables, tomatoes, soy, other pulses, citrus fruits, grapes, berries, olives, herbs, tea - to name a few).

3. Limit traditional dishes/foods heavily preserved/pickled in salt, or breaded and fried.

4. Consume fat that, ideally, should be unrefined from whole foods such as nuts, seeds, beans, olives, fish, lean meat. Limit fatty spreads in cooking or on bread. Minimize or combine foods containing hidden animal fats (fatty meat, full-fat dairy products, some fast/processed food, and hydrogenated plant fats (some fast/processed food, commercial cakes/biscuits).

5. Reserve added liquid fats (oils, coconut products) for cooked meals, vegetables and salads. Liquid plant fats added during cooking or at the table are useful if they encourage the consumption of a variety of low energy dense foods (especially plant foods, fish) by improving the flavour of such dishes (traditional vegetable dishes cooked with coconut milk or extra virgin olive oil). Added oils may also assist in the absorption of fat soluble nutrients and phytochemicals from plant foods. Encourage a variety of liquid plant fats for cooking which have been minimally processed (cold pressed or 'extra virgin').

6. Enjoy food and eating in the company of others, but avoid the regular use of energy dense (nutrient poor) celebratory foods which are high in fat and or sugar.

7. Encourage food industry and fast food chains to produce ready-made meals that minimize or combine liquid plant fats with low energy dense plant foods (frozen vegetarian meals based on pulses, vegetables and extra virgin olive oil) as alternatives to animal-based convenience foods containing animal fats or hydrogenated plant fats. Functional foods produced by the food industry (bread based on whole grains and seeds like soy linseed bread) can also be reflected by FBDGs.

8. Transfer as much as possible of one's food culture and health knowledge and related skills (in food production, choice, preparation, and storage) to one's children and grandchildren and to the broader community. Ensure knowledge is transferred. Teach cooking techniques (as part of survival skills) to all primary and secondary schoolchildren.

The development of culturally sensitive FBDGs, in light of the best scientific evidence, is to be preferred to food-changes driven by studies on single food components and single disease outcomes; the risk-benefit ratio is likely to be much lower in this way. This changing understanding and acknowledgement of people's personal and cultural needs as well as more integrative, and not only reductionist nutrition science, is now reflected in FBDGs. There is, yet, much to be learned and distilled from the pooling of food cultural tradition.

References

1.	FAO/WHO (1992) International Conference on Nutrition, the World Declaration and Plan of Action on Nutrition, Rome.
2.	FAO (1995) Nutrition Education for the Public, FAO Food and Nutrition Paper No 59, Rome.
3.	WHO & FAO (1996) Preparation and use of food-based dietary guidelines. Report of a joint FAO/WHO consultation Nicosia, Cyprus. WHO, Geneva.
4.	Wahlqvist ML, Worsley A, Harvey P, Crotty P, Kouris-Blazos A. (in press) Food-Based Dietary Guidelines for the Western Pacific: the shift from nutrients and food groups to food availability, traditional cuisines and modern foods in relation to emergent chronic non-communicable diseases. WHO, Manila, 1999.
5.	Wahlqvist ML, Kouris-Blazos A, Savige G. (in press) Food Based Dietary Guidelines for Older Adults: healthy ageing and the prevention of chronic non-communicable diseases. In: Nutritional Guidelines for the Elderly. Joint WHO/Tufts University Consultation on Nutrition Guidelines for the Elderly, Boston, USA, 26-29 May 1998.
6.	WHO (1998) Preparation and Use of Food-Based Dietary Guidelines. Report of a Joint FAO/WHO Consultation. WHO technical report series 880. Geneva.

Dr M Wahlqvist was Head of Medicine at Monash University for 12 years and is now Professor of Medicine, Associate Dean and Director of the International Health & Development Unit of the Asia Pacific Health & Nutrition Centre, and the FAO Centre of Excellence in Food Quality, Safety and Nutrition at Monash University. He is Editor-in-Chief of the Asia Pacific Journal of Clinical Nutrition. Dr A Kouris-Blazos is Deputy Director of the International Health and Development Unit and lecturer in human nutrition at Monash University. Contact information: 8^th fl, Menzies Bldg, Monash University, Wellington Rd, Clayton, Melbourne, Victoria 3168, Australia; tel + 61 3 9905 8145; fax + 61 3 9905 8146; email mark.wahlqvist@med.monash.edu.au and antigone.blazos@med.monash.edu.au

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