european food based dietary guidelines

8/18/2019 European Food Based Dietary Guidelines

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Review

European food-based dietary guidelines: A comparisonand 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

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

a r t i c l e i n f o

Article history:

Received 6 November 2014Accepted 9 January 2015

Keywords:

FBDGsDietary guidelinesEuropean countriesHealthy dietNoncommunicable diseases

a b s t r a c t

Objectives: The aim of this study was to review and update information about food-based dietaryguidelines (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 allEuropean 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 mainfood groups are grains, vegetables, fruits, and vegetables and fruits as a uni ed group. Some dif-ferences include the modality of food classication. Despite dietary pattern results from geographicconditions and cultural (ethnic) heritages, most nutritional key points are similar among thedifferent 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, andsalt. Other healthy behaviors are frequently but not always indicated.Conclusions: FBDGs still seem insuf cient as far as ethnic peculiarities, agreement on how to groupfoods, and subgroup population nutritional requirements.

2015 Elsevier Inc. All rights reserved.

Introduction

Food and nutrition play a key role in the prevention andtreatment of some of the most common chronic non-

communicable diseases (NCDs) such as obesity, cardiovasculardisease (CVD), diabetes, and some types of cancer. It is wellknown that these diseases derive, at least in part, from anexcessive intake of some nutrients and a shortage of others, inparticular of certain micronutrients [1,2]. Consumers often areconfused by the information and advice continuously offered bydifferent sources on nutrition and healthy lifestyles and some-times even by the details on food labels about composition in

nutrients (carbohydrates, fat, protein, vitamins, and minerals). Inorder to spread simple and understandable nutritional infor-mation, scientic societies such as the Food and AgriculturalOrganization (FAO) and the World Health Organization (WHO)

have produced and updated food-based dietary guidelines(FBDGs) since 1996 [3–5]. FBDGs were conceived to providegeneral indications of what a population should eat in termsof foods rather than of nutrients. They are written in aneasy-to-understand language with illustrations, and addresspublic health concerns, such as chronic NCDs, by providing abasic framework for use when planning meals or daily menus, toachieve a healthy balanced diet.

The aim of this study was to collect all the available nationalFBDGs from European countries identied according to WHOEuropean-Member-States classication. The collected FBDGswere compared according to their pictorial representation,message on healthy eating, variety of food grouping (including

CM and LS contributed equally to this study. The authors have no conicts of interest to declare.* Corresponding author. Tel.: þ39 081 373 7887; fax: þ39 081 373 7808.

E-mail address: [email protected] (C. Montagnese).

http://dx.doi.org/10.1016/j.nut.2015.01.0020899-9007/ 2015 Elsevier Inc. All rights reserved.

Contents lists available at ScienceDirect

Nutrition

j o u r n a l h o m e p a g e : w w w . n u t r i t i o n j r n l . c o m

Nutrition 31 (2015) 908–915

mailto:[email protected]://dx.doi.org/10.1016/j.nut.2015.01.002http://www.sciencedirect.com/science/journal/08999007http://www.nutritionjrnl.com/http://dx.doi.org/10.1016/j.nut.2015.01.002http://dx.doi.org/10.1016/j.nut.2015.01.002http://dx.doi.org/10.1016/j.nut.2015.01.002http://dx.doi.org/10.1016/j.nut.2015.01.002http://www.nutritionjrnl.com/http://www.sciencedirect.com/science/journal/08999007http://dx.doi.org/10.1016/j.nut.2015.01.002http://crossmark.crossref.org/dialog/?doi=10.1016/j.nut.2015.01.002&domain=pdfmailto:[email protected]


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beverages), and eventually the recommended quantities for eachfood group. Finally, other healthy lifestyle suggestions wereconsidered.

Materials and methods

FBDGs from European countries identied according to the WHO European-Member-States classication 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


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Other food guides included a house for Hungary, a four-leaf clover for Turkey, and stairs for France (Fig. 1C–E, respec-tively). In the Hungarian house, each part represents a foodgroup, with a size proportional to the quantity suggested inthe diet. The ground and rst oors are two rectangles withthe same area (representing the main food groups consisting

in cereals, vegetables, and fruits); the roof is up of twodifferent-sized triangles indicating meat to be consumed morethan 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 consumesmall quantities of these products, the upper leaf was chosento emphasize their nutritional importance. The right leaf of the clover contains meat, eggs, and legumes; the bottom rightleaf includes vegetables and fruits and the left leaf bread andcereals. In the French stairs, foods to be consumed in higheramounts are at the top, whereas those to be consumed insmall quantities are at the bottom. French guidelines also areshown in a table containing recommendations on the amountof each of the six food groups and on salt and uids to be

consumed. The table also contains recommendations onphysical activity.

Only Bulgaria and Turkey provided a rationale on the formchosen to represent their FBDGs: Bulgaria adopted the pyramidbecause its shape provides a simple message on the propor-tionality of foods to eat daily. Turkey used the four-leaf clover tosymbolize happiness; heart-shaped leaves indicate that eatinghabits are essential to prevent CVDs.

Additional information

Although FBDG graphical presentations are designed to standon their own, some additional text is often added. The text can bepart 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 recommendednumber of servings (e.g., Irish pyramid). Alternatively, the textcan be an attached leaet or a detailed booklet. For 58%of FBDGs,the visual aid is accompanied by a list of diet tips. Some FBDGsalso include advice on a varied diet, healthy body mass index(BMI), water or alcoholic beverage intake or emphasize culturaland social messages (e.g., “enjoy your meals”; “start your day

with breakfast”; “make mealtime a social time”; “enjoy mealswith all members of the family”; “eat a variety of foods every

Fig.1. Germa n, 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.

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day”). Twelve of 33 (39%) FBDGs are accompanied by physicalactivity recommendations. Occasionally, there is advice on foodhygiene.

Twelve countries (Turkey, Bulgaria, Hungary, Luxembourg,Latvia, Spain, Italy, the Netherlands, Ireland, Slovenia, RussianFederation, 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 storefoods safely and three of them (Italy, Spain, and the Netherlands)have additional text on how to treat and store different foodgroups either cooked or raw, and on suggested refrigerator andfreezer temperature.

Recommendations and advice on healthier cooking methodsare present in 13 countries.

Eight countries (Slovenia, Russian Federation, Portugal,Albania, Latvia, Ireland, Belgium, Estonia) recommend choosinghealthy cooking methods to reduce the amount of added fat (e.g.,“Steaming, grilling, baking and boiling are healthier thanfrying”). Five countries (Italy, Spain, Bulgaria, Germany, and

Luxembourg) include advice on healthy cooking not only toreduce added fat, but also to preserve natural taste and foodquality, 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 jointnutrition label for healthier food products. The keyhole is acommon label used in these countries to draw attention tohealthier 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 thatidenties the healthiest foods in a food group. Foods labeled withthis symbol contain less fat, sugars, and salt and morebers thanfoods of the same group. With this system, consumers can easilyidentify healthier foods. The keyhole is optional and food pro-ducers are responsible for ensuring that foods exhibiting thesymbol 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, RussianFederation, and Malta) present additional text with informationon foods (e.g., margarines, bakery, etc.) containing trans-fattyacids and the risk for CVDs.

Foods pictured in the graphics

Food pictures were designed to be part of the FBDG graphicsin most countries. Some countries such as Portugal, Estonia,United Kingdom, Croatia, Latvia, and Sweden provide a widevariety of colored fruit, vegetables, and cereals. On the otherhand, the Finnish circle represents a single meal: a plate dividedin three parts, with each being a single dish (potatoes, sh, andvegetables). Interestingly, this representation provides quanti-tative information: Half of the meal could provide an equalamount of cereals and proteins and the other half only vegeta-bles. Along with the plate, a glass of milk, a piece of fruit, and aslice of whole bread with butter represent a complete balancedmeal. No food pictures were represented in the Italian pyramidand in the Hungarian house only food names for each food group

are designed as part of the graphic. Furthermore, for the Italianand Hungarian FBDG graphics, each food group name was

designed with a different color to emphasize the difference interms of nutrient and energy (and servings) amount.

Regarding the frequencies of food pictures represented in theFBDGs (Table 2), fruit, vegetables, sh, and bread were reportedin all of the guidelines, whereas alcohol and sweet snacks wererepresented 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 inbottles.

Food grouping

According to the Glossario di Alimentazione e NutrizioneUmanaby the Federazione delle Societa Italiane di Nutrizione, a “foodgroup” isdened as a category into which different foods may beplaced according to their similar origin of production, similarnutritional properties, similar marketing characteristics, or allthree.

The largest number of countries classi

ed foods into 5 or 6groups (eight and nine countries, respectively), whereas somecountries recommended choosing foods among 7 groups (sevencountries), 8 (four countries) or 4 (three countries). Norwayproposes 10 food groups and Greece 12. We were unable toobtain any graphic formats or information about food groups forLithuania. Among the 50 different food groups identied, themost frequently represented were grains, vegetables, fruits,vegetables and fruits, protein rich foods, dairy foods, alternateproteins rich foods, fat-rich foods, sugar-rich foods, and bever-ages. Fruits and vegetables are grouped together in 22 FBDGspossibly because of their similar production and relatively closenutritional value, and split in 9 countries; their consumption isalways strongly encouraged. The Norway FBDG groups fruits and

vegetables with berries, whereas Estonia and Sweden use thedenition “fruit and berries,” indicating the importance of berry

Table 2

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

Food pictures %

Fruit 100Bread 100Fish 100Vegetables 100Milk, yogurt 97

Potatoes 97Pasta 93Red meat 90Rice 90Fats (butter, others) 87Eggs 87Legumes 83Oils 80Poultry 77Sweets and sugars 70Noncaloric beverages (caf e, tea, water, etc.) 60Nuts 48Caloric beverages 43Breakfast cereals 43Salad snacks 37Sausages 31Canned tuna 31Alcoholic beverages 10Sweet snacks 10Salt 3

FBDG, food-based dietary guideline* Lithuania (no FBDG graphic), Hungary and Italy (no food pictured in FBDG

graphic) were excluded from the analysis.

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consumption in these countries. Fats and sugars are reported as aunique 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 sugaror fats and sugar-rich foods. Milk and dairy products were in aseparate food group for 23 FBDGs and grouped with animalproteins in 4 countries (Estonia, Latvia, Israel, and Switzerland).

Potatoes are grouped as grains in 15 FBDGs, vegetables in 4countries (Albania, Switzerland, France, and Luxembourg), rootvegetables in Sweden and as a separate group in Greece. Le-gumes are grouped with protein-rich foods in 9 FBDGs, withgrains in Albania, Switzerland, France, and Luxembourg, withvegetables and potatoes in Sweden, with vegetables and fruits inTurkey, separately in Portugal and classied as an alternativeprotein source in Greece where they are grouped with olives andnuts. Some countries grouped nuts in the protein group (Estonia,Latvia, Ireland, Bulgaria, Spain, and Malta) due to their valuedprotein content. Other countries (Switzerland, Estonia, andIsrael) place them in the fat and oil group because of their highfat content; others in the fat and sugar group (Albania) or sugargroup (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 beveragegroup as a separate group of “noncaloric uids.” Caloric bever-ages are placedin the sugar group (11 countries) or fats and sugargroup (6 countries), whereas Switzerland and Luxembourggroup alcoholic beverages with sugar. Italy and Austria are theunique 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 anFBDG format and additional text to furnish accessory informa-tion and advice on the type and quantity of foods to beconsumed. Recommendations and advice are given as textpositioned close to the graphic, either on a simple leaet or on alarger 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 foodpyramid advises to “vary on a daily basis” for high-fat foods,protein-rich foods, fruits and vegetables, and grains and to “eatsparingly” 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 eachfood group. Only fried foods are limited to one to two portionsper week. United Kingdom, Belgium, Romania, and Francerecommend a daily serving for main food groups, whereasBelgium 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 consumptionfor sh, poultry, olives, pulses, nuts, potatoes, and eggs; andmonthly consumption for red meats. Italian FBDGs report twodifferent pyramids both for daily and weekly servings.

Detailed data on serving sizes are available only for 15countries (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. aseparate group for water, tea, or coffee) to recommend a dailyconsumption of uids. Twenty-two countries (79%) recommenda daily consumption of 1.5 L of water. Spain, Ireland, and

Estonia indicate the daily consumption of 1 L of water. Greeceand Israel recommend drinking plenty of water (no quantitativeinformation provided). Nineteen of the 34 countries (56%)recommend “moderate consumption” of caloric beverages (e.g.,soft drinks, drinks with added sugar). Seventeen FBDGs includerecommendations on alcohol consumption, some providingquantitative information by sex. Six countries (Romania, Norway,Denmark, Hungary, Greece, and Finland) recommend consuming1 unit/d for women and 2 units/d for men; three countries(United Kingdom, Italy, and France) recommend consuming2 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 informationbut advise moderate alcohol consumption. Poland guidelines

recommend avoiding alcohol. Three countries recommendconsuming 20 (Russian Federation) or 10 g (Albania andSlovenia) 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 withsugar. Italy is the unique country that considers alcoholics as aseparate group and Austria is the only country that considerscaloric 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 dene a quantitativeinformation recommending 5 g/d (Latvia, Bulgaria, CzechRepublic, Turkey, Norway, Malta, and Portugal) or 6 g/d sodiumchloride (Austria, Ireland, Albania, France, United Kingdom, Italy,the Netherlands, Denmark, Slovenia, Russian Federation, Estonia,and Belgium). Finland and Iceland recommended a daily saltintake 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 otherhealthy behaviors, such as maintaining a healthy body weightand preventing obesity (76%); to eat a variety of foods, preferablyvegetables rather than animal products (82%); to eat in enjoyablesurroundings 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 intermediatemeals) or simply to eat at regular times (54%); and to have somebreaks 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 partof the format or as a key topic in the supportive information.Moderate daily physical activity is needed to maintain body masswithin the recommended range (BMI 20–25 kg/m2) and to

reduce the risk for chronic diseases such as CVDs, stroke, andtype 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 specic popula-tion subgroups. Fifteen countries (44%; France, Italy, Norway,

Luxembourg, Sweden, Albania, Denmark, Turkey, Estonia,Ireland, Romania, United Kingdom, Spain, the Netherlands, andIceland) provide advice on improving the nutritional status of pregnant and breast-feeding women. Malta provides advice onlyfor breast-feeding women. Italy and Albania include advice forwomen in menopause. Specic recommendations regardingchildren (59%: Italy, Ireland, United Kingdom, Estonia, theNetherlands, 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 FBDGsinclude specic dietary guidelines for Asians: “taking a daily10 mg vitamin D supplement if they rarely get outdoors or arehousebound, if they wear clothes that cover all their body whenoutdoors or eat no meat or oily sh.”

Discussion

Governments are struggling with the growing social andeconomic consequences of an alarming increase in NCDs, inparticular obesity and its comorbidities. Public health policiesand research focused on strategies to improve nutrition andphysical activity are therefore necessary to prevent nutritionalexcess and/or decit and inactivity consequences [2,8,9]. AfterWorld War II, food-based advice focused on the issue of ensuringadequate intake of both macronutrients (proteins, carbohy-drates, and fats) and micronutrients (vitamins and minerals),often using a system of food grouping [5], which privileged theconsumption of meat and dairy products. However, during the1970s, dietitians became particularly concerned with the over-consumption of fats, essentially saturated fats, sugar, and the lackof ber in the diet. As a result, advice in developed countriestended to become more nutrient-based, with emphasis onincreasing consumption of vegetable foods, thus a higher varietyin menu selection. In the European Food Safety Authority (EFSA)Scientic Report, seven steps for the development of FBDGs were

identi

ed, the most important being identifying the relationshipbetween diet and health, identifying country-specic 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 culturallyacceptable to dietary habits, lifestyle, and so on. In some cases,the denition of FBDG is not suitable, for example, in the case of advice on foods containing calcium, fat, or proteins; also in thesecases, the terms FBDGs were used according to the latest EFSArevision [11], to simplify the messages in the manuscript. In fact,according to the EFSA, FBDGs should be practical, that is, thefoods recommended in it must be affordable, accessible, andvaried 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 foodpyramid, which blends the two graphical representations: The

German nutrition circle to provide quantitative FBDGs foradults and the three-dimensional food pyramid with four tri-angle sides that illustrate qualitative recommendations for anadequate choice within the major food groups [6,7]. Thethree-dimensional food pyramid was developed by the DGE as acomplement to the DGE nutrition circle. It was intended as a newgraphic model for the implementation of nutrition recommen-

dations. It is clear that experts struggled to add as many featuresas possible, obtaining comprehensive but chaotic informationnot easily intelligible by commonpeople. The German Agency forConsumer Information (AID) published a simpler and easier tounderstand food pyramid that is frequently used in nutritionaleducation for children [12].

The multidisciplinary approach to FBDG increases the likeli-hood of addressing national health problems, and creates greaterawareness and acceptance of guidelines among populations[13–15]. Key strategies for an effective message are to identifyspecic nutrient gaps and feasible intakes and to encouragetypical food consumption and proper choice ranges. FBDGcommunication 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 effectivenessand make appropriate adjustments. Updates are essential toadapt the guidelines to the evolving scientic knowledge on therelationships between food, nutrition, and health and to changefood habits and lifestyles. Today, nearly all European countrieshave developed FBDGs based on the principle of providingguidance for a healthy balanced diet that will help to preventCVDs, metabolic diseases, and cancer. FBDGs are more commonin western than in eastern European countries, in particular, inBaltic countries, central, southern, and northern Europeancountries. Guidelines collected in this research represent 64% of all European countries (34 of 53); 74% (28) are members of theEU. The Russian Federation, Albania, and Slovakia adoptedcountrywide integrated NCD intervention dietary guidelines[16], whereas Finland adopted Nordic Recommendations as theirown of cial FBDGs. Three countries (Andorra, Monaco, and SanMarino) with


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way to illustrate what foods congure a healthy diet. Instantly,the shape suggests that some foods are good and should beeaten more often, and that others should be eaten only occa-sionally. The layers represent major food groups that contributeto the total diet. On the other hand, some authors previouslycriticized the pyramid because it gives the impression of beingcounterintuitive in displaying what is “best” at the bottom of

the pyramid and what is “worst” at the top [17–20]. Evaluationof the guidelines’ effectiveness, for example by assessing theimpact of the graphical representation and/or messages onpeople’s behavior, is necessary to improve communicationstrategy. Despite European FBDGs being developed by differentexperts for each country and for use in different cultures, manysimilarities exist between them. Common recommendationsinclude 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 wereavailable for only 15 countries. For this reason, food grouprecommendations could not be compared in terms of nutrientintakes: In fact, when information on serving sizes was indi-rectly obtained through specic 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 messagesabout what to eat as well as some qualifying information to helppeople to avoid eating too much of certain foods. Foods cate-gories are similar in most countries but there is still pooragreement on how to group foods. Some grouping differenceswere due to the different emphasis given to food nutritionalproperties or to local preferences in their consumption, cookingpreparation. For example, some countries have a unique “pro-tein-rich foods” group that combines meat, milk and dairyproducts, sh, legumes, and nuts; some others categorize thesefoods in different groups. Potatoes and legumes are not unani-mously grouped, in some cases they are grouped togetherpossibly due to local foods habits. Legumes and nuts are both of vegetable origin and healthy, but their caloric content isremarkable 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 notintegrating animal foods. Finally, to avoid essential amino aciddeciency, diets need to be widely varied. Fat- and sugar-richfoods are considered as a group in 10 FBDGs, whereas in 20FBDGs they are considered individually. The combination of these two types of foods is justied for their high-caloric contentand not according to nutrient composition. Manufactured fatsand sugars are grouped together because their regular con-

sumption is potentially unhealthy for the presence of simplesugars and saturated/hydrogenated fats. In this case, theirgrouping was made according to their main characteristics andnot their nutrient composition.

In our opinion, a more accurate distinction between freshand processed (canned) foods is necessary as these types of foods require the addiction to unhealthy nutrients such as saltsand sugars, and other additives. The graphic representationhelps to simplify FBDG messages and to better illustrate pro-portions of different foods with similar characteristics to beincluded in a balanced diet. Graphic formats provide aconsumer-friendly framework so that if foods from the maingroups are eaten each day, an important rst step is taken to-ward achieving a healthy diet, without specic nutrient

knowledge. One of the earliest ways to group foods was basedon their origin, as plant- or animal-based foods, a classication

familiar to most people. Most of the graphic in FBDGs furtherdivides animal-based foods into two separate groups: the“meat-related group,” which includes sh, eggs, pulses, and insome 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 particularlyimportant 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 vegetablescontaining carbohydrates), which provide a fat-free, carbohy-drate-rich source of energy and certain types of bersand “fruitsand vegetables,” important for vitamin C as well as othermicronutrients and protective elements. Foods containingsugar, added sugar in particular, featured as a separate group insome schemes but are mostly combined with fats and oils in afatty and sugary food category that includes confectionery,bakery products, and soft drinks. This group always receives asmall proportion of the total daily intake to indicate that thesefoods 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 torepresent foods but different colors address suggested foods. Thenew colors are appreciated, but we believe that images allow amore immediate and sharper message. Ultimately, recommen-dations are made on drinking enough uids, controlling alcoholintake, body weight, and other aspects of lifestyle, such as gettingenough physical activity and eating regular meals. Occasionally,advice on food hygiene and social/relational aspects of eating isalso considered.

Generally, European FBDGs report only rough suggestions tolimit consumption of caloric and alcoholic beverages as well assalty foods and salt intake. It is interesting that the new WHOrecommendations suggest decreasing sugar consumption to


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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 revisedaccording to continuous ethnic, social, and cultural modicationsand should represent a relevant, but not unique, effort toimprove 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 theinformation received.

Supplementary data

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

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