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Nutrition 31 (2015) 908915

Contents lists available at ScienceDirect

Nutrition
journal homepage: www.nutritionjrnl.com

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
a
b

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

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 6 November 2014
Accepted 9 January 2015

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 unied group. Some differences include the modality of food classication. 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 insufcient as far as ethnic peculiarities, agreement on how to group
foods, and subgroup population nutritional requirements.
2015 Elsevier Inc. All rights reserved.

Keywords:
FBDGs
Dietary guidelines
European countries
Healthy diet
Noncommunicable diseases

Introduction
Food and nutrition play a key role in the prevention and
treatment of some of the most common chronic noncommunicable 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 sometimes even by the details on food labels about composition in

CM and LS contributed equally to this study. The authors have no conicts of


interest to declare.
* Corresponding author. Tel.: 39 081 373 7887; fax: 39 081 373 7808.
E-mail address: montagnese@ceinge.unina.it (C. Montagnese).
http://dx.doi.org/10.1016/j.nut.2015.01.002
0899-9007/ 2015 Elsevier Inc. All rights reserved.

nutrients (carbohydrates, fat, protein, vitamins, and minerals). In


order to spread simple and understandable nutritional information, scientic 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 [35]. 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 identied according to WHO
European-Member-States classication. The collected FBDGs
were compared according to their pictorial representation,
message on healthy eating, variety of food grouping (including

C. Montagnese et al. / Nutrition 31 (2015) 908915

beverages), and eventually the recommended quantities for each


food group. Finally, other healthy lifestyle suggestions were
considered.

909

were available both in the local German language and in Italian,


due to the different regional cultural settings.
Food guide illustration shapes

Materials and methods


FBDGs from European countries identied according to the WHO EuropeanMember-States classication and divided into eight geographic subregions to
facilitate comparative analysis were collected (Appendix A). Sources of information 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
leaets, 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 according to graphic patterns, foods pictured, and food grouping composition.
Other specic integrative recommendations on the type of beverage consumed,
salt intake, healthy lifestyle (physical activity), and other healthy behavior items
were also considered.

Results
WHO identies 53 European countries, divided into eight
geographic subregions; 28 countries are federated as the European Union (EU) for a total population of 904,168,000. Ofcial
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
ofcial 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 European (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 Independent 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, leaets, and booklets). 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 ofcial members of the EU. We obtained complete
data for 26 of them. We were unable to obtain ofcial information 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 information (Web pages, leaets, 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

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. 1A). The
four faces of the pyramid provide a qualitative classication 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 beverages. Colors on the left side of the pyramid indicate the nutritional value of foods and give advice on the amount to be
consumed. The base of the three-dimensional food pyramid is
the Deutsche Gesellschaft fr Ernhrung (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 sections, each representing a food group; the area of the food section is proportional to the recommended amount. The Swedish
circle (Fig. 1B), 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 22)

Circle
(n 7)

Others*
(n 3)

No food guide
graphic (n 1)

Albania
Austria
Belgium
Bulgaria
Croatia
Czech Republic
Estonia
Germanyy
Greece
Ireland
Israel
Italy
Latvia
Luxembourg
Malta
Moldovan Republic
Poland
Romania
Russian Federation
Slovenia
Spain
Switzerland

Denmark
Iceland
The Netherlands
Norway
Portugal
Sweden
United Kingdom

France
Hungary
Turkey

Lithuania

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 dened as a three-dimensional pyramid even if it combines circle
and pyramid models.

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C. Montagnese et al. / Nutrition 31 (2015) 908915

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. 1CE, respectively). 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 proportionality 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 leaet 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

C. Montagnese et al. / Nutrition 31 (2015) 908915

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 established in 1989 by the Swedish National Food Agency and combines a food circle and a pyramid. The keyhole is a food label that
identies 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 producers are responsible for ensuring that foods exhibiting the
symbol conform to the Danish Veterinary and Food Administrations 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 quantitative information: Half of the meal could provide an equal
amount of cereals and proteins and the other half only vegetables. 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

911

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
, tea, water, etc.)
Noncaloric beverages (cafe
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
 Italiane di Nutrizione, a food
by the Federazione delle Societa
group is dened 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 classied 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 identied, 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 beverages. 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
denition fruit and berries, indicating the importance of berry

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C. Montagnese et al. / Nutrition 31 (2015) 908915

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. Legumes 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 classied 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 beverages 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 information 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 leaet or on a
larger booklet. The Spanish food pyramid suggests daily consumption of cereals, potatoes, fruits, vegetables, olive oil, milk,
dairy, and protein-rich foods. Occasional consumption is suggested 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 pyramid 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, Sweden, 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, Luxembourg, 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 Luxembourg 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 dene 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 intervals (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 2025 kg/m2) and to
reduce the risk for chronic diseases such as CVDs, stroke, and
type 2 diabetes.

C. Montagnese et al. / Nutrition 31 (2015) 908915

Albania, Switzerland, and United Kingdom include recommendation to stop smoking.


FBDGs for specic subgroups of the population
Some FBDGs include dietary guidelines for specic population 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. Specic 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, Iceland, Italy, Sweden, Croatia, Norway, Switzerland, Romania,
United Kingdom, France, Albania, Malta, Belgium, Estonia,
Denmark, Latvia, and Finland), and the elderly (47%: Spain, Iceland, Luxembourg, Italy, Romania, Croatia, Estonia, Albania,
Switzerland, Ireland, France, United Kingdom, Malta, Belgium,
Denmark, and Latvia) are included. United Kingdom FBDGs
include specic 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 decit 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, carbohydrates, 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 overconsumption 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)
Scientic Report, seven steps for the development of FBDGs were
identied, the most important being identifying the relationship
between diet and health, identifying country-specic diet-related 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 denition 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 materials 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

913

German nutrition circle to provide quantitative FBDGs for


adults and the three-dimensional food pyramid with four triangle 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 recommendations. 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 likelihood of addressing national health problems, and creates greater
awareness and acceptance of guidelines among populations
[1315]. Key strategies for an effective message are to identify
specic 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 scientic 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 ofcial 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 ofcial FBDGs and/or supportive dietary-related information. In conclusion, data examined derived from 34 European
countries, for a total of 746,440,000 European citizens (83% of the
entire European population classied 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 sources are detailed in Appendix C.
The pyramid graphic proved to be one of the most effective
and efcient methods for practical nutritional communication
and in particular for conveying messages of moderation, proportionality, and variety in food guidelines. Translating nutrition advice into a colorful pyramid seems to be an outstanding

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C. Montagnese et al. / Nutrition 31 (2015) 908915

way to illustrate what foods congure 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 occasionally. 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 [1720]. Evaluation
of the guidelines effectiveness, for example by assessing the
impact of the graphical representation and/or messages on
peoples 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 carbohydrates, 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 indirectly obtained through specic calculations, the data was
unreliable.
The use of food groups, as in food pyramids and circles, ensures 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 categories 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 protein-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 unanimously 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 proteins (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
deciency, 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 justied for their high-caloric content
and not according to nutrient composition. Manufactured fats
and sugars are grouped together because their regular consumption 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 proportions 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 toward achieving a healthy diet, without specic nutrient
knowledge. One of the earliest ways to group foods was based
on their origin, as plant- or animal-based foods, a classication

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 nonanimal foods in these groups is important for vegetarians.
Similarly, plant-based foods are usually subdivided into cereals (improperly including potatoes, which are root vegetables
containing carbohydrates), which provide a fat-free, carbohydrate-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, recommendations 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 rened sugar and sugar-added foods and several
diseases.
More emphasis should be given to minority ethnic communities; 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 constitutes a healthy diet and in how to group foods across Europe.
There is a remarkable difculty in food classication, 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.

C. Montagnese et al. / Nutrition 31 (2015) 908915

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

[7]

[8]

[9]

Acknowledgments
[10]

The authors acknowledge the Austrian, Danish, Estonian,


Finnish, German, Icelandic, Israelite, Lithuanian, Dutch, Luxembourgish, Maltese, Norwegian, and Swedish embassies for the
information received.

[11]

[12]

Supplementary data
[13]

Supplementary data related to this article can be found online


at http://dx.doi.org/10.1016/j.nut.2015.01.002.
[14]

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