- Email: [email protected]
Setting dietary guidance: the Canadian experience
Setting dietary guidance: The Canadian experience MARY BUSH, MSc, RD; SHARON KIRKPATRICK, MHSc, RD
ABSTRACT This article outlines processes underlying recent dietary guidance in Canada. In 1977, Nutrition Recommendations for Canadians were adapted from the Report of the Committee on Diet and Cardiovascular Disease. In the late 1980s, as science revealed new relationships between dietary patterns and chronic disease, the unified front of consistent dietary guidelines began to crumble when researchers and health organizations began to provide “unique” dietary advice. Evolution in health promotion concepts during this time, combined with the need for updated dietary guidance, influenced Health Canada to appoint two advisory committees in 1987. The Scientific Review Committee was charged with describing the dietary pattern that would supply recommended levels of essential nutrients while reducing risk of chronic disease, resulting in updated Nutrition Recommendations. The Communications and Implementation Committee translated the scientific recommendations into dietary advice for the public, leading to Canada’s Guidelines to Healthy Eating. From this process, Canada’s Food Guide to Healthy Eating emerged. The development of the Dietary Reference Intakes has resulted in updated nutrient requirement values and better tools for dietary assessment and planning. Health Canada recognizes the need to ensure alignment with this updated science through continuing leadership in defining and communicating accurate dietary guidance for Canada. J Am Diet Assoc. 2003;103:S22-S27.
T
his article provides a perspective on the process of developing dietary guidance in Canada. It provides a brief history of dietary guidance in Canada and outlines the processes underlying recent dietary guidance, including Canada’s first national Nutrition Recommendations released in 1977, their revision in 1990, and the subsequent development of Canada’s Guidelines for Healthy Eating and revisions to Canada’s Food Guide. Consideration of the content and process determinants of current dietary guidance in Canada suggests potential directions for the future. THE HISTORY OF DIETARY GUIDANCE IN CANADA Health Canada has been in the business of promoting healthful eating to Canadians since 1942, when the Official Food Rules were released as part of a wartime nutrition program (1). The Food Rules were intended to improve the health of Canadians by promoting better eating habits and focussed on patterns of eating that would provide adequate amounts of essential nutrients. The Official Food Rules underwent revision through the 1940s, ’50s and ’60s to reflect current science on nutrient requirements. The word “official” was dropped in 1944, and later the name was changed to Canada’s Food Guide, acknowledging that more than one dietary pattern can be consistent with good health (2). As science evolved, new evidence emerged—not only about the role of nutrition in promoting health, but also about the role of nutrition in preventing chronic disease. In response, dietary guidance began to embrace the prevention of chronic disease. In the mid-1970s, an expert committee was struck to examine the relationship between diet and cardiovascular disease. This work resulted in the publication of the Report of the ComM. Bush is Director General and, at the time of this study, S. Kirkpatrick (currently a doctoral student in the Department of Nutritional Sciences, University of Toronto) was a nutrition officer with Office of Nutrition Policy and Promotion, Health Products and Food Branch, Health Canada, Ottawa, ON, Canada. Address correspondence to: Mary Bush, MSc, RD, Office of Nutrition Policy and Promotion, Health Products and Food Branch, Health Canada, Qualicum Towers, Tower A, 2936 Baseline Road, Ottawa, ON K1A 0K9 Canada. E-mail: [email protected]. Copyright © 2003 by the American Dietetic Association. 0002-8223/03/10312-2005$30.00/0 doi: 10.1016/j.jada.2003.09.033
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mittee on Diet and Cardiovascular Disease in 1977 (3), which included several recommendations to emphasize or reduce certain dietary components. These recommendations were later adapted and endorsed by Health Canada as Nutrition Recommendations for Canadians (4,5). At that time, it was recognized that broad acceptance and use of these recommendations was essential to their success. Organizations developing nutrition education for consumers needed to be aware of and in agreement with them. Thus, efforts to garner support from a broad cross-section of stakeholders were undertaken. The result was support for the recommendations by provincial and territorial departments of health, professional associations, and voluntary agencies, as well as national organizations related to food industry, fitness, health, agriculture, and education (6). Recognizing that the Recommendations were of a technical and scientific nature, they were never promoted directly to consumers. Rather, they were directed to health professionals only, with the encouragement that they be integrated into education programs for the public in appropriate ways (7). Furthermore, although the Recommendations had been derived from a report on cardiovascular disease, their dissemination was not as disease-specific recommendations but as guidance to be used in public health education and programs targeted to general good health. That same year (ie, 1977), Health Canada released a new Canada’s Food Guide (8). However, it was another five years before the Nutrition Recommendations were integrated into dietary guidance for consumers. In the 1982 release of Canada’s Food Guide, Nutrition Recommendations for Canadians were integrated with the addition of messages regarding variety in food choices, balance between energy intake and expenditure, and moderation in the consumption of fat, sugar, salt, and alcohol (9). This marked the first time in Canada that the influence of diet on chronic disease became part of dietary advice from the federal government to the public. INFLUENCES ON DIETARY GUIDANCE THROUGH THE 1980s The 1980s were an exciting time for nutrition in Canada. Developments in the field of health promotion began to shift focus to the role of environments and not just lifestyle choices in health outcomes. There was new understanding of the processes and strategies needed to change the environmental context for healthy living. There was also an explosion of evidence reported in the scientific literature of discoveries of the relationship of dietary components to chronic disease. Both of these developments are fundamental to understanding how Canada has approached the development of dietary guidance. Health promotion is the process of enabling people to increase control over and improve their health (10). Health promotion principles emphasize that effective programs include a combination of strategies, and that “health education” is only one of a range of important strategies to effect change in health. In the 1980s, the federal government set forth a plan for enhanced work in health promotion, which included nutrition as one of six priorities (11). The objective of health promotion related to nutrition was to increase the number of Canadians who were at “reduced risk of nutrition-related diseases and who have improved nutritional status” (11). Four health promotion strategies were identified as being important for effective programs. These strategies included informing and equipping the public, promoting a supportive social environment, promoting self-help and citizen participation, and stimulating
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The Canadian diet should provide energy consistent with the maintenance of body weight within the recommended range. The Canadian diet should include essential nutrients in amounts recommended. The Canadian diet should include no more than 30% of energy as fat (33 g/1,000 kcal or 39 g/5,000 kJ) and no more than 10% as saturated fat (11 g/1,000 kcal or 13 g/5,000 kJ). The Canadian diet should provide 55% of energy as carbohydrate (138 g/1,000 kcal or 165 g/5,000 kJ) from a variety of sources. The sodium content of the Canadian diet should be reduced. The Canadian diet should include no more than 5% of total energy as alcohol, or two drinks daily, whichever is less. The Canadian diet should contain no more caffeine than the equivalent of four cups of coffee per day. Community water supplies containing less than 1 mg/liter should be fluoridated to that level.
FIG 1. Nutrition Recommendations for Canadians (1990). (Source: Nutrition Recommendations: A Call for Action. Health Canada, Ottawa, ON. 1989. Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2003.)
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Enjoy a VARIETY of foods. Emphasize cereals, breads, other grain products, vegetables, and fruit. Choose lower-fat dairy products, leaner meats, and foods prepared with little or no fat. Achieve and maintain a healthy body weight by enjoying regular physical activity and healthy eating. Limit salt, alcohol and caffeine.
FIG 2. Canada’s Guidelines to Healthy Eating (1990). (Source: Nutrition Recommendations: A Call for Action. Health Canada, Ottawa, ON. 1989. Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2003.)
supportive health education and other programs. Nutrition policy and programs in Canada developed within this context. Applying health promotion principles to stimulate action, create momentum, and facilitate change at the individual and environmental levels required new techniques and several principles emerged (12). Intersectoral collaboration was a central theme or approach to accomplish change. The involvement of different sectors brought different perspectives that led to strengthened outcomes. Equally essential, involving multiple sectors led to increased understanding of the importance of nutrition by stakeholders whose central interest was not nutrition, but whose decisions had major influence on what foods are available and on individual capacity to make choices. The range of disciplines recognized as making important contributions to the understanding of the determinants of healthful eating broadened. Sciences recognized as critical to nutrition initiatives included not only the biological, medical, and environmental sciences, but also social, economic, and political sciences. New initiatives were recognized as opportunities for engagement and processes were designed to facilitate intersectoral and interdisciplinary collaboration. Issues were
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FIG 3. Canada’s Food Guide to Healthy Eating (1992). (Source: Canada’s Food Guide to Healthy Eating. Health Canada, Ottawa, ON. 1992. Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2003.)
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FIG 3 (continued). Canada’s Food Guide to Healthy Eating (1992). (Source: Canada’s Food Guide to Healthy Eating. Health Canada, Ottawa, ON. 1992. Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2003.)
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managed in a more inclusive manner. This had a major impact on the processes used to develop nutrition policy, which is described in detail in the next section, which outlines the 1990 dietary guidance update. The 1980s were also a time of major scientific pronouncements on the role of diet on health and disease prevention. Scientific investigation into relationships between dietary patterns and dietary components and chronic disease intensified. At the same time, the press raced to keep consumers up to date with the evolving science. A proliferation of nutrition and dietary guidelines began to emerge from various organizations across Canada as the 1977 Nutrition Recommendations began to be perceived as out of date given all of the new and emerging information (13). Although many of the new organization-specific guidelines shared common elements, different aspects of the diet were emphasized depending on the disease and the organization. This breakdown in the unified front of consistent national nutrition messages resulted in growing confusion among health professionals and consumers alike. THE PROCESS UNDERLYING THE 1990 DIETARY GUIDANCE UPDATE In 1986, the National Institute of Nutrition, a nongovernmental organization with a mandate to advance the knowledge and practice of nutrition in Canada, hosted a meeting on dietary guidelines (14). This meeting was attended by representatives of government, industry, professional associations, and voluntary agencies. All agreed that scientific understanding was inadequate to generate disease-specific dietary guidelines, but also that the science underpinning Nutrition Recommendations for Canadians was in need of updating (15). Ultimately, a plan for an innovative and collaborative process to revise the existing Nutrition Recommendations emerged. The process recognized the need for a scientific description of a healthful diet and also the need to have this science translated into dietary guidelines written for the public. In response, Health Canada appointed two advisory committees to work collaboratively—a Scientific Review Committee and a Communications/Implementation Committee (16). The appointment of two distinct committees with different membership recognized the importance of science expertise to report in scientific language the characteristics of a healthful diet and that translating scientific guidelines into actionable messages for consumers required a different set of expertise. To ensure that the work evolved collaboratively, a liaison was provided by Health Canada coordinators. In addition, the process set in motion an approach that looked across nutrition-related chronic diseases rather than the earlier focus on one disease. The Scientific Review Committee was charged with describing the characteristics of a diet that would supply recommended levels of nutrients while reducing the risk of chronic disease (17). In completing this task, the Committee reviewed the scientific evidence on nutrient requirements, as well as the relationships between diet, nutrition and disease. The result of this exercise was Nutrition Recommendations for Canadians (18), a set of eight statements outlining the desired characteristics of the Canadian diet for use by the scientific and professional community (Figure 1). The Scientific Review Committee also updated the Recommended Nutrient Intakes (16), marking the first time in Canada that a review of nutrient requirements and a review of the role of diet in disease prevention were conducted concurrently (13). The second committee, the Communications/ImplementaS26 / December 2003 Suppl 2 Volume 103 Number 12
tion Committee, was the first of its kind in Canada. It consisted of representatives of the academic community, industry, and nongovernmental organizations who provided expertise in nutrition communications and education, community nutrition, policy, planning, and research, recognizing the unique contribution provided by communicators and educators in translating scientific guidelines into actionable messages. The mandate of the Committee was to translate the Nutrition Recommendations into dietary advice for the Canadian public and to recommend implementation strategies to facilitate comprehensive use and integration of the dietary guidelines into the policies, programs, and messages (19). The Communications/Implementation Committee designed a very inclusive, intersectoral and multidisciplinary process in fulfilling its mandate. Consultation with nutritionists, universities, professional associations, industry groups, and nongovernmental health organizations was designed not only to garner input on strategies for implementation, but also to maximize consensus on one common set of dietary guidelines to be used by all stakeholders when communicating with Canadians. The result of this process was Canada’s Guidelines for Healthy Eating (19)—five statements that are the key nutrition messages to be communicated to healthy Canadians older than two years of age (Figure 2). The translation of the Nutrition Recommendations into Canada’s Guidelines for Healthy Eating was guided by a number of principles, including scientific accuracy, positive tone, action-orientation, and a level of language that would enable comprehension by the majority of Canadians (19). Although the Guidelines were based on the scientifically derived Nutrition Recommendations, they do not include numbers, percentages, or technical terms. For example, the Nutrition Recommendations identified a desired dietary characteristic as consuming “no more than . . . 10% of energy as saturated fat” (18). Canada’s Guidelines for Healthy Eating translated this statement as: “Choose lower fat dairy products, leaner meats and foods prepared with little or no fat” (18), recognizing the primary sources of saturated fat in the diets of Canadians. A series of recommendations for implementation accompanied Canada’s Guidelines for Healthy Eating (19). The influence of health promotion was evident in the strategies that were identified. The need to go beyond the provision of information in order to promote healthful eating was clearly recognized. Thus, a plan was developed to assist in the implementation of the Guidelines, including five strategies for action: the development of food and nutrition policies; collaboration and coordination among partners; multisectoral, community-based nutrition initiatives; the creation of supportive environments in various locations including schools and worksites; and research and evaluation. All sectors, including national, provincial and local governments, nongovernmental organizations, the food industry, and consumers, were called upon to make a commitment to the communication and implementation of the Guidelines. Furthermore, provisions were made to enable organizations to use the Guidelines as their own, as well as for the Guidelines to appear on food labels and in food advertising (20). This development enabled a new era of collaboration of government, nutrition educators and disease-specific health charities with the food industry as healthful eating messages were communicated to consumers on food labels and in food advertising. Another vehicle identified for the implementation of Canada’s Guidelines to Healthy Eating was Canada’s Food Guide.
Feedback from nutrition professionals and a review of the literature led to the conclusion that there was a continuing need for a key nutrition education tool like the Food Guide to support the implementation of the Guidelines (19). However, it was also concluded that substantial changes to the Food Guide were needed to ensure its relevance and usefulness. The Communications/Implementation Committee made a series of recommendations, including the need to recognize the total diet rather than continuing with the foundation diet that previous food guides had embraced. The total diet approach provides guidance to meet nutrient recommendations across a range of energy intakes, in contrast to the foundation diet approach in which minimum food intakes were suggested to provide essential nutrients in amounts recommended. An extensive process was then undertaken by Health Canada, including market research, communication research, and widespread consultation (21). Criteria governing the revision of the Food Guide included that it be readable, acceptable, realistic, accessible, affordable, easy to understand, practical, attractive, and motivating (21). The ultimate product of the process was seen to be more than a piece of paper—the multisectoral and multidisciplinary process of developing it was designed to engage all stakeholders in the importance of healthful eating and an understanding of what that meant and what was needed. The result of this process was Canada’s Food Guide to Healthy Eating (22) (Figure 3), which was launched in 1992. CONCLUSION AND DIRECTIONS FOR THE FUTURE This article will conclude with thoughts on content and process determinants of current dietary guidance, and possible directions for the future. In terms of content, the 1990 dietary guidance review included an updated scientific description of the characteristics of a healthful diet in the form of Nutrition Recommendations, as well as key nutrition messages for consumers in the form of Canada’s Guidelines for Healthy Eating. Furthermore, the review resulted in an updated consumer tool to guide food choices in the form of Canada’s Food Guide to Healthy Eating. The process embraced an integrated approach, using two linked committees with distinct but complementary expertise to incorporate current science and address consumer needs. Health promotion principles were emphasized in that, whereas the products of the review were considered important in terms of content, the process was important in terms of changing conditions to support healthful eating. The need to go beyond the provision of information in order to promote healthful eating was clearly recognized. Finally, the process placed consumer needs at the center. The result was evidence-based, consumer-friendly, actionable Guidelines, as well as a comprehensive implementation strategy, including tools such as Canada’s Food Guide to Healthy Eating. A decade later, Canada’s participation in the development of the Dietary Reference Intakes has resulted in updated nutrient requirement values and better tools for dietary planning and assessment. Thus, there is a need to review our dietary guidance—including the Nutrition Recommendations for Canadi-
ans, Canada’s Guidelines to Healthy Eating, and Canada’s Food Guide for Healthy Eating—and, if necessary, update that guidance to ensure that it adequately promotes the nutritional health and well being of Canadians. Current health issues, such as prevalence of nutrition-related chronic diseases including obesity, will need to be carefully considered. The process that was implemented during the previous guidance review will inform the next review, and those aspects that served Canadians well can be identified and maintained. The development and implementation of updated dietary guidance will need to involve stakeholders from all sectors, including the public, and will need to be based on the best evidence available so that the resulting guidance is scientifically sound, communicates with the public in a meaningful way, and continues to support efforts to improve nutritional health and well being. References 1. Pett LB. Food makes a difference. Can J Public Health. 1942;33:565-570. 2. Health & Welfare Canada. Rules out— guide in. Can Nutr Notes. 1961;17: 49-50. 3. Report of the Committee on Diet and Cardiovascular Disease. Ottawa, ON: Health & Welfare Canada; 1976. 4. Beare-Rogers JL. Food and nutrition guidelines in Canada. In: Selvey N, White PL, eds. Nutrition in the 1980s: Constraints on Our Knowledge. New York: Alan R. Liss, Inc; 1981:481-489. 5. Murray TK, Rae J. Nutrition recommendations for Canadians. Can Med Assoc J. 1979;120:1241-1242. 6. Murray TK, Rae J. Nutrition and heart disease—a prevention program. J Can Diet Assoc. 1979;39:6-10. 7. Murray TK. Diet and health: The Canadian experience. Am J Clin Nutr. 1987;45:1390-1393. 8. Canada’s Food Guide. Ottawa, ON: Health & Welfare Canada; 1977. 9. Action Towards Healthy Eating Technical Report: The Report of the Task and Technical Groups on Canada’s Food Guide and the Task Group on Food Consumption. Ottawa, ON: Health & Welfare Canada; 1990. 10. World Health Organization. Ottawa Charter for Health Promotion, First International Conference on Health Promotion; 1986. 11. Nielsen H. Nutrition in health promotion programs: A Canadian perspective. Hum Nutr Appl Nutr. 1983;37A:165-171. 12. Achieving Health for All: A Framework for Health Promotion. Ottawa, ON: Health & Welfare Canada; 1986. 13. Murray TK, Beare-Rogers JL. Nutrition recommendations, 1990. J Can Diet Assoc. 1990;51:391-395. 14. National Institute of Nutrition. Rapport. 1986;1(3). 15. National Institute of Nutrition. Rapport. 1987;2(2). 16. National Institute of Nutrition. Rapport. 1987;2(3). 17. Nutrition Recommendations: The Report of the Scientific Review Committee. Ottawa, ON: Health Canada; 1990. 18. Nutrition Recommendations... A Call For Action. Summary Report of the Scientific Review Committee and the Communications/Implementation Committee. Ottawa, ON: Health Canada; 1989. 19. Action Towards Healthy Eating: The Report of the Communications/ Implementation Committee. Ottawa, ON: Health Canada; 1990. 20. Guidelines on the Use of Nutrition Recommendations and Canada’s Guidelines to Healthy Eating in the Sale of Food. Ottawa, ON: Health Canada; 1995. 21. Connolly CR. A new era in nutrition guidance in Canada. Rapport. 1992; 7(4). 22. Canada’s Food Guide to Healthy Eating. Ottawa, ON: Health Canada; 1992.
This manuscript is based on a presentation given at the Dietary Guidelines Symposium at the University of Toronto in 2002. The authors thank Stefa Katamay for her valuable contribution to the original presentation.
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ABSTRACT This article outlines processes underlying recent dietary guidance in Canada. In 1977, Nutrition Recommendations for Canadians were adapted from the Report of the Committee on Diet and Cardiovascular Disease. In the late 1980s, as science revealed new relationships between dietary patterns and chronic disease, the unified front of consistent dietary guidelines began to crumble when researchers and health organizations began to provide “unique” dietary advice. Evolution in health promotion concepts during this time, combined with the need for updated dietary guidance, influenced Health Canada to appoint two advisory committees in 1987. The Scientific Review Committee was charged with describing the dietary pattern that would supply recommended levels of essential nutrients while reducing risk of chronic disease, resulting in updated Nutrition Recommendations. The Communications and Implementation Committee translated the scientific recommendations into dietary advice for the public, leading to Canada’s Guidelines to Healthy Eating. From this process, Canada’s Food Guide to Healthy Eating emerged. The development of the Dietary Reference Intakes has resulted in updated nutrient requirement values and better tools for dietary assessment and planning. Health Canada recognizes the need to ensure alignment with this updated science through continuing leadership in defining and communicating accurate dietary guidance for Canada. J Am Diet Assoc. 2003;103:S22-S27.
T
his article provides a perspective on the process of developing dietary guidance in Canada. It provides a brief history of dietary guidance in Canada and outlines the processes underlying recent dietary guidance, including Canada’s first national Nutrition Recommendations released in 1977, their revision in 1990, and the subsequent development of Canada’s Guidelines for Healthy Eating and revisions to Canada’s Food Guide. Consideration of the content and process determinants of current dietary guidance in Canada suggests potential directions for the future. THE HISTORY OF DIETARY GUIDANCE IN CANADA Health Canada has been in the business of promoting healthful eating to Canadians since 1942, when the Official Food Rules were released as part of a wartime nutrition program (1). The Food Rules were intended to improve the health of Canadians by promoting better eating habits and focussed on patterns of eating that would provide adequate amounts of essential nutrients. The Official Food Rules underwent revision through the 1940s, ’50s and ’60s to reflect current science on nutrient requirements. The word “official” was dropped in 1944, and later the name was changed to Canada’s Food Guide, acknowledging that more than one dietary pattern can be consistent with good health (2). As science evolved, new evidence emerged—not only about the role of nutrition in promoting health, but also about the role of nutrition in preventing chronic disease. In response, dietary guidance began to embrace the prevention of chronic disease. In the mid-1970s, an expert committee was struck to examine the relationship between diet and cardiovascular disease. This work resulted in the publication of the Report of the ComM. Bush is Director General and, at the time of this study, S. Kirkpatrick (currently a doctoral student in the Department of Nutritional Sciences, University of Toronto) was a nutrition officer with Office of Nutrition Policy and Promotion, Health Products and Food Branch, Health Canada, Ottawa, ON, Canada. Address correspondence to: Mary Bush, MSc, RD, Office of Nutrition Policy and Promotion, Health Products and Food Branch, Health Canada, Qualicum Towers, Tower A, 2936 Baseline Road, Ottawa, ON K1A 0K9 Canada. E-mail: [email protected]. Copyright © 2003 by the American Dietetic Association. 0002-8223/03/10312-2005$30.00/0 doi: 10.1016/j.jada.2003.09.033
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mittee on Diet and Cardiovascular Disease in 1977 (3), which included several recommendations to emphasize or reduce certain dietary components. These recommendations were later adapted and endorsed by Health Canada as Nutrition Recommendations for Canadians (4,5). At that time, it was recognized that broad acceptance and use of these recommendations was essential to their success. Organizations developing nutrition education for consumers needed to be aware of and in agreement with them. Thus, efforts to garner support from a broad cross-section of stakeholders were undertaken. The result was support for the recommendations by provincial and territorial departments of health, professional associations, and voluntary agencies, as well as national organizations related to food industry, fitness, health, agriculture, and education (6). Recognizing that the Recommendations were of a technical and scientific nature, they were never promoted directly to consumers. Rather, they were directed to health professionals only, with the encouragement that they be integrated into education programs for the public in appropriate ways (7). Furthermore, although the Recommendations had been derived from a report on cardiovascular disease, their dissemination was not as disease-specific recommendations but as guidance to be used in public health education and programs targeted to general good health. That same year (ie, 1977), Health Canada released a new Canada’s Food Guide (8). However, it was another five years before the Nutrition Recommendations were integrated into dietary guidance for consumers. In the 1982 release of Canada’s Food Guide, Nutrition Recommendations for Canadians were integrated with the addition of messages regarding variety in food choices, balance between energy intake and expenditure, and moderation in the consumption of fat, sugar, salt, and alcohol (9). This marked the first time in Canada that the influence of diet on chronic disease became part of dietary advice from the federal government to the public. INFLUENCES ON DIETARY GUIDANCE THROUGH THE 1980s The 1980s were an exciting time for nutrition in Canada. Developments in the field of health promotion began to shift focus to the role of environments and not just lifestyle choices in health outcomes. There was new understanding of the processes and strategies needed to change the environmental context for healthy living. There was also an explosion of evidence reported in the scientific literature of discoveries of the relationship of dietary components to chronic disease. Both of these developments are fundamental to understanding how Canada has approached the development of dietary guidance. Health promotion is the process of enabling people to increase control over and improve their health (10). Health promotion principles emphasize that effective programs include a combination of strategies, and that “health education” is only one of a range of important strategies to effect change in health. In the 1980s, the federal government set forth a plan for enhanced work in health promotion, which included nutrition as one of six priorities (11). The objective of health promotion related to nutrition was to increase the number of Canadians who were at “reduced risk of nutrition-related diseases and who have improved nutritional status” (11). Four health promotion strategies were identified as being important for effective programs. These strategies included informing and equipping the public, promoting a supportive social environment, promoting self-help and citizen participation, and stimulating
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The Canadian diet should provide energy consistent with the maintenance of body weight within the recommended range. The Canadian diet should include essential nutrients in amounts recommended. The Canadian diet should include no more than 30% of energy as fat (33 g/1,000 kcal or 39 g/5,000 kJ) and no more than 10% as saturated fat (11 g/1,000 kcal or 13 g/5,000 kJ). The Canadian diet should provide 55% of energy as carbohydrate (138 g/1,000 kcal or 165 g/5,000 kJ) from a variety of sources. The sodium content of the Canadian diet should be reduced. The Canadian diet should include no more than 5% of total energy as alcohol, or two drinks daily, whichever is less. The Canadian diet should contain no more caffeine than the equivalent of four cups of coffee per day. Community water supplies containing less than 1 mg/liter should be fluoridated to that level.
FIG 1. Nutrition Recommendations for Canadians (1990). (Source: Nutrition Recommendations: A Call for Action. Health Canada, Ottawa, ON. 1989. Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2003.)
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Enjoy a VARIETY of foods. Emphasize cereals, breads, other grain products, vegetables, and fruit. Choose lower-fat dairy products, leaner meats, and foods prepared with little or no fat. Achieve and maintain a healthy body weight by enjoying regular physical activity and healthy eating. Limit salt, alcohol and caffeine.
FIG 2. Canada’s Guidelines to Healthy Eating (1990). (Source: Nutrition Recommendations: A Call for Action. Health Canada, Ottawa, ON. 1989. Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2003.)
supportive health education and other programs. Nutrition policy and programs in Canada developed within this context. Applying health promotion principles to stimulate action, create momentum, and facilitate change at the individual and environmental levels required new techniques and several principles emerged (12). Intersectoral collaboration was a central theme or approach to accomplish change. The involvement of different sectors brought different perspectives that led to strengthened outcomes. Equally essential, involving multiple sectors led to increased understanding of the importance of nutrition by stakeholders whose central interest was not nutrition, but whose decisions had major influence on what foods are available and on individual capacity to make choices. The range of disciplines recognized as making important contributions to the understanding of the determinants of healthful eating broadened. Sciences recognized as critical to nutrition initiatives included not only the biological, medical, and environmental sciences, but also social, economic, and political sciences. New initiatives were recognized as opportunities for engagement and processes were designed to facilitate intersectoral and interdisciplinary collaboration. Issues were
Supplement to the Journal of THE AMERICAN DIETETIC ASSOCIATION / S23
FIG 3. Canada’s Food Guide to Healthy Eating (1992). (Source: Canada’s Food Guide to Healthy Eating. Health Canada, Ottawa, ON. 1992. Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2003.)
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FIG 3 (continued). Canada’s Food Guide to Healthy Eating (1992). (Source: Canada’s Food Guide to Healthy Eating. Health Canada, Ottawa, ON. 1992. Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2003.)
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managed in a more inclusive manner. This had a major impact on the processes used to develop nutrition policy, which is described in detail in the next section, which outlines the 1990 dietary guidance update. The 1980s were also a time of major scientific pronouncements on the role of diet on health and disease prevention. Scientific investigation into relationships between dietary patterns and dietary components and chronic disease intensified. At the same time, the press raced to keep consumers up to date with the evolving science. A proliferation of nutrition and dietary guidelines began to emerge from various organizations across Canada as the 1977 Nutrition Recommendations began to be perceived as out of date given all of the new and emerging information (13). Although many of the new organization-specific guidelines shared common elements, different aspects of the diet were emphasized depending on the disease and the organization. This breakdown in the unified front of consistent national nutrition messages resulted in growing confusion among health professionals and consumers alike. THE PROCESS UNDERLYING THE 1990 DIETARY GUIDANCE UPDATE In 1986, the National Institute of Nutrition, a nongovernmental organization with a mandate to advance the knowledge and practice of nutrition in Canada, hosted a meeting on dietary guidelines (14). This meeting was attended by representatives of government, industry, professional associations, and voluntary agencies. All agreed that scientific understanding was inadequate to generate disease-specific dietary guidelines, but also that the science underpinning Nutrition Recommendations for Canadians was in need of updating (15). Ultimately, a plan for an innovative and collaborative process to revise the existing Nutrition Recommendations emerged. The process recognized the need for a scientific description of a healthful diet and also the need to have this science translated into dietary guidelines written for the public. In response, Health Canada appointed two advisory committees to work collaboratively—a Scientific Review Committee and a Communications/Implementation Committee (16). The appointment of two distinct committees with different membership recognized the importance of science expertise to report in scientific language the characteristics of a healthful diet and that translating scientific guidelines into actionable messages for consumers required a different set of expertise. To ensure that the work evolved collaboratively, a liaison was provided by Health Canada coordinators. In addition, the process set in motion an approach that looked across nutrition-related chronic diseases rather than the earlier focus on one disease. The Scientific Review Committee was charged with describing the characteristics of a diet that would supply recommended levels of nutrients while reducing the risk of chronic disease (17). In completing this task, the Committee reviewed the scientific evidence on nutrient requirements, as well as the relationships between diet, nutrition and disease. The result of this exercise was Nutrition Recommendations for Canadians (18), a set of eight statements outlining the desired characteristics of the Canadian diet for use by the scientific and professional community (Figure 1). The Scientific Review Committee also updated the Recommended Nutrient Intakes (16), marking the first time in Canada that a review of nutrient requirements and a review of the role of diet in disease prevention were conducted concurrently (13). The second committee, the Communications/ImplementaS26 / December 2003 Suppl 2 Volume 103 Number 12
tion Committee, was the first of its kind in Canada. It consisted of representatives of the academic community, industry, and nongovernmental organizations who provided expertise in nutrition communications and education, community nutrition, policy, planning, and research, recognizing the unique contribution provided by communicators and educators in translating scientific guidelines into actionable messages. The mandate of the Committee was to translate the Nutrition Recommendations into dietary advice for the Canadian public and to recommend implementation strategies to facilitate comprehensive use and integration of the dietary guidelines into the policies, programs, and messages (19). The Communications/Implementation Committee designed a very inclusive, intersectoral and multidisciplinary process in fulfilling its mandate. Consultation with nutritionists, universities, professional associations, industry groups, and nongovernmental health organizations was designed not only to garner input on strategies for implementation, but also to maximize consensus on one common set of dietary guidelines to be used by all stakeholders when communicating with Canadians. The result of this process was Canada’s Guidelines for Healthy Eating (19)—five statements that are the key nutrition messages to be communicated to healthy Canadians older than two years of age (Figure 2). The translation of the Nutrition Recommendations into Canada’s Guidelines for Healthy Eating was guided by a number of principles, including scientific accuracy, positive tone, action-orientation, and a level of language that would enable comprehension by the majority of Canadians (19). Although the Guidelines were based on the scientifically derived Nutrition Recommendations, they do not include numbers, percentages, or technical terms. For example, the Nutrition Recommendations identified a desired dietary characteristic as consuming “no more than . . . 10% of energy as saturated fat” (18). Canada’s Guidelines for Healthy Eating translated this statement as: “Choose lower fat dairy products, leaner meats and foods prepared with little or no fat” (18), recognizing the primary sources of saturated fat in the diets of Canadians. A series of recommendations for implementation accompanied Canada’s Guidelines for Healthy Eating (19). The influence of health promotion was evident in the strategies that were identified. The need to go beyond the provision of information in order to promote healthful eating was clearly recognized. Thus, a plan was developed to assist in the implementation of the Guidelines, including five strategies for action: the development of food and nutrition policies; collaboration and coordination among partners; multisectoral, community-based nutrition initiatives; the creation of supportive environments in various locations including schools and worksites; and research and evaluation. All sectors, including national, provincial and local governments, nongovernmental organizations, the food industry, and consumers, were called upon to make a commitment to the communication and implementation of the Guidelines. Furthermore, provisions were made to enable organizations to use the Guidelines as their own, as well as for the Guidelines to appear on food labels and in food advertising (20). This development enabled a new era of collaboration of government, nutrition educators and disease-specific health charities with the food industry as healthful eating messages were communicated to consumers on food labels and in food advertising. Another vehicle identified for the implementation of Canada’s Guidelines to Healthy Eating was Canada’s Food Guide.
Feedback from nutrition professionals and a review of the literature led to the conclusion that there was a continuing need for a key nutrition education tool like the Food Guide to support the implementation of the Guidelines (19). However, it was also concluded that substantial changes to the Food Guide were needed to ensure its relevance and usefulness. The Communications/Implementation Committee made a series of recommendations, including the need to recognize the total diet rather than continuing with the foundation diet that previous food guides had embraced. The total diet approach provides guidance to meet nutrient recommendations across a range of energy intakes, in contrast to the foundation diet approach in which minimum food intakes were suggested to provide essential nutrients in amounts recommended. An extensive process was then undertaken by Health Canada, including market research, communication research, and widespread consultation (21). Criteria governing the revision of the Food Guide included that it be readable, acceptable, realistic, accessible, affordable, easy to understand, practical, attractive, and motivating (21). The ultimate product of the process was seen to be more than a piece of paper—the multisectoral and multidisciplinary process of developing it was designed to engage all stakeholders in the importance of healthful eating and an understanding of what that meant and what was needed. The result of this process was Canada’s Food Guide to Healthy Eating (22) (Figure 3), which was launched in 1992. CONCLUSION AND DIRECTIONS FOR THE FUTURE This article will conclude with thoughts on content and process determinants of current dietary guidance, and possible directions for the future. In terms of content, the 1990 dietary guidance review included an updated scientific description of the characteristics of a healthful diet in the form of Nutrition Recommendations, as well as key nutrition messages for consumers in the form of Canada’s Guidelines for Healthy Eating. Furthermore, the review resulted in an updated consumer tool to guide food choices in the form of Canada’s Food Guide to Healthy Eating. The process embraced an integrated approach, using two linked committees with distinct but complementary expertise to incorporate current science and address consumer needs. Health promotion principles were emphasized in that, whereas the products of the review were considered important in terms of content, the process was important in terms of changing conditions to support healthful eating. The need to go beyond the provision of information in order to promote healthful eating was clearly recognized. Finally, the process placed consumer needs at the center. The result was evidence-based, consumer-friendly, actionable Guidelines, as well as a comprehensive implementation strategy, including tools such as Canada’s Food Guide to Healthy Eating. A decade later, Canada’s participation in the development of the Dietary Reference Intakes has resulted in updated nutrient requirement values and better tools for dietary planning and assessment. Thus, there is a need to review our dietary guidance—including the Nutrition Recommendations for Canadi-
ans, Canada’s Guidelines to Healthy Eating, and Canada’s Food Guide for Healthy Eating—and, if necessary, update that guidance to ensure that it adequately promotes the nutritional health and well being of Canadians. Current health issues, such as prevalence of nutrition-related chronic diseases including obesity, will need to be carefully considered. The process that was implemented during the previous guidance review will inform the next review, and those aspects that served Canadians well can be identified and maintained. The development and implementation of updated dietary guidance will need to involve stakeholders from all sectors, including the public, and will need to be based on the best evidence available so that the resulting guidance is scientifically sound, communicates with the public in a meaningful way, and continues to support efforts to improve nutritional health and well being. References 1. Pett LB. Food makes a difference. Can J Public Health. 1942;33:565-570. 2. Health & Welfare Canada. Rules out— guide in. Can Nutr Notes. 1961;17: 49-50. 3. Report of the Committee on Diet and Cardiovascular Disease. Ottawa, ON: Health & Welfare Canada; 1976. 4. Beare-Rogers JL. Food and nutrition guidelines in Canada. In: Selvey N, White PL, eds. Nutrition in the 1980s: Constraints on Our Knowledge. New York: Alan R. Liss, Inc; 1981:481-489. 5. Murray TK, Rae J. Nutrition recommendations for Canadians. Can Med Assoc J. 1979;120:1241-1242. 6. Murray TK, Rae J. Nutrition and heart disease—a prevention program. J Can Diet Assoc. 1979;39:6-10. 7. Murray TK. Diet and health: The Canadian experience. Am J Clin Nutr. 1987;45:1390-1393. 8. Canada’s Food Guide. Ottawa, ON: Health & Welfare Canada; 1977. 9. Action Towards Healthy Eating Technical Report: The Report of the Task and Technical Groups on Canada’s Food Guide and the Task Group on Food Consumption. Ottawa, ON: Health & Welfare Canada; 1990. 10. World Health Organization. Ottawa Charter for Health Promotion, First International Conference on Health Promotion; 1986. 11. Nielsen H. Nutrition in health promotion programs: A Canadian perspective. Hum Nutr Appl Nutr. 1983;37A:165-171. 12. Achieving Health for All: A Framework for Health Promotion. Ottawa, ON: Health & Welfare Canada; 1986. 13. Murray TK, Beare-Rogers JL. Nutrition recommendations, 1990. J Can Diet Assoc. 1990;51:391-395. 14. National Institute of Nutrition. Rapport. 1986;1(3). 15. National Institute of Nutrition. Rapport. 1987;2(2). 16. National Institute of Nutrition. Rapport. 1987;2(3). 17. Nutrition Recommendations: The Report of the Scientific Review Committee. Ottawa, ON: Health Canada; 1990. 18. Nutrition Recommendations... A Call For Action. Summary Report of the Scientific Review Committee and the Communications/Implementation Committee. Ottawa, ON: Health Canada; 1989. 19. Action Towards Healthy Eating: The Report of the Communications/ Implementation Committee. Ottawa, ON: Health Canada; 1990. 20. Guidelines on the Use of Nutrition Recommendations and Canada’s Guidelines to Healthy Eating in the Sale of Food. Ottawa, ON: Health Canada; 1995. 21. Connolly CR. A new era in nutrition guidance in Canada. Rapport. 1992; 7(4). 22. Canada’s Food Guide to Healthy Eating. Ottawa, ON: Health Canada; 1992.
This manuscript is based on a presentation given at the Dietary Guidelines Symposium at the University of Toronto in 2002. The authors thank Stefa Katamay for her valuable contribution to the original presentation.
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