**3. Guideline for healthy eating**

#### **3.1. Balanced diet**

Consuming a healthy diet throughout life is one key for maintaining strength and good health. Eating a wide variety of foods in the right proportions can achieve and maintain healthy body weight and prevent malnutrition of all forms as well as a range of NCDs. Foods from nature provide both nutrients and non-nutrients that benefit human health. The basic elements, or nutritional requirements, for a healthy diet must include the right amounts of energy, protein, fat, carbohydrates, vitamins, minerals and water for the body. These requirements, in fact, differ for different individuals and at different life stages. However, sets of


**Table 1.** Impacts from double burden malnutrition in the world as quoted by World Health Organization in 2010.

nutrient requirements have been established for general populations living in many countries. These sets go by different names, such as Dietary Reference Intake (DRI) in the United States and Canada, Dietary Reference Values (DRV) in the United Kingdom, etc. The human body needs different nutrients for different functions in differing amounts. Carbohydrate, fat and protein—known as 'macronutrients'—are required in much larger amounts than minerals and vitamins that are called 'micro-nutrients'. In addition, the human body's physiological function is also regulated by non-nutrient substances that are found naturally in food. Consequently, the term 'balanced diet' must contain the right amounts of the right kinds of nutrients and non-nutrients. Nutrient and non-nutrient requirements for a healthy diet are, in fact, quite individualized, since they relate to genetics, age, gender, physical activity and health status of an individual.

#### **3.2. Food-based dietary guidelines**

While under-nutrition in the form of PEM and micro-nutrient deficiencies remains unsolved in many developing countries, unfortunately the challenge of over-nutrition has also rapidly emerged, thus presenting the world with a double-burden in terms of malnutrition. Incidences of overweight, obesity and diet-related NCDs, which were mainly found in more affluent developed countries, are now growing in many developing countries at an alarming rate. The worldwide prevalence of obesity more than doubled between 1980 and 2014. Globally, NCDs are now the leading causes of death. Cardiovascular diseases, diabetes, cancer and chronic respiratory diseases caused up to 68% of deaths in 2012 [3]. Almost three-quarters of all NCD deaths occur in low- and middle-income countries [4]. Four major risk factors have been primarily responsible for the rise in NCDs are tobacco use, physical inactivity, alcohol use and unhealthy diets [5]. The rapid rise in NCDs is predicted to impede poverty reduction in low-income countries, particularly by increasing household costs associated with health care. Vulnerable and socially disadvantaged people become ill and die sooner than people of higher socio-economic status, since they are at higher risk of being exposed to harmful products, such as tobacco or unhealthy food, and have limited access to health services. To lessen the impact of NCDs on individuals and society, a comprehensive approach is needed that requires all sectors, including health, finance, foreign affairs, education, agriculture, planning and others, to work together to reduce the risks associated with NCDs, as well as promote interventions to prevent and control them. A global action plan for the prevention and control of NCDs 2013–2020 was initiated by WHO and member states. This plan aims to reduce the

Malnutrition, in every form, presents significant threats to human health. Today the world faces a double burden of malnutrition that includes both under-nutrition and over-nutrition, especially in developing countries (**Table 1**). Hunger and inadequate nutrition contribute to early deaths among mothers, infants and young children, and impaired physical and brain development in young children. Meanwhile, growing rates of overweight and obesity are linked to a rise in life-threatening chronic diseases (e.g. hypertension, stroke, cardiovascular disease, diabetes, cancer) that are difficult to treat in places with limited resources and already overburdened health systems. Nutrition problems that emerge in either direction impair individual productivity, which slow down national growth. The cost of malnutrition is approxi-

Consuming a healthy diet throughout life is one key for maintaining strength and good health. Eating a wide variety of foods in the right proportions can achieve and maintain healthy body weight and prevent malnutrition of all forms as well as a range of NCDs. Foods from nature provide both nutrients and non-nutrients that benefit human health. The basic elements, or nutritional requirements, for a healthy diet must include the right amounts of energy, protein, fat, carbohydrates, vitamins, minerals and water for the body. These requirements, in fact, differ for different individuals and at different life stages. However, sets of

number of premature deaths from NCDs by 25% by 2025 [6].

mately 3.5 trillion USD per year [7].

194 Adiposity - Epidemiology and Treatment Modalities

**3. Guideline for healthy eating**

**3.1. Balanced diet**

Information contained in the FAO/WHO recommendations on energy, protein and nutrient requirements is quite abstract and difficult for consumers to understand. Consequently, a simplified message was developed in terms of Food-Based Dietary Guidelines (FBDG) by transforming nutrients into food groups for better understanding. In the Cyprus meeting in 1995, FAO and WHO in collaboration with experts developed eating guidelines for healthy lifestyles for preventing under-nutrition, over-nutrition and unsafe food consumption [8]. These guidelines serve as principles for countries to adopt and adapt as their own guidelines. Upon implementation, a guideline can be periodically revised in line with current scientific evidence. Over 100 countries worldwide have developed their own FBDGs that are suitable for their own nutrition situations, food availability, culinary cultures and eating habits. From the simplified message, FBDGs have been developed into more consumer-friendly formats, especially in terms of graphic design. Examples of graphical FBDGs from different countries are shown in **Figure 4**. Many of the designs are specific to the cultures of implementing countries. In addition, a design can also be modified if it proves to be an ineffective tool for consumer education, especially for preventing NCDs. For example, the USA's graphical

**Figure 4.** Examples of graphical FBDGs implemented in different countries. *Source*: http://www.fao.org/nutrition/ nutrition-education/food-dietary-guidelines/en/.

FBDG was changed from a pyramid pattern into a plate pattern (**Figure 5**). In addition, many countries later included exercise in their graphical FBDGs, since food alone cannot lead to a healthy life. Messages on the graphical FBDGs of every country are similarly shown as food groups, not nutrients, which general consumers can more easily understand.

#### **3.3. Nutrient reference values for nutrition labelling**

In 1941, the Food and Nutrition Board first developed a set of recommended nutrient requirements known as recommended dietary allowances or RDAs. These allowances were meant to provide 'nutrients beyond enough' for civilians and military personnel, since the values included a 'margin of safety' [9]. The established values for a nutrient can be different for different requirements due to age and gender. These RDAs were subsequently revised every 5–10 years until 1997 when dietary reference intake (DRI) was introduced in order to broaden the existing RDA system. The DRI consisted of a set of four reference values: (i) estimated average requirements (EARs) wherein the average nutrient intake satisfies the needs of 50%

Nutrition Labelling: Educational Tool for Reducing Risks of Obesity-Related Non-communicable Diseases http://dx.doi.org/10.5772/65728 197

**Figure 5.** Series of changes in USA's graphical FBDGs. *Source*: http://www.cnpp.usda.gov.

of healthy individuals, (ii) recommended dietary requirements (RDA) or nutrient amounts sufficient to meet the requirements of 97.5% of a population, (iii) adequate intake (AI) or the approximate value determined from observations or experiments on nutrient intake from a group or groups of healthy people (where there was no established RDA) and (iv) tolerable upper intake (UL) or the highest level of nutrient intake that is considered to be safe and causes no side effects in most people [10]. Since these sets of values were developed for specific purposes, they could be adopted directly for use as references among general consumers.

In 1985, CODEX grouped nutrients into a single set and established their reference values known as 'nutrient reference values-requirements (NRVs-R)' to be used for individuals aged older than 36 months as shown in **Table 2** [11]. Most of the NRVs-R values are similar to those listed in the RDA. The CODEX values are meant to be used as references in preparing nutrition labels for consumer education. It is expected that a consumer can decide the appropriateness of a food for his/her health by considering what percentage of a nutrient's daily requirement (%NRVs) can he/she obtain from eating a portion of a food. Percentage NRVs is meant to help consumers in making correct food choices for their health. Other than the term NRVs-R as defined by CODEX, other terminologies have been developed, such as daily value (DV) used by the U.S. Food and Drug Administration (USFDA) for their Nutrition Fact Panel (NFP). Moreover, nutrient reference values–non-communicable disease (NRVs-NCD) has also been specifically established by CODEX for consumer education in order to educate the risks of NCDs.

#### **3.4. Nutrients related to the risks of NCDs**

FBDG was changed from a pyramid pattern into a plate pattern (**Figure 5**). In addition, many countries later included exercise in their graphical FBDGs, since food alone cannot lead to a healthy life. Messages on the graphical FBDGs of every country are similarly shown as food

**Figure 4.** Examples of graphical FBDGs implemented in different countries. *Source*: http://www.fao.org/nutrition/

In 1941, the Food and Nutrition Board first developed a set of recommended nutrient requirements known as recommended dietary allowances or RDAs. These allowances were meant to provide 'nutrients beyond enough' for civilians and military personnel, since the values included a 'margin of safety' [9]. The established values for a nutrient can be different for different requirements due to age and gender. These RDAs were subsequently revised every 5–10 years until 1997 when dietary reference intake (DRI) was introduced in order to broaden the existing RDA system. The DRI consisted of a set of four reference values: (i) estimated average requirements (EARs) wherein the average nutrient intake satisfies the needs of 50%

groups, not nutrients, which general consumers can more easily understand.

**3.3. Nutrient reference values for nutrition labelling**

nutrition-education/food-dietary-guidelines/en/.

196 Adiposity - Epidemiology and Treatment Modalities

To prevent diet-related NCDs, WHO recommended healthy populations to limit their intake of saturated fat, *trans* fat, cholesterol, sugar, sodium and total energy, while ensuring adequate intakes of carbohydrate, protein and dietary fibre [12, 13]. Nutrient intake goals for preventing NCDS are shown in **Table 3**. Similarly, the FBDGs of most countries recommend limiting the consumption of fat, sugar or salt, as well as foods and beverages high in energy. For fat, concern is placed on not only the quantity but also the quality of fat consumed, especially saturated fats and *trans* fat. In addition, and based on convincing evidence, CODEX


\* For the declaration of β-carotene (provitamin A) the following conversion factor should be used: 1 µg retinol = 6 µg β-carotene.

\*\*Nutrient reference values for vitamin D, niacin and iodine may not be applicable for countries where national nutrition policies or local conditions provide sufficient allowance to ensure that individual requirements are satisfied.

**Table 2.** A set of numerical values of nutrient requirements (NRV-R) that are based on scientific data for purposes of nutrition labelling and relevant claims.

established NRVs-NCD that recommended limiting saturated fat and sodium—two main nutrients for lowering risks of NCDs—to not higher than 20 g and 2000 mg/day, respectively [11]. *Trans* fat is classified as the worst quality fat with recommended consumption at less than 1% of total energy. *Trans* fat increases blood low-density lipoprotein (bad) cholesterol as well as decreases high-density lipoprotein (good) cholesterol. The USFDA stated that partially hydrogenated oils (PHOs) are the primary dietary source of artificial *trans* fat in processed foods and must not be classified as 'generally recognized as safe' or GRAS for use in human food [14]. In contrast, increased intake of fruits, vegetables, whole grains and nuts is


*Notes*: <sup>a</sup> This is calculated as total fat – (SFAs + PUFAs + *trans* fatty acids).

established NRVs-NCD that recommended limiting saturated fat and sodium—two main nutrients for lowering risks of NCDs—to not higher than 20 g and 2000 mg/day, respectively [11]. *Trans* fat is classified as the worst quality fat with recommended consumption at less than 1% of total energy. *Trans* fat increases blood low-density lipoprotein (bad) cholesterol as well as decreases high-density lipoprotein (good) cholesterol. The USFDA stated that partially hydrogenated oils (PHOs) are the primary dietary source of artificial *trans* fat in processed foods and must not be classified as 'generally recognized as safe' or GRAS for use in human food [14]. In contrast, increased intake of fruits, vegetables, whole grains and nuts is

\* For the declaration of β-carotene (provitamin A) the following conversion factor should be used: 1 µg retinol = 6 µg

\*\*Nutrient reference values for vitamin D, niacin and iodine may not be applicable for countries where national nutrition policies or local conditions provide sufficient allowance to ensure that individual requirements are satisfied.

**Table 2.** A set of numerical values of nutrient requirements (NRV-R) that are based on scientific data for purposes of

**Nutrients Values of NRV-R**

Vitamin A (µg) 800\* Vitamin D (µg) 5\*\* Vitamin C (µg) 60 Vitamin K (µg) 60 Thiamin (mg) 1.2 Riboflavin (mg) 1.2 Niacin (mg NE) 15\*\* Vitamin B6 (mg) 1.3 Folate (µ DFE) 400 Folic acid (µg) 200 Vitamin B12 ((µg) 2.4 Pantothenate (mg) 5 Biotin (µg) 30

198 Adiposity - Epidemiology and Treatment Modalities

Calcium (mg) 1000 Magnesium (mg) 300 Iron (mg) 14 Zinc (mg) 15 Iodine (µg) 150\*\*

Protein 50

Copper Value to be established Selenium Value to be established

**Vitamins**

**Minerals**

β-carotene.

nutrition labelling and relevant claims.

b The percentage of total energy available after taking into account that consumed as protein and fat, hence the wide range. c The term 'free sugars' refers to all monosaccharides and disaccharides added to foods by the manufacturer, cook or consumer, plus sugar naturally present in honey, syrups and fruit juices.

<sup>d</sup>The suggested range should be seen in the light of the Joint WHO/FAO/Consultation on Protein and Amino Acid Requirements in Human Nutrition, held in Geneva from 9 to 16 April 2002.

e Salt should be iodized appropriately. The need to adjust salt iodization, depending on observed sodium intake and surveillance of iodine status of the population, should be recognized.

f Wholegrain cereals, fruits and vegetables are the preferred sources of NSP. The recommended intake of fruits and vegetables and consumption of wholegrain foods is likely to provide >20 g per day of NSP (>25 g per day of total dietary fibre).

\* Adapted from Diet, nutrition and the prevention of chronic diseases. Report of a joint WHO/FAO expert consultation (WHO Technical Report Series 916) [13].

**Table 3.** Recommendations for nutrient intakes in population by WHO and CODEX\* (% of total energy, unless otherwise stated).

recommended by all organizations for preventing NCDs. An average intake of a minimum of 400 g of fruits and vegetables per day, or five servings, is recommended for preventing the risks of NCDs, such as heart disease, cancer, diabetes and obesity [13]. Eating a variety of vegetables and fruits clearly ensures an adequate intake of potassium and most micro-nutrients, dietary fibre and a host of essential non-nutrient substances. The consumption of fruits and vegetables can replace foods high in saturated fats, sugar or salt.

Balanced eating at all life stage, beginning with conception, is crucial for preventing chronic diseases. Over the last two decades, growing evidence has shown that *in utero*, infant and young child under-nutrition are directly linked to vulnerability to adult NCDs [2, 15]. Consequently, public health and nutrition interventions during the first 1000 days of life, or from conception to 2 years of age, are encouraged.

It is globally accepted that deaths related to NCDs can be partly reduced by investments to promote healthy diets following WHO's recommended eating pattern among populations. Appropriate information via food and nutrition labelling, as well as restrictions on the marketing of unhealthy foods, are major interventions to promote healthy diets [16] (**Figure 6**).
