Summary of Dietary Guidance Regional Meetings (May-June 2005)

Introduction:

Developing dietary guidance that defines and promotes healthy eating among Canadians has been a priority at Health Canada over many years. The overall purpose of dietary guidance is to identify and promote a pattern of eating that meets nutrient needs and reduces the risk of nutrition-related chronic diseases such as obesity, diabetes, cancer and cardiovascular disease. Health Canada's guidance is based on an analysis of the scientific evidence about the role of nutrition in health as well as an understanding of the environment within which Canadians are making food choices and current patterns of consumption. As scientific knowledge evolves and Canadians continue to adapt to their changing environments, it is important to provide appropriately updated and relevant dietary guidance for Canadians.

Since Canada's Food Guide to Healthy Eating and supporting materials were released in the early 1990's, a number of changes have taken place that resulted in a decision to review and update dietary guidance in Canada. Some of these changes include updated nutrient reference values for healthy populations, as well as an evolving food supply and patterns of eating, rising rates of nutrition-related chronic disease, and an environment that affects the lifestyles of Canadians and their food choices.

Background

An important part of the process to update dietary guidance in Canada involves ongoing stakeholder consultation. In May and June 2005, a series of half-day meetings were held with stakeholders across the country. The objectives of the meetings were:

• to update stakeholders on Health Canada's proposed approach for national dietary guidance
• to provide stakeholders with an opportunity to participate in a dialogue on the proposed approach
• to seek input from stakeholders on the types of information and tools that would be useful and effective in delivering healthy eating guidance to Canadians.

The agenda for the meetings was divided into two parts.

Part One of the Agenda

Participants were given an overview of Health Canada's proposed approach to update national dietary guidance and the opportunity to provide feedback. The proposed approach included:

• A decision that the 1990 Nutrition Recommendations for Canadians as such would not be updated. The estimates of nutrient requirements contained in the 1990 Nutrition Recommendations and the evidence supporting these have been superseded by the requirement estimates developed in the series of DRI reports;
  
  
• A report that summarizes the DRIs and their uses and interpretation will be developed through a contract between Health Canada and the U.S. Institutes of Medicine. The report will be available in 2006 in both English and French;
  
  
• Health Canada will provide explanations on how the DRIs are being implemented in Canadian policy initiatives (e.g., the development and updating of Prenatal and Infant Feeding statements; and an updated Food Guide);
  
  
• Work will continue to build the evidence base that will form the underpinning for dietary guidance in Canada including:
  • Considering the linkages between food patterns and chronic disease
  • Considering the changing environmental factors
  • Undertaking communications and marketing research.

Part one of the meeting concluded with an open question and answer session.

Part Two of the Agenda

Participants were provided with an outline of a proposed package of key tools that could be included as a basic Food Guide package for release in the Spring 2006 and asked for their reaction and input. The proposed tools included:

• Resource for consumers
• Resource for health professionals
• Interactive web based application
• Opportunities to sustain messaging/ongoing dialogue with Canadians

During this part of the meeting, those who participated in person were organized into small groups (average number of participants per group was 7) and asked to complete booklets containing feedback questions. A small percentage of stakeholders participated via teleconference with the opportunity to submit additional comments by fax or email.

Participants

There were approximately 1000 stakeholders involved from several sectors including health profession associations, non-government organizations, universities, the food industry, consumer groups, and all levels of government (Table 1).

Table 1: Breakdown of Regional Meeting Participants by Province

City & Province	Number of Booklets*	Number of Participants (in person)**	Number of Participants (teleconference)
St. John's, Newfoundland	6	32	0
Halifax, Nova Scotia	10	142	0
Moncton, New Brunswick	8	68	0
Charlottetown, Prince Edward Isl.	6	39	0
Burnaby, British Columbia	13	105	0
Edmonton, Alberta	12	74	0
Regina, Saskatchewan	7	27	19
Winnipeg, Manitoba	11	59	0
Ottawa, Ontario	13	108	0
Montreal, Quebec	11	78	0
Toronto, Ontario	19	133	0
Yellowknife, Northwest Territories		19	7
Teleconference: Northern Ontario		N/A	55
Teleconference: British Columbia		N/A	30
Total		884	111

* Average number of participants per booklet was 7.
** Based on a "final" participants' list.

Methodology

Data Collection
The data in this report is based on response of participants (in part two of the agenda) to three key questions:

Q1: What do you like about the proposed key tools? Why?

Q2: What improvements or enhancements to the key tools would you suggest? Why?

Q3: Given the target population of Canadians, two years of age and over, how do we balance the specific needs of different users?

Data Analysis
Comments from the booklets and teleconferences were grouped into common themes and quantified by tallying the number of comments related to a common theme and comparing it to the total number of booklets submitted to determine an approximate ratio.

The comments received from the different meetings were similar and thus summarized collectively. The participants offered a number of interesting examples and suggestions for tools, content, and communication of the Food Guide. For the purposes of this report, comments have been generalized to give an overview of the responses.

Report Organization

The organization of the report is as follows:

• General information
  • Positive aspects of the proposed key tools (Q1 analysis)
  • Addressing the issue of customization of the Food Guide for diverse dietary needs (Q3 analysis)
• Feedback on the resource tools (Q2 analysis) as specifically related to:
  • Consumers
  • Health professionals
  • Internet web site
• Communication of healthy eating messages, which addresses implementation and delivery of the Food Guide
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General Information

Positive Aspects of Proposed Key Tools
Participants were asked what aspects they liked about the proposed key tools (Q1). The most common responses in order of decreasing frequency were:

• Incorporation of an interactive web-based component (~2/3 of respondents). This would be especially useful in targeting youth, would help deliver more personalized messages to diverse people, and would be an excellent resource for consumers and professionals to obtain additional health and nutritional information.
  
  
• Practical action-oriented messages and implementation tips (~1/3 of respondents) that would help Canadians translate the Food Guide to daily life.
  
  
• Three types of resources - health professional, consumer, web-based - recognizing different requirements for various groups (~1/3 of respondents).
  
  
• Increased availability of information and resources to consumers and health professionals (~1/3 of respondents) in hard copy including more information, additional web resources, and the inclusion of more science-based messages (rationale) for greater overall education. It was thought that a rationale would also result in more confidence and consistent messaging as well as increased understanding and credibility of the Food Guide.
  
  
• A broader healthy living message through integration of the Food and Physical Activity guides (~1/3 of respondents).

Stakeholders also mentioned the robust package conducive to maximum accessibility by having web and paper resources, clearer terminology (e.g., moderation), and the flexibility and user-friendliness of the proposed tools. Positive comments were also made about the plan for improved graphics to increase visual appeal and to target different groups (e.g., low-literacy) as well as the proposed social marketing plan and phased-in approach for the production of supplementary resources.

Customizing the Food Guide to Individuals
Many participants acknowledged the challenge of how to individualize the Food Guide recommendations to different Canadians while maintaining a simple, compact, practical guide that is accessible to all, user-friendly for professionals and educators, and clearly delivers the key messages. There were two perspectives on how to address the diversity of the Canadian population:

1. A general guide applicable to most of the population with additional resources/ tools to address individual needs. For simplicity reasons, many stakeholders did not want multiple guides, but rather well-developed tools that would help consumers and professionals personalize the guide if required.
   
   
2. Multiple guides to target different groups. Many suggested various age-specific guidelines, similar to the Physical Activity Guide, because of the perception that one guide could not address the needs of everyone and too general a guide could result in more confusion and be less effective. The main concern raised was in addressing the different nutritional needs related to age/stage, particularly with regards to portion sizes for children, adults, and seniors. Adapting the Food Guide to address different targets could result in more meaningful guidance.

Other segments of the population that would best be served with more specific guidance and advice included multi-cultural groups (through the use of language and visual adaptations), vegetarians, poor socioeconomic groups, adolescents, pregnant women, infants, and those on specialized diets and with specific health problems. The subgroups most frequently mentioned are listed in Table 2. These numbers are based on comments from Question 3. For example, 38 booklets mentioned that seniors had special dietary needs.

Table 2: Target Groups Most Often Mentioned

Target Group	# of Times Mentioned
Seniors	38
Ethnic/culturally diverse	34
Children *	27
Vegetarians	16
ESL/ low literacy/ low income	16
Adult	16
Teens	15
Preschoolers	9
Pregnant women	7
Parents	7
Infants	6
Youth	5
Prenatal	4
Gender-specific	4
Chronic disease (diabetes, CVD, etc...)	4
Children (2-5 years olds)	4
Athletes/ active	4
Aboriginal/ First Nations	4
Urban/ rural locations	3
According to Physical Activity Guide breakdown	3
Postnatal	2
Allergic	2
Specific health problems	1

* True number significantly higher since many comments/ suggestions specifically targeted resources/ tools to educate children or for parents/ educators of children. Serving size was the main issue suggesting separate guides to distinguish seniors, children, and adults.

Regardless of the preferred guide format, the need for additional resources to target different individuals and the ability to customize the guidance was a theme in all of the feedback. Reinforcement of the message through personal communication in a number of settings (e.g., schools, community groups, etc) and by different professionals/partners (e.g., physicians, teachers, librarians, etc) was also considered to be important.

Feedback on Resource Tools

General Criteria for Resources

• Simple, clear, ready-to-use.
• Adaptable and accessible to different people (e.g., language translations, visual representations, widespread availability).
• Guidance should be practical and simple for consumers to relate to their daily life.
• Tearsheets and posters are popular resources.
• Web and paper resources are required.
• Interactive resources preferred.
• Strong visual/graphics component to deliver messages that could be understood by many audiences.

Consumer Resources
Numerous suggestions were received on how to adapt resources to consumer needs, adapt the Food Guide to different populations, provide practical implementation tips, and educate consumers.

Consumers require practical resources to translate the Food Guide to their daily life. Many felt that children in particular should be targeted through fun activities, schools, and healthy messaging directed at parents. Practical meal planning tips, shopping lists, meal scenarios for different lifestyles (e.g., mother with school-age children, students living in a university residence), recipes, and food preparation tools were suggested. Tools that give the Food Guide a clear everyday presence in the lives of Canadians were also suggested (e.g., refrigerator magnets, credit-card sized tip sheet or key chain).

It was suggested to target different cultural groups by translating the Guide into key languages (e.g., Chinese, Arabic, Vietnamese, Hindi, and Punjabi, native), including popular ethnic foods in the main Food Guide, or the option to include them in personalized guides (e.g., pictorial representations of ethnic vegetables), and separate multi-cultural guides. Consumers with different literacy levels could be targeted using improved graphic representations. Large print resources were recommended for seniors.

Confusion about serving sizes and serving ranges was identified most often as the concept that consumers have difficulty grasping. Better visual depictions of portion sizes and practical examples such as the dinner plate method, Zimbabwe hand jive method, tennis ball, computer mouse, or palm of the hand were recommended. Additionally, narrower serving ranges based on age were suggested to minimize confusion.

Supplemental resources giving more examples of foods in each food group were recommended as resources to address the issue of combination foods. This would allow ethnic groups and those who purchase convenience foods to better assess their food intake. For example, one group suggested a resource showing the "anatomy of a sandwich" decomposing each of the elements (e.g., bread, cheese, meat) into their respective food groups. A number of participants felt that the "other foods" category required more examples to clarify the terminology. Some stakeholders felt that recognition of eating settings and realistic food choices (e.g., prepared and convenience foods, restaurants, fast food, meal replacement bars, etc) should be addressed by providing additional resources on how these foods fit into the Food Guide. Examples of healthy substitutions to traditionally unhealthy food options (e.g., snacks) could be given as well.

A number of stakeholders requested additional resources to teach consumers to relate the Nutrition Facts Table with the serving sizes in the Food Guide, to address current and trendy health foods, supplements, health issues and fads, and resources to reflect regional/seasonal food availability. Fact sheets helping consumers to understand the food groups as well as the scientific rationale behind them were also recommended since consumers could also be divided into those who want specific dietary guidance (e.g., an apple and two carrots) and those who prefer to understand the science behind the recommendations to make their own food choices. Additional scientific evidence for the Food Guide should be available to consumers to increase its credibility and provide the additional detail that consumers seek.

Some participants felt that sugars, different types of fats, water, and fibre should be separated from the food groups to highlight their significance in healthy/unhealthy dietary patterns.

Professional Resources
In general, participants responded positively to the concept of having targeted resources for consumers and health professionals and making available the science/rationale behind messages in the Guide. Some felt that the term "professional" should be broadened to include the spectrum of educators and communicators of the message (e.g., personal trainers, teachers, day care workers, food banks, etc) in addition to health professionals (physicians, dietitians, etc).

Participants suggested that resources should be simple, clear, practical, visual, and ready-to-use. Resource kits that would make all of the information available in one location would be useful. Some comments included suggestions that the guide and resources should be concise so that the information could be delivered in one minute or less for use by physicians.

A broader range of foods (e.g., more variety, less common, ethnic, combination) should be included so that the guide could be adapted to different populations. Easy access to information explaining the science behind the recommendations was also requested. Some health professionals also felt that the level of detail behind current health professional resources was insufficient and simplistic.

Educators requested ready-to-use, interactive tools that could be used with children (e.g., lesson plans, flash cards, colouring sheets, wall charts, etc). Working with teachers to develop resources was suggested as was incorporating the Food Guide in the curriculum. Specific training and resources were also suggested to help educators learn the material themselves.

Specialized "train the trainer" sessions were also recommended to teach educators and health professionals how to use the resources and learn how to promote the Food Guide.

Specific resources targeted at the food industry were also recommended to help develop healthier products in line with the Food Guide. A number of stakeholders commented on the importance of the food industry in helping to deliver the healthy eating message and the lack of resources directly targeted towards them.

Web Resources
The majority (70% of participants) thought that interactive web-based resources would be useful, particularly if targeted at the younger population, and would need to be interactive to allow consumers to customize the information (e.g., age, gender, height, weight, level of physical activity). There were suggestions for a personalized Food Guide that could be generated on the web site based on a blank template that could then be printed. The use of common web tools such as the ability to create a personalized user account and the ability to track visitors to the site, was also mentioned. Some recommended specific areas such as a "Kids' Zone" with games and activities, as well as areas for consumers and health professionals.

In addition to being able to provide individuality, web resources should be user-friendly and straightforward to navigate. The URL should be recognizable and easy to access via the main Health Canada web site or a simple internet search.

Web resources were also identified as being key in providing additional information to interested individuals, increasing accessibility to healthy eating information, and being adaptable to all foods. This could allow the food guide to be general in nature, with the web providing more detailed personal information. Various links should be provided to existing resources such as health or food-related sites and numerous participants suggested a link to the Dietitians of Canada EATracker and direct links to personalized advice from a dietitian via the Internet or a 1-800 number.

Many also emphasized that the web site could not be the only method to disseminate the Food Guide. Paper resources for the online materials and personal contact were still considered important for many segments of the population (e.g., low socio-economic groups, low-literacy or low-income groups, ethnic groups and the elderly). A CD or DVD version of the web could also be provided for those with computers but limited Internet access.

Communicating Healthy Eating Messages

In general, stakeholders felt that the communication of healthy eating messages to Canadians should be simple, targeted, consistent, based on scientific evidence, and readily available.

A clearly defined communication plan for the new Food Guide was recommended. Some stakeholders felt that the proposed phased-in approach to supplementary resources was a good idea, thus maximizing on opportunities to market the Food Guide and "keep it fresh".

Numerous stakeholders emphasized the critical role of an extensive social marketing plan to increase the awareness of Canada's Food Guide. Mass marketing and advertising using popular media (e.g., television, radio, posters on buses, etc) was suggested, as was increasing the availability of the Guide at different "points of purchase" (e.g., supermarkets, pharmacies, doctors' offices, work places, libraries, or through mass distribution techniques such as with income tax forms). Some participants suggested that the Food Guide should become another "diet" option and possibly branded.

The need for partnerships such as with nutrition and health experts, restaurants, non-governmental organizations, the food industry, pharmacies, institutions, special interest groups such as The Canadian Diabetes Association, etc. at various stages of the implementation plan was also frequently mentioned. These partnerships could be used to develop targeted resources, increase the distribution of the Food Guide, and better convey healthy eating messages.