PNPAS & EIPAS: Transforming the food environment in Portugal

The National Programme for the Promotion of Healthy Eating

To address the issue, the Portuguese government launched the National Programme for the Promotion of Healthy Eating (PNPAS) in 2012. The development and implementation of the programme were coordinated by the Directorate-General for Health (DGS), a public agency of the Ministry of Health that plans, regulates, coordinates, and supervises all health promotion activities in Portugal, including food and nutrition programmes [2].

The PNPAS is a comprehensive programme aimed at improving and ensuring equal access to healthy foods for everyone. It aligns its strategies with various stakeholders in the sector, from food production to consumers, and takes into account international guidelines from organisations such as the European Commission, the World Health Organisation (WHO), and the European Agency for Food Safety [1].

The main goals of the PNPAS are to improve the nutritional status of the Portuguese population by promoting the availability and accessibility of healthy foods, regulating the availability of unhealthy foods, enhancing food literacy, and fostering collaboration across different sectors. The programme is based on the core principles of the Mediterranean Diet.

The PNPAS has five main objectives:

1. Knowledge: The PNPAS aims to enhance understanding of food consumption patterns, determinants, and consequences among the Portuguese population. This involves conducting research on food consumption, as well as developing educational resources to promote awareness of the importance of healthy eating.
2. Availability: This involves taking actions to modify the availability of specific foods in public spaces. These actions include strict regulations on foods offered in hospitals, workspaces, and schools. Collaboration with food retailers and foodservice providers is essential to ensure that healthy foods are more accessible and affordable.
3. Information and training: The PNPAS focuses on informing and training individuals, families, communities, and professionals in the food sector on how to make informed choices when purchasing, cooking, and storing healthy foods.
4. Transversal actions: Identifying and promoting cross-sectoral actions that encourage the consumption of nutritious foods. Collaboration with various sectors such as agriculture, sports, environment, education, social security, and municipalities is crucial to create an enabling environment for healthy eating.
5. Professional qualifications: The PNPAS aims to improve the qualifications and working methods of professionals who have the potential to influence knowledge, attitudes, and behaviours in the food domain. This objective focuses on enhancing the capabilities of professionals to promote healthy eating practices.

Achievements

During the first few years, the programme achieved significant milestones by developing a new communication strategy to effectively disseminate accurate information on food and nutrition. Various digital channels were utilised, including the PNPAS website (https://alimentacaosaudavel.dgs.pt/), the Nutrimento Blog (www.nutrimento.pt), and social media platforms, to reach a wide audience [3]. Additionally, the programme provided support for research projects aimed at increasing the availability of data on nutritional status, food consumption, and health outcomes. For instance, the development of the National Food and Nutrition Survey in 2015 has filled a data gap of over 40 years regarding the food consumption patterns of the Portuguese population.

In 2013, the Portuguese government introduced mandatory nutrition standards for school lunch meals, ensuring that they meet specific nutritional requirements. These standards include the provision of a minimum amount of fruits and vegetables in each meal [2].

In 2016, the Portuguese government collaborated with the Ministry of Social Security to establish a new strategy for the Portuguese food aid programme targeting the most deprived individuals. This strategy was based on three main pillars: developing nutritional guidelines for the Portuguese Food Basket to ensure it provides the necessary nutrients for good health, empowering social institutions responsible for distributing the food basket through training to enhance efficiency, and improving the food and nutrition literacy of beneficiaries. The food basket is distributed on a monthly basis to the most deprived individuals, with the aim of meeting at least 50% of their nutritional needs [2].

Alongside these policy actions, the PNPAS has also undertaken several educational initiatives, such as launching a successful Massive Open Online Course focused on promoting healthy eating habits, which attracted over 8,000 participants across two editions [2]. Furthermore, the programme has developed informative materials tailored to specific vulnerable populations, including braille materials providing information about the Mediterranean diet for individuals with visual impairments.

Another significant strategic initiative by the PNPAS involves promoting a nutritious diet in workplace environments and restaurants. As a partner of the Fighting Obesity through Offer and Demand (FOOD) programme, which involves multiple European countries and collaborators, Portugal has joined forces to target two main groups: working population and the restaurants where they go for lunch (watch a video to learn more: http://www.food-programme.eu/en/about/food-from-2009-to-today/article/fighting-obesity-through-offer-and-demand). Meal voucher is at the core of the healthy food promotion by FOOD. The voucher represents the partnership between the businesses and food establishments that agreed to follow the specific recommendations. The FOOD recommendations have been developed after an extensive 8-month analysis of inventory, surveys, and studies. This process allowed the partners to create straightforward and applicable guidelines for both employees and restaurant owners/chefs. The table below presents daily suggestions aimed at fostering instinctive habits for a healthier and more balanced diet in Portugal:

Source: http://www.food-programme.eu/en/tools/article/recommendations

Also, if the establishment follows the FOOD guidelines, it gets included into the digital locator of recommended places that public can access here: http://www.food-programme.eu/en/restaurant-finder/article/restaurant-finder-310.

The Integrated Strategy for the Promotion of Healthy Eating

The PNPAS ran from 2012 to 2016 as planned, but it faced challenges due to the absence of a multi-sectorial approach and difficulties in obtaining a formal whole-of-government commitment towards the Public Health Programme Goals [2]. In 2016, the Portuguese government established a work group to analyse the experience of PNPAS and develop an inter ministerial strategy to further improve healthy dietary habits among the population. This work group was tasked with creating new strategies based on the WHO's "health in all policies" concept. By December 2017, the new programme was announced as the Integrated Strategy for the Promotion of Healthy Eating (EIPAS), which involved more stakeholders, including seven different ministries [2].

The EIPAS strategy was developed through a process of public consultations and incorporating input from various stakeholders. Similar to PNPAS, EIPAS is coordinated by the DGS and receives full funding from the Portuguese government [2].

EIPAS encompasses 51 intervention measures that are categorised into four strategic areas:

1. Modification of the food environment: This area focuses on enhancing the accessibility and affordability of healthy foods while reducing the availability of unhealthy options.

   - Monitoring the nutritional composition of the food supply

   - Reformulation of food products

   - Improvement of food supply in State institutions

   - Improvement of food supply in restaurants

2. Improving the quality and accessibility of information: This area aims to provide individuals with the necessary information to make informed decisions about their food choices.

   - Monitoring nutritional labelling of food products

   - Limitation of food advertising and marketing

   - Promoting communication about healthy eating in State institutions and the food sector

   - Local strategies for promoting healthy eating

   - Dissemination of good practices in promoting healthy eating

3. Promoting and developing consumer literacy and autonomy for healthy food choices: This area aims to empower individuals to make informed decisions about their food consumption.

   - Improved communication about nutrition in the first 1000 days of life for parents and the population

   - Promotion of the Mediterranean Diet and national products

   - Improved communication about healthy eating to the general population

   - Qualification and training of professionals

4. Promoting innovation and entrepreneurship in the field of healthy eating: This area supports the development of new products and services that promote healthy eating.

   - Digital communication in public institutions

Achievements

Under EIPAS, Portugal has achieved several significant milestones.

Firstly, in 2017, the government introduced a sugar tax on sweetened beverages. This tax applies to beverages with at least 8 grams of sugar per 100 millilitres and is set at €16.46 per hectolitre for such beverages, and €8.22 per hectolitre for those with less sugar content. The tax is applied to all sweetened beverages, including soft drinks, energy drinks, sports drinks, and fruit juices. It is not applied to alcoholic beverages, milk, or unsweetened tea and coffee [4]. The revenue from the tax is being used to fund the Portuguese National Health Service [5].

A study by Goiana-da-Silva et al (2020) reported that implementing tax measures targeting sugar consumption in Portugal could potentially prevent 40 to 78 new obesity cases per year. Also, taxation had an effect on overall sugary beverages consumption resulting in an estimated 7% decrease in sales. Moreover, to avoid the higher tax, manufacturers reformulated their products to contain lower sugar levels, leading to an estimated 11% reduction in energy intake from the beverages containing sugar [4].

Secondly, a new food aid programme was launched in 2016 to assist low-income groups. This initiative ensures that individuals and families who struggle financially have access to nutritionally adequate food.

Moreover, mandatory nutrition standards were implemented for vending machines and buffets/cafeterias in healthcare and educational facilities between 2016 and 2017. These standards require healthcare vending machines to offer at least 50% healthy food options, such as fruits, vegetables, and whole grains.

In 2019, public food establishments were encouraged to prioritise purchasing food from local producers, promoting sustainability and supporting the local agriculture industry.

Furthermore, Portugal has taken the lead in the European Union by enacting a regulation governing the digital marketing of unhealthy foods to children. This regulation, which came into effect in April 2019 under Law No. 30/2019, aims to protect children under the age of 16 from advertising campaigns promoting high-energy products and those with excessive levels of salt, sugar, and saturated fats. More information on Portugal's marketing regulations can be found here. 

To know more about EIPAS ongoing progress visit: www.eipas.pt

Portugal serves as an example of how regulatory health policies can effectively benefit the population. Through initiatives such as PNPAS and EIPAS, Portugal has demonstrated a strong commitment to improving public health. By implementing measures like sugar taxes, mandatory nutrition standards, and restrictions on unhealthy food marketing, Portugal has shown that regulatory interventions can have a positive impact on promoting healthy lifestyles. The country's proactive approach can be used as an example for other nations seeking to prioritise the well-being of their population through effective health policies.

References 

[1] Graça, P., Gregório, M. (2015) “Strategy for the promotion of healthy eating in Portugal”. Health by Numbers Portugal; 4; 36-40.

[2] Graça, P., Gregório, M.J., de Sousa, S.M. et al. (2018) A new interministerial strategy for the promotion of healthy eating in Portugal: implementation and initial results. Health Res Policy Sys 16, 102. https://doi.org/10.1186/s12961-018-0380-3.

[3] Graça, P., Gregório, M.J., de Sousa, S.M. et al. (2016) “The Portuguese National Programme for the Promotion of Healthy Eating: 2012–2015. Report”. Public health panorama, Volume 2; Issue 2. https://apps.who.int/iris/bitstream/handle/10665/325433/php-2-2-184-209-eng.pdf?sequence=1&isAllowed=y

[4] Goiana-da-Silva, F., et al (2020) “Projected impact of the Portuguese sugar-sweetened beverage tax on obesity incidence across different age groups: A modelling study”. Plos Medicine. Open access https://doi.org/10.1371/journal.pmed.1003036

[5] The Portugal News. (2021). Government to increase tax on sugary drinks. The Portugal News. Retrieved from https://www.theportugalnews.com/news/2021-10-18/government-to-increases-tax-on-sugary-drinks/63010

[6] Portugal | Institute for Health Metrics and Evaluation (healthdata.org)