Developing tools to measure adherence to Canada’s new Food Guide

Thursday, March 12, 2020
Ottawa, Ontario

The Canadian Institutes of Health Research in collaboration with Health Canada


Health Canada, undertaking preliminary work to develop adherence tools for Canada’s new Food Guide (CFG), sought to engage researchers and policy experts in an open dialogue around how the draft adherence tools could be improved or adapted so that they are relevant and useful to a variety of users. 

The BBE provided an opportunity for participants to consider the following questions:

  1. How can Health Canada strengthen its draft adherence tools for assessing Canadians’ adherence to Canada’s new Food Guide (CFG)?
  2. What partnerships and mechanisms would facilitate the validation of Health Canada’s draft adherence tools?
  3. How do you see these tools being used? By whom?

Background and Policy Context

In January 2019, Health Canada launched Canada’s new Food Guide (CFG). Its objective is to promote healthy eating and overall nutritional well-being, and support improvements to the Canadian food environment. Health Canada used the best available evidence to translate the science on food, nutrients, and health into healthy eating guidelines that are relevant and useful to the Canadian context. The guidelines provide advice on nutritious foods and beverages that are the foundation for healthy eating; describes the types of foods and beverages that can have a negative impact on health when consumed on a regular basis; and highlights the importance of food skills as a practical way to support healthy eating. The new CFG not only provides advice on healthy food choices (“what to eat”) and but also provides advice on eating habits (“how to eat”), including guidance to eat with others and to enjoy your food. Where appropriate, these recommendations on “how” to eat will be considered along with the “what” to eat, when assessing Canadian’s adherence to the new CFG.

Assessing adherence to the CFG in a consistent manner with practical and validated adherence tools is important to reduce the risk of inconsistent research findings which could impact policy decision making and lead to confusing messages to the public. Adaptations of these tools could be explored in the future in a variety of settings with different life stage groups (e.g. children) and cultures (e.g. Indigenous).

Lessons can be learned from the development of other dietary adherence tools

Various tools have been developed to characterize healthy dietary patterns and diet quality.  Typically, they assess the amounts and types of foods in a diet according to a set of recommendations. Most of them use a point-based system. For example, the US Healthy Eating Index, helps measure alignment of dietary patterns with national dietary guidelines on a scale of 0-100 points. In 2009, Didier Garriguet developed a Canadian adaptation of the Healthy Eating Index that was used to assess adherence with the 2007 Canada’s Food Guide (Garriguet, 2009).

More recently, the World Cancer Research Fund and the American Institute for Cancer Research (WCRF/AICR) developed a standardized scoring system to quantify adherence to the 2018 WCRF/AICR recommendations related to cancer risk and mortality in adult populations (Shams-White et al. 2019). All of these tools aim to assess what is eaten, usually in terms of quantity and quality. To our knowledge, only one research group, based in Brazil, has developed a multidimensional self-applied scale to evaluate healthy eating practices or behaviours according to the recommendations of the Brazilian Dietary Guidelines (includes 24 items assessed using a 4-point Likert scale: “strongly agree”, “agree”, “disagree” and “strongly disagree”) (Gabe and Jaime, 2019).

Since Canada’s Food Guide includes recommendations on food choices as well as eating habits, a tool to assess adherence to its recommendations should include components that will measure both of these dimensions.

Health Canada’s Draft Tools

To assist with the development of the draft CFG adherence tools, Health Canada first agreed upon guiding principles for the development of the tools (e.g. reflect key CFG guidance, assess eating habits and food choices separately). A scan of the literature was then performed to identify similar adherence tools developed by others. This was followed by the identification of the key dietary guidance components to be assessed by the tools. Finally, Health Canada drafted two adherence tools, which were presented during the BBE for discussion.

Anticipated Outcomes

The BBE will help to spread awareness among the policy and research community of Health Canada’s development of adherence tools for the new CFG, help limit duplication of effort anncourage uptake of the new tools.  This BBE will facilitate focused discussions with experts who have experience in the development of a variety of adherence tools as well as those that have used these tools in various settings. Health Canada will use the experiences and knowledge shared at the BBE, as well as connections made, to further refine and validate the new adherence tools.

Once the tools are finalised, Health Canada plans to publish the process used to develop the adherence tools in peer-review journals and spread awareness of the availability of the tools to stakeholders via webinars and/or conferences.  Depending on the type of tool developed, the intention is also to make the individual scores available as a derived variable in the Canadian Community Health Survey 2015 - Nutrition. This will allow researchers to incorporate this variable into surveillance analysis using Canada’s national nutritional survey.

Presentation Summaries

The BBE was facilitated by Elaine De Grandpré, Manager, Knowledge Translation and Exchange, Food Directorate, Health Canada

Here is a summary of the evidence presented by each of the presenters:

What is Canada’s Food Guide?

Sylvie St-Pierre, Manager, Research and Data Analysis Unit, Office of Nutrition Policy and Promotion, Health Canada

The scene setting presentation outlined the various components of Canada’s Food Guide (CFG), as well as a brief overview of what is still to come. Overall, there are two main types of guidance in CFG, the “what to eat” – guidance on food choices, and the “how to eat” – guidance on eating habits. During the initial development of the CFG adherence tools, a variety of users were identified; all of which have different needs and access to different resources. This led Health Canada to propose two different types of tools to assess the “what to eat” of CFG guidance.

Developing a measure of alignment with Canada’s Food Guide: Approaches & considerations

Sharon Kirkpatrick, Associate Professor, School of Public Health and Health Systems, University of Waterloo

Canada's Food Guide marks a departure from prior dietary guidelines, explicitly recognizing “Healthy eating is about more than the foods you eat. It is also about where, when, why and how you eat” (Health Canada, 2019). The use of a plate to depict a pattern of eating is consistent with international trends towards a focus on proportionality. This holistic approach recognizes the complexity of eating patterns, while simplifying guidance to the public by moving away from quantitative targets. With prior Food Guides, examinations of how well population eating patterns aligned primarily leveraged such quantitative targets, for example, using dietary intake data to estimate proportions of individuals within subgroups who met (or failed to meet) food group recommendations. Indices that aim to simultaneously capture multiple dimensions of dietary guidelines, such as the Healthy Eating Index (HEI), have also taken advantage of quantitative targets through their multi-dimensional scoring approaches. The US HEI offers insights in terms of dietary components to be included in an index reflecting Canada’s Food Guide and their scoring, as well as approaches to ensure scores yielded by applying the index to dietary intake data provide meaningful information reflecting alignment with guidelines. Insights into contextual aspects of eating emphasized by the Food Guide may be gleaned depending on the type of intake data collected, but may also require novel approaches. An index and other approaches developed must be evaluated thoroughly to ensure the resulting information provides useful information for understanding alignment with the Food Guide across subgroups of interest.

Approaches to developing a dietary adherence tool: the lessons from Brazil

Maria Laura da Costa Louzada, Assistant Professor, Department of Nutrition, School of Public Health, Universidade de São Paulo (on Behalf the Center of Epidemiological Studies on Nutrition and Health (NUPENS) team)

The Dietary Guidelines for the Brazilian Population contain the official principles and recommendations for healthy eating for the Brazilian Population.  They are based on a new paradigm of healthy eating and provides information on what to eat, considering characteristics of industrial food processing, and organizing these recommendations around tasty and culturally appropriate meals. Due to its innovations, the development of instruments to monitor the population's adherence to its recommendations is a huge challenge. The development and the application of three instruments was discussed. The first was a questionnaire with 24 items answered on a 4-point Likert scale.  It has been validated in terms of content, appearance and construct and encompasses questions about what to eat, ways of eating, planning and domestic organization. The second tool consists in a short questionnaire containing questions (yes/no) about the consumption of 20 categories of ultra-processed foods in the day before the interview. A preliminary validation analyses showed that there is a good agreement between the scores provided by this questionnaire and the percentage of calories from ultra-processed food estimated through an open 24h-recall. Since 2018, this questionnaire has been incorporated into the Brazilian Vigitel System (Surveillance of NCD-risk and protective factors through telephone interviews). The last questionnaire described is part of the Brazilian National Food and Nutrition Surveillance System (surveillance of individuals within the primary health services). It consists in a short questionnaire containing questions (yes/no) about the consumption of 4 categories of ultra-processed foods, 3 categories of unprocessed or minimally processed foods and 2 questions about eating modes.

Draft tools to assess adherence to Canada’s new Food Guide (CFG)

Lisa-Anne Elvidge Munene, Nutrition Advisor, Office of Nutrtion Policy and Promotion, Health Canada and
Didier Brassard, Research Analyst, Office of Nutrition Policy and Promotion, Health Canada, PhD Candidate, Laval University

This presentation provided an overview of Health Canada’s preliminary work to develop the draft tools.  The first “what to eat” tool links key CFG recommendations to components that could be assessed with a 24-hour recall, primarily for use by researchers and academics. Health Canada proposed that the second “what to eat” tool be in the form of a behaviour-based questionnaire without the need of a 24-hour recall. Finally, Health Canada also proposed to assess the “how to eat” with a behaviour-based questionnaire.  Health Canada sought experts’ feedback to help refine and improve its proposed tools.

Recommended Readings

  1. Gabe, K. T., & Jaime, P. C. (2019). Development and testing of a scale to evaluate diet according to the recommendations of the Dietary Guidelines for the Brazilian Population. Public health nutrition22(5), 785-796.
  2. Kirkpatrick, S. I., Baranowski, T., Subar, A. F., Tooze, J. A., & Frongillo, E. A. (2019). Best Practices for Conducting and Interpreting Studies to Validate Self-Report Dietary Assessment Methods. Journal of the Academy of Nutrition and Dietetics119(11), 1801-1816.
  3. Reedy, J., Lerman, J. L., Krebs-Smith, S. M., Kirkpatrick, S. I., Pannucci, T. E., Wilson, M. M., ... & Tooze, J. A. (2018). Evaluation of the healthy eating index-2015. Journal of the Academy of Nutrition and Dietetics118(9), 1622-1633.

Online References

  1. Health Canada. (2019). Canada’s Dietary Guidelines.
  2. Health Canada. (2019). Canada's Dietary Guidelines - Appendix A: Healthy eating recommendations.
  3. Health Canada. (2019). Canada’s Food Guide.
  4. Health Canada. (2019). Food guide snapshot.
  5. Monteiro, C. A., Cannon, G., Moubarac, J. C., Martins, A. P. B., Martins, C. A., Garzillo, J., ... & Levy, R. B. (2015). Dietary guidelines to nourish humanity and the planet in the twenty-first century. A blueprint from BrazilPublic Health Nutrition18(13), 2311-2322.
  6. National Cancer Institute. Dietary Assessment Primer.
  7. National Cancer Institute. Dietary Assessment Instrument Profiles.
Date modified: