Food-based dietary guidelines

Food-based dietary guidelines are the communication of dietary recommendations and not the recommendations themselves. FBDGs have been the cornerstone of UK dietary advice since 1994. The original FBDG (The Balance of Good Health, 1994 based on various recommendations from the Committee on Medical Aspects of Food and Nutrition Policy (COMA)) was updated in relation to communications presentation of the FBDG in 2005 (the eatwell Plate). It was further updated in 2016 to the current UK FBDG (the Eatwell Guide)⁽³⁾, following changes to UK dietary recommendations, most notably those from the Scientific Advisory Group on Nutrition (SACN) report on Carbohydrates and Health⁽⁴⁾.

To achieve the updated FBDG, Public Health England, in conjunction with the devolved governments in Scotland, Wales and Northern Ireland, considered a range of options for depicting the impact of changes to dietary recommendations. The work to update the FBDG included an independently chaired external reference group and consumer testing across a range of socioeconomic, ethnic and geographical groups. Wording in the final FBDG was adapted to promote environmental sustainability but these were not modelled in the same manner as the dietary elements owing to the limited evidence base for sustainability elements (summarised in ⁽⁵⁾.

In the UK, the Eatwell Guide has been used to underpin dietary advice as well as policy development and implementation. The robust evidence that underlies the development of UK dietary recommendations and their communication is key to defending against challenge, including legal challenge⁽⁶⁾.

Personalised nutrition

Personalised nutrition is currently not well-defined though evidence for such approaches is emerging⁽⁷⁾. Cross et al. (2024) reported potential benefit of personalised nutrition on systolic and diastolic blood pressure in individuals at high cardiovascular risk. Results were inconsistent for plasma lipid and anthropometric outcomes^{(Reference Cross, Stanford and Gómez-Martín8)}. However, the range of interventions, route of delivery, implementers and intervention period varied widely which limits the ability to easily assess the applicability and effectiveness of interventions when considered together.

The use of personalised monitors, e.g., continuous glucose monitors have become a recent, if controversial, aspect of some personalised approaches. Hengist et al. (2025) reported that individual postprandial Continuous Glucose Monitoring (CGM) responses to duplicate meals were highly variable in adults without diabetes. Authors conclude that personalised dietary advice on the basis of CGM measurements would require more reliable methods involving aggregated repeated measurements^{(Reference Hengist, Ong and McNeel9)}.

Approaches that reflect personalised nutrition may already be present within the spectrum of advice and interventions practised within the UK. In addition, these approaches may already reflect the key messages of the UK’s Eatwell Guide. In fact, much of the work of registered nutritionists and dietitians reflect the personalisation of dietary information towards the benefit of individuals.

Currently there is no evidence on cost effectiveness of personalised approaches. Research on whether further personalisation of FBDGs at population and/or sub-population (including ethnic groups) level will also present opportunities and benefits remains to be undertaken.

It is likely that the costs (for providers and participants) of developing, targeting, implementing and monitoring personalised nutrition will restrict its applicability for many in the UK population. As such, while there are reports of beneficial outcomes for individuals (see above), care needs to be taken to ensure that its use would not widen diet-related health inequality.

Dietary indices – the Eatwell Diet score

The move towards a systems-based approach to diet in the UK has introduced a range of policies and legislation from the provision of information to taxes on high-sugar drinks.

At the population level, adherence to dietary recommendations can be assessed through surveys such as the UK’s National Diet and Nutrition Survey at a population level⁽¹⁰⁾ and through the use of dietary indices within cohorts. There are many indices in the nutrition field including for example the Healthy Eating and the Mediterranean Diet Index^{(Reference Guenther, Casavale and Reedy11,Reference Miller, Webb and Micha12)} . While many indices reflect similar dietary patterns there are differences which impact on consistent utilisation across individual research groups, populations and geographies.

Recently, research has started to consider an index to assess compliance with the Eatwell Guide. The Rank Prize Funds forum on the Eatwell Guide highlighted limited but promising evidence linking higher adherence to the Eatwell Guide with positive health outcomes^{(Reference Shannon, Townsend and Malcomson13)}, including cardiometabolic profile during mid-childhood^{(Reference Buckland, Taylor and Emmett14)}, abdominal obesity in post-menopausal women^{(Reference Best and Flannery15)}, systolic and diastolic blood pressure and body mass index (BMI) in older adults^{(Reference Gregory, Griffiths and Jennings16)} and life expectancy gain^{(Reference Fadnes, Celis-Morales and Økland17)}. Best et al. considered the Mediterranean Diet Index alongside the Eatwell Guide Score (EGS) demonstrating similar associations^{(Reference Best and Flannery15)}.

A range of other analyses have also reported favourable outcomes^{(Reference Alhulaefi, Watson and Gregory18,Reference Espino, Po and Wellard19)} , one of which presented a novel analysis based on diversity within a food group. Many researchers appear to use or adapt the approach of Scheebeek et al. who have reported on both dietary health and environmental considerations of the Eatwell Guide^{(Reference Scheelbeek, Green and Papier20,21)} . However, as with any developing area of research, there remain a number of issues on which consensus will be needed before a standardised EGS will be achieved.

Currently there is no agreed group of nutrients or foods that form the basis of an EGS and it remains unclear whether data collection and subsequent disaggregation of foods into ingredients is standardised to the level of accuracy undertaken in developing the Eatwell Guide in 2016. Care will also need to be taken within cohort studies to ensure that study populations remain comparable given cohort populations are allocated to proportions (quantiles, quintiles, etc.) of adherence which may not overlap intakes across different cohorts. Few studies have included ethnic minority participants, and it remains unclear how to calculate some dietary references for children – e.g., fruit and vegetables. Additionally, many cohorts and surveys may have difficulty recruiting more vulnerable populations which has implications for working towards reducing health inequalities.

Further work is needed on whether a unitary or graded score is helpful in differentiating adherence and associations with outcomes. Additionally, given the EGS results in a single value per individual further work is required to assess the level of dietary change in single or multiple foods/nutrients that may impact overall EGS, whether this is meaningful for outcome associations both for individuals and populations and whether this can be utilised as a meaningful stimulus to continued and sustained behaviour change.

This may be an area of research interest to understand the role of such indices in helping positive dietary change at both individual and population level and whether such approaches can be personalised in a manner beneficial to overall public health.

Updating food-based dietary guidelines

In the UK, the Eatwell Guide was last updated in 2016 following changes in dietary recommendations on carbohydrates and health⁽³⁾. Although SACN have continued their work assessing dietary health there have been no major changes in UK dietary recommendations and thus no evidence-based need for UK governments to consider further updates to the UK’s FBDG. However, the need to improve accessibility and/or use of the Eatwell Guide⁽²²⁾ is likely to be under regular review.

There is recognition in the UK that health professionals like and use the Eatwell Guide when working with patients but there have been calls for more support⁽²²⁾. Interestingly demands for translational support, interactive approaches and resources appear reflective of the approach that was utilised by the Foods Standards Agency (2001–2013) before machinery of government changes meant the eatwell website was no longer active⁽²³⁾. This included specific advice on adapting the FBDG for different dietary approaches including that for ethnic minorities. Similar information is available on UK government websites (e.g., nhs.uk^(24,25) , but perhaps not written in the same format. Presentational aspects of current government websites may be limiting useability resulting in these recent calls for changes to government advice (e.g., ⁽²²⁾).

When the Eatwell Guide was developed there was limited evidence on diet and environmental sustainability. The evidence in 2016 was granular and less robust than the nutritional evidence base. As such, the optimisation modelling used in the update of the UK’s FBDG only looked to reflect the more secure evidence base associated with nutrition and health. Consumer consultation during the review of the UK’s FBDG in 2016 helped to better understand how to present sustainability messages.⁽⁵⁾ The updated model was confirmed as delivering environmental benefit^{(Reference Scheelbeek, Green and Papier20)}.

A range of countries have since updated their own FBDG, with some including environmental considerations. Van Dooren et al. discuss a framework for consideration of different approaches to the development of environmentally more sustainable FBDGs^{(Reference van Dooren, Loken and Lang26)}. Hadida et al., through qualitative approaches assessed the learning from the approaches taken in the Netherlands, Denmark, Chile, France and the Flanders region of Belgium^{(Reference Hadida, Turner and Alae-Carew27)}. It appears that the approaches to updating FBDGs in these countries have followed a similar approach on dietary aspects to that utilised to update the Eatwell Guide. Sustainability elements, even when utilised within optimisation modelling, appear to be the outcome of expert opinion with variations in extent of wording in relation to adjusting communication for recommendations on individual food/nutrient on a country basis. There remains limited data on environmental impacts of diet with considerable reliance on green house gas emission data. Equally, there are limitations in the environmental evidence owing to the granularity of the analysis permissible which may reduce the robustness of the evidence in comparison to some dietary evaluations.

Further research is needed to underpin any consensus on wider environmental impacts of diet, identification of better evidence of the impact of individual foods/food components on the environment and consideration of such impact based on trade patterns, environmental security of producing nations and future trade patterns. To achieve this consideration will be needed that goes beyond the use of food balance sheets and extend to include key food groups where there is currently very limited data. Fish, for example, is often cited as having insufficient data to include in environmental impact analysis.

Although justification for utilising greater expert opinion in environmental analysis can be considered it may not be seen as the basis of changes to FBDGs in all countries particularly where there is potential for legal challenge.