Intended for healthcare professionals

Analysis Food for Thought

Making nutrition guidelines fit for purpose

BMJ 2019; 365 doi: (Published 16 April 2019) Cite this as: BMJ 2019;365:l1579
  1. Lisa A Bero, professor1,
  2. Susan L Norris, scientist2,
  3. Mark A Lawrence, professor3
  1. 1Charles Perkins Centre, Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Sydney, Australia
  2. 2Department of Information, Evidence and Research, World Health Organization, CH-1211 Geneva, Switzerland
  3. 3Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Science, Deakin University, Geelong, Australia
  1. Correspondence to: L Bero lisa.bero{at}

Guidelines must ask the right questions and incorporate complexity to improve their relevance and quality, argue Lisa Bero and colleagues

Dietary risk factors are the leading contributors to the global burden of disease.1 But what we choose to eat also affects the health of the planet.2 Nutrition guidance therefore serves multiple purposes, including promoting health and wellbeing, maintaining adequate nutrition, combating dietary excesses and imbalances associated with non-communicable diseases, and protecting sustainable food systems. However, existing nutritional guidelines often do not consider the right questions or fail to take full account of available evidence because they rely on methods borrowed from other fields. We need different types of evidence informed nutrition guidelines to tackle these unprecedented challenges to population health.3

Unsuitability of current approaches

The current approach to developing nutrition guidelines has been adapted from established methods for clinical practice guidelines and was not created with nutrition questions and evidence in mind.4 Although these methods are applicable to some types of nutrition guidelines, such as setting dietary or nutrient reference intake values, they are unsuitable for food and diet based guidelines for several reasons.567

Important questions related to nutrient interactions, dietary patterns, or food systems are studied mostly using observational designs rather than the randomised controlled trial that predominates in clinical studies. Randomised trials present several problems when studying nutrition exposures or interventions,89 although advances in trial design, such as pragmatic trials, can help improve problems related to generalisability of results.9

Rigorous guidelines are usually underpinned by a systematic review of available trials, and although review methods have also been evolving, they are optimised for randomised trials of single component interventions. Most of the nutrition guidelines and policy statements in the World Health Organization’s e-Library of Evidence for Nutrition Actions (eLENA) database of systematic …

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