Evaluation of the Norwegian nutrition policy with a focus on the action plan on nutrition 2007-2011

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Evaluation of the Norwegian Nutrition Policy with
focus on the Action Plan on Nutrition (2007-2011)
The WHO Regional Office for Europe
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Evaluation of the Norwegian Nutrition Policy with
focus on the Action Plan on Nutrition (2007-2011)
World Health Organization Regional Office for Europe
Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark
Tel.: +45 39 17 17 17. Fax: +45 39 17 18 18. E-mail: contact@euro.who.int
Web site: www.euro.who.int
Evaluation of the Norwegian nutrition policy with a focus on the Action Plan on Nutrition 2007–2011
Evaluation of the Norwegian Nutrition Policy with
focus on the Action Plan on Nutrition (2007-2011)
Evaluation of the Norwegian nutrition policy with
a focus on the Action Plan on Nutrition 2007–2011
World Health Organization Regional Office for Europe
UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark
Tel.: +45 45 33 70 00. Fax: +45 33 70 01. Email: contact@euro.who.int
Web site: www.euro.who.int

Evaluation of the Norwegian nutrition policy with
a focus on the Action Plan on Nutrition 2007–2011

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© World Health Organization 2013
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ABSTRACT
The WHO Regional Office for Europe conducted an evaluation of the Norwegian Action Plan on Nutrition (2007–2011)
in 2012. The evaluation was commissioned by the Directorate of Health of the Norwegian Ministry of Health and Care
Services under the terms of the framework agreement between the Regional Office and the Directorate of Health.
The overall aim of the assignment was to provide an independent evaluation of the Action Plan on Nutrition and an
assessment of the possible options for the future in terms of policy recommendations.
Keywords
DIET
FOOD
HEALTH POLICY
NUTRITION AND FOOD SAFETY
NUTRITION POLICY
SOCIOECONOMIC FACTORS
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Contents
Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
1. Introduction .......................................................1
1.1 Why this evaluation and why now? ...........................1
1.2 Nutrition and public health policy in Norway ...................1
1.3 Terms of reference ........................................2
1.4 Process and conduct of the review ...........................2
2. Nutrition in Norway: analysis of the situation ............................2
2.1 Nutrition policy ...........................................2
2.2 Broader policy context .....................................7
3. Evaluation of the implementation of the Action Plan. . . . . . . . . . . . . . . . . . . . . . .9
3.1 General comments ........................................9
3.2 Evaluation of focus areas and measures in the Action Plan .......13
3.3 Findings in relation to social inequalities in dietary intake ........21
4. Overall recommendations of the evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
4.1 General recommendations .................................25
4.2 Specific recommendations regarding the Action Plan ............25
4.3 Key priorities in nutrition policy .............................27
5. Future policy priorities .............................................30
References ........................................................31
Annex 1 List of experts on the evaluation panel ..........................34
Annex 2 List of key informants ........................................35
Annex 3 Internal government monitoring matrix ..........................37

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Acknowledgements
This report was commissioned by the Directorate of Health of the Norwegian Ministry of Health and Care Services.
The WHO Regional Office for Europe would like to express its appreciation to the key national informants for the
documentation and data they supplied relative to the objectives specified in the Norwegian Action Plan on Nutrition
2007–2011. Thanks are also due to the national and international experts on the evaluation panel for their valuable
contribution to a consultative workshop with policy-makers and stakeholders, held in Oslo in April 2012, and to the
preparation of this report. The Regional Office is most grateful to the Norwegian Directorate of Health for its support for
the printing of this report.

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1. Introduction
1.1 Why this evaluation and why now?
This report presents the findings of an evaluation of the Norwegian Action Plan on Nutrition 2007–2011. Recipe for a
healthier diet (1) and recommendations for the future.
The evaluation was commissioned by the Directorate of Health of the Norwegian Ministry of Health and Care Services
under the terms of the framework agreement between the WHO Regional Office for Europe and the Directorate of Health,
and was carried out by the Nutrition, Physical Activity and Obesity Programme of the Regional Office. The overall aim
of the assignment was to provide an independent evaluation of the Action Plan on Nutrition and an assessment of the
possible options for the future in terms of policy recommendations. More specifically, the objectives of the evaluation
were detailed in the terms of reference and mainly focused on:
• ananalysisoftheresultsofthepolicyandacomparisonwithitsobjectives;
• anassessmentoftheefciencyofthepolicyinmeetingtheseobjectives;
• considerationofwhetherchangesareneededtothepolicyandsuggestionsforpossibleimprovementstothescope,
structureandworkingpractices,withdueconsiderationofdifferentpolicyoptions;and
• recommendationsforthedesignoffuturepolicy.
This report details the work undertaken and the answers to the points set out in the terms of reference. The analysis is
based on the stakeholder consultation process that took place in an intensive evaluation workshop in Norway in April
2012, including interviews with stakeholders and policy-makers and a review of the existing documents and data.
The evaluation was planned as a two-stage process: quantitative and qualitative. The first stage was to gather relevant
and available documentation and data related to the objectives specified in the Action Plan (a quantitative internal
evaluation was carried out by the Directorate of Health).
The second stage was a qualitative evaluation, whereby the Regional Office supported the Directorate of Health in
setting up a group of national and international experts to conduct an intensive workshop in Oslo from 16 to 20 April
2012, with the aims of interviewing key informants (policy-makers and stakeholders), analysing the available data and
discussing suggestions and inputs for the future. The members of the evaluation panel are listed in Annex 1 and the key
informants in Annex 2. This report, which has been written by the Regional Office together with the external expert group,
is an output of the consultation process and provides a summary evaluation for the Directorate of Health.
1.2 Nutrition and public health policy in Norway
The Action Plan on Nutrition 2007–2011. Recipe for a healthier diet (1) set out the government’s measures to promote
health and prevent disease through a healthier diet. The emphasis of the Plan was on helping to make it easier for
individuals to make healthy choices, to facilitate good meals in kindergartens, schools and among the elderly, and to
increase knowledge about food, diet and nutrition. The aim of the Plan was to improve public health through a healthy
diet, with two main goals:
• tochangethedietinlinewiththerecommendationsofthehealthauthorities,and
• toreducesocialinequalitiesindiet.
These two goals were translated into five main strategies:
• toimprovetheavailabilityofhealthyfoodproducts
• toincreaseconsumers’knowledge
• toimprovethequalicationsofkeypersonnel
• todevelopalocalbasisofnutrition-relatedwork,and
• tostrengthenthefocusonnutritioninthehealthcareservices.
The evaluation focused on the overall goals and measures proposed and taken forward with the Action Plan.

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1.3 Terms of reference
The review panel agreed on the following terms of reference:
• toreviewprogressin the implementation oftheActionPlan and to considerwhetherimplementationlocally and
nationallyhadbeenappropriateandeffectiveinaddressingthePlan’sactionpoints;
• to review the impacts and outcomes of the implementation of the Plan, the extent to which the activities
identified had been fulfilled and the targets achieved, and whether the changes identified were attributable to
thePlan;
• toidentifyfuture challenges, and torecommendstrategic areas of actionrequiredto strengthen the policygoals
of improving the national diet and counteracting obesity and noncommunicable diseases by means of reducing
inequalities related to access to and choice of food and diet, as well as access to care in the field of nutrition-related
diseases.
1.4 Process and conduct of the review
At the start of the evaluation process, in April 2012, the Regional Office organized a consultative workshop involving
international and national experts who selectively interviewed people responsible for implementing policy and other
relevant staff. Their approach was based on the methodology used for the evaluation of Australia’s National Mental
Health Strategy (2), the methodology used for the Scottish Diet Action Plan review (1996–2005) (3) and other relevant
country experiences in which the Regional Office was directly involved.
The review process aimed to detail what was proposed by the Action Plan and what had been achieved in terms of
implementation, drawing from two main sources of evidence.
First, the Norwegian national dietary survey (4) (the Directorate of Health’s monitoring and surveillance system) provided
the baseline for the quantitative review. In addition, an internal governmental monitoring process had been set up
consisting of intersectoral meetings several times a year to follow up the implementation of the Action Plan through
assessment of all 73 measures proposed in the Plan. This work was summarized in a matrix which was made available
for the expert panel in preparation for the workshop (Annex 3).
Second, the workshop in Oslo involved a series of interviews conducted by the external expert group (working
largely in pairs or threes) with policy-makers and stakeholders who had had responsibility for, or been involved in,
the implementation of different initiatives on the ground or had worked in relevant areas. These informants were
identified and invited by the Directorate of Health. Some interviews were in English, some were in Norwegian, some
in a mixture of both languages with informal translation. Most were conducted face to face or by telephone. Most
were recorded for back-up purposes.
2. Nutrition in Norway: analysis of the situation
2.1 Nutrition policy
2.1.1 Overview of the Action Plan on Nutrition 2007–2011
The Action Plan on Nutrition served as a policy framework for decision-makers, professionals, experts and others in the
public and private sectors who play a role in the population’s diet. For good dietary habits to be achieved, many sectors
need to work together. For this reason, 12 ministries collaborated in developing the Action Plan and taking forward
intersectoral action during its implementation. The Plan contained 73 specific measures to promote health and prevent
illness by changing eating habits in line with the nutrition recommendations of the health authorities. Reducing social
inequalities in diet was one of the two overall goals. The measures emphasized contributions that made it easier for
individuals to make healthier choices, to facilitate the provision of healthy meals in kindergartens, schools and among the
elderly, and to increase people’s knowledge about food, diet and nutrition. The Action Plan, which ended in 2011, was a
follow-up to the White Paper No. 16 (2002–2003). Recipe for a healthier Norway (5). It was also underpinned by WHO’s
Global Strategy on Diet, Physical Activity and Health (2004) (6), the European Charter on Counteracting Obesity (7) and
the WHO European Action Plan for Food and Nutrition Policy 2007–2012 (8).

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The Action Plan on Nutrition must also be viewed in connection with the Nordic Plan of Action for Better Health and
Quality of Life through Diet and Physical Activity (9), adopted in July 2006, and the Action Plan on Physical Activity
(2005–2009). Working together for physical activity (10). The launch of the Action Plan on Nutrition was followed by
publication of the White paper No. 20 (2006–2007). National strategy to reduce social inequalities in health (11). There
was a parallel working process between the Action Plan and the strategy to reduce social inequalities in health.
Section 2.1.2 below describes the historical perspective since 1963, as the Action Plan was built on several earlier
political documents.
2.1.2 Overview of nutrition policy since 1975
In the 1970s, Norway moved substantially to promote world food security. It expanded its emergency grain reserve and in
1975 joined the World Food Programme, increasing its commitment by 300% within five years. It also increased its official
development assistance from 0.65% of gross national product in 1975 to 1.0% in 1985 (compared with the Netherlands
and Sweden at about 0.88% and the United States at 0.22% in 1983).The food supply and nutrition policy objectives set
in 1975 were changed slightly in 1993 (12). The goals of the Ministry of Agriculture remained self-sufficiency with respect
to certain foods and, with due regard to the environment, the maintenance and promotion of agricultural development in
outlying rural areas. Nutrition is not explicitly mentioned in reports on agriculture at ministerial level, although it was the
Ministry of Agriculture that presented the first nutrition policy white paper in 1975 (13) which encouraged healthy dietary
habits and proposed a nutrition and food policy in line with the recommendations of the World Food Conference (14).
Parliament endorsed two new white papers in 1993, one on the new agricultural policy and the other on health policy.
The latter emphasized disease prevention and health promotion, and had a separate section on nutrition policy objectives
and instruments for action (15). The most important measures to influence the core diet in the last 50 years have included
improvements in the content of fatty acids in margarine (1960–1980), reduction of the content of trans-fatty acids to a low
level (1995–2005), maintenance of a high degree of grinding of sifted wheat flour (1960s), improvements in the baking
quality of whole wheat (1980s), blending of overseas wheat with a high content of selenium into flour, introduction of
low-fat milk (1984) and consultations with the food industry on the level of salt in food products (1980s).
Beyond the food available nationally and the kinds of food that consumers buy, national dietary patterns must be assessed
by what people actually eat. Such information was sparse in Norway until the mid-1980s. In that decade, the health-related
components of the nutrition policy were implemented most extensively through information and education, to a far more
limited extent in its economic, community service and regulatory aspects, and least of all in the field of integration with
relevant government processes. Other ambitions at the time were to influence the composition of core foods and use of fiscal
measures, as well as to have dialogues with the food industry and the food service sector. A specific research programme
was established where one of the purposes was to stimulate research on nutrition-related issues within a broader range of
academic disciplines such as anthropology, sociology and economics. By all accounts, the pace of implementation was too
slow to meet some of the prognoses for 1990 set in the white paper on nutrition from 1975–1976 (13).
In the 1990s, nutrition policy was administered intersectorally by linking it with policies that touched on health, agriculture,
fisheries, consumer affairs, education and research. The government stressed the need for cooperation between these
sectors in order to achieve the goals and objectives of the food and nutrition policy. Three organizations had a role
in coordinating nutrition policy: (i) the Interministerial Council, which only existed for a few years; (ii) the Nutrition
Council, which together with the Interministerial Council came administratively under the then Ministry of Health and
SocialAffairs;and(iii)theNorwegianFoodAuthority.Thelast-namedmergedin2004withotherinstitutionsandisnow
called the Norwegian Food Safety Authority, with the task of enforcing food legislation emanating from the Ministry of
Agriculture and Food, the Ministry of Fisheries and Coastal Affairs and the Ministry of Health and Social Affairs. The
Authority coordinates all official control of foodstuffs, provides expertise and advice to municipal food control authorities,
and gives information and advice to other relevant groups such as consumers and the food industry (12).
2.1.3 Overview of the Norwegian diet and diet-related problems
The Action Plan contained defined general goals (Table 1) and quantitative goals (Tables 2 and 3) for dietary changes.
Dietary trends before and during the period of the Plan are described with the latest available statistics and compared
with targets. Food balance sheets go up to 2010, but for several of the other statistics the most recent data are from 2008
or 2009. Thus it has not been possible to describe the trends for the entire period of the Plan. In essence, trends before
and after 2005 are compared.

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Table 1. General goals for the development of the Norwegian diet 2007–2011
and trends in food supply 2000, 2005 and 2010
Dietary factor Goal 2000 2005 2010 Evaluation
Fat, E% 25–35 34 35 37 Negative trend
Saturated fat, E% Approximately 10 15 15 16 Negative trend
Trans fat, E% <1 <1 Goal reached
Polyunsaturated fat, E% 5–10 6 6 6 Within the target
Protein, E% 10–20 13 15 15 Within the target
Carbohydrates, E% 50–60 52 50 47 Below recommended level
Sugar, E% < 10 17 15 13 Beneficial, target not reached
Dietary fibre, g/day Approximately 30 24 24 27 Beneficial, target not reached
Vegetables, kg/year Promote 59 62.6 72.6 Significant increase in 20 years
Fruit and berries, kg/year Promote 69.3 82.4 88 Significant increase in 10 years
Potatoes, fresh, kg/year Promote 33 26.6 25.7 Significant decrease in 50 years
Potato products, kg/year Decrease 27.3 33.5 31.4 Significant increase in 50 years
Whole grain cereals Promote No data
Fish and sea food, kg/year Promote 35 35.5 35.9 Little change in the last 10 years
Fatty meat products Decrease Meat contributed the same amount
of fat in 2005 and 2010
Meat, kg/year 63.9 71.3 73.8 Significant increase
Fatty dairy products Decrease Dairy products accounted for less
fat in 2010
Whole milk, kg/year 30.3 31.2 19.7 Shift from fat to lean milk
Cheese, kg/year 14.5 17.0 17.9 Consumption of fatty cheese increased
Cream, kg/year 6.8 7.3 7.3 Small changes
Butter, kg/year Decrease 3.3 3.0 3.0 Small changes
Margarine, kg/year Decrease 11.1 9.3 8.6 Decreased
Shift to soft margarine Proportion of edible oils and light
and edible oils margarine increased
Salt Decrease No data
Sugar, kg/year Decrease 43.4 35.5 31 Significant decrease
Soft drinks with sugar, Decrease 90 60a 63 Decreased over time, but increased
litre/year since 2007
Sweets, kg/year Decrease 12.7 13.2 14.3 Increase over 50 years
Good meal habits Promote Unclear due to lack of data
Note. Evaluation based on food supply statistics and household consumption surveys.
a 2007, data missing for 2005–2006.
In the period 2005–2010, food supply statistics showed that the intake of dietary fat and saturated fat increased after
having been relatively unchanged over the previous decade (Table 1).
The percentage of the population with an intake of saturated fatty acids above 10% of the total energy intake is now
significantly high. Dietary content of saturated fat is now significantly higher than recommended. Dietary intake of
protein, trans-fatty acids and polyunsaturated fatty acids has remained within the recommended limits during this period.
The importance of added sugars in the diet decreased after 2000 but is still greater than recommended. The average
amount of fibre in the diet has increased but is still below the recommendations.
The consumption of vegetables, fruits and berries has increased over time and continued to increase in 2005–2010.
During the period 2005–2009, the proportion of the population with an estimated daily intake of vegetables increased to
about 20% and the proportion of people who eat fruit and berries daily increased to more than 20% (Table 2).

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Table 2. Quantitative goals for the development of the diet 2007–2011 and evaluation of trends
Goal 2001 2005 2009 Evaluationa
(%) (%) (%)
20% change in the proportion of the population that eat or drink:
vegetables daily,% Promote 39b 36 42 Increased to 17% 2005–2009
fruit and berries daily,% Promote 43b 40 50 Increased to 25% 2005–2009
fish for dinner 3 times/week,% Promote 23 22 22 Unchanged
fish spread (mackerel in
tomato sauce) >once a week,% Promote 17 20 26 Increased to 30% 2005–2009
tap water daily,% Promote 73 83 87 Increased
Children and young people who eat or drink:
sweets daily (aged 15 years),% Decrease 19 13 9 Decreased to 31% 2005–2009
soft drinks and/or sugar-sweetened
squash daily (aged 15 years),% Decrease 27 18 15 Decreased to 17% 2005–2009
breakfast daily at home (aged
15–24 years),% Promote 56 55 58 Small change
sugar intake above 10 E% Decrease Decreased for 2-year-olds from
11.7 E% to 6.7 E%
saturated fat intake above 10 E% Decrease Decreased for 2-year-olds from
14.2 E% to 13 E%
a Evaluation based on data from Norkost 3 (4) and Currie C et al. (16).
b 2003, data missing for 2001.
Table 3. Breastfeeding goals 2007–2011 and trends
Breastfeeding among infants Goal 1998–1999 2006–2007 Evaluationa
(%) (%) (%)
Exclusively breastfed at 4 months 44–70 44 46 Goal not reached
Exclusively breastfed at 6 months 7–20 7 9 Goal not reached
Breastfed at 12 months 36–50 36 46 Goal almost reached
a Evaluation based on data from Spedkost – 6 måneder (17).
The consumption of fresh potatoes fell and the consumption of processed potatoes rose significantly in the period 1970–2000
and there has been little change since. Grain consumption increased in the same period but has since fallen somewhat.
It is uncertain whether the proportion of whole grain cereals has risen. Fish consumption has changed little over the
past decade. The proportion of the population who said they ate fish for dinner three times a week changed little in
2001–2009, while the proportion who ate fish spreads (mackerel in tomato sauce) at least once a week increased by
30% in 2005–2009. The consumption of meat increased for a long time up to 2007, but fell slightly in both 2009 and
2010. Consumption of red meat was about the same level in 2010 as in 2005, while consumption of white meat increased
significantly in the period 2005–2009. It is still uncertain whether the rising trend in meat consumption over a long time
has stopped.
There has long been a shift from fat to lean types of milk, which continued in the period 2005–2010. Consumption of
creamchangedlittleduringthisperiod;cheeseconsumption,ontheotherhand,hasbeenincreasingforalongtimeand
continued to do so in this period.
The consumption of margarine, which had been falling for a long time, continued to decrease in the period 2005–2010,
while butter consumption remained at about the same level. Sales of edible oils have increased over the last decade.

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The total consumption of sugar has decreased significantly over the last decade. Sales of chocolate and sweets, which
increased significantly in the period 1970–2008, fell slightly in 2009 and 2010. Sales of soft drinks with added sugar
decreased significantly in the period 1997–2004 and then increased slightly again in the period 2007–2010.
The Action Plan defined some dietary goals for children and young people (Table 2). Two cross-sectional studies were
conducted,one in 2001andonein2008, withtheaimofanalysingchanges in:children’smealpatterns;associations
betweenmealpatternandgender,parentaleducationallevelandnumberofparentsinthehousehold;andassociation
between intake of unhealthy snacks, meal pattern and the mentioned variables (18). The studies showed that there were
no significant changes in children’s meal patterns from 2001 to 2008: in both years more than 90% of the participants
reported that they had eaten breakfast the previous day, while approximately 95% had eaten lunch, 94% had eaten
dinner, 82% had eaten supper and about 70% had eaten all four meals. The results also showed, however, that in spite of
children having a stable meal pattern between 2000 and 2008, some did skip meals. The characteristics associated with
skipping meals were living in a one-parent family, having parents with low education and being a boy (18). Simultaneously,
in 2008 children reported a less frequent intake of fruit juice, lemonade and regular soft drinks, and a more frequent
intake of diet soft drinks, than in 2001.
The proportion of young people who said they drank soft drinks or ate sweets daily decreased significantly in the period
2001–2009 among both 15-year-olds and those aged 15–24 years. Dietary surveys show that the proportion of one-year-
old children given sweet drinks fell from 64% to 20% between 1998 and 2006. The total intake of added sugars decreased
from 10% to 4% of dietary energy among one-year-old children and from 12% to 7% of dietary energy among two-year-
olds. During the same period the dietary content of saturated fat decreased among two-year-olds. There are no more
recent surveys that might shed light on the dietary content of sugar and saturated fat among children and adolescents.
The Action Plan defined a separate objective to increase the proportion of adolescents who eat breakfast daily. Among
schoolchildren aged 15 years, the proportion eating breakfast five days a week changed little among girls and decreased
slightly among boys between 2001 and 2009. In the group aged 15–24 years, the proportion who said they ate breakfast
at home daily or ate breakfast at school changed little in the same period. The proportion that only took drinks for
breakfast or had failed to eat breakfast at least twice during the previous seven days decreased from 2003 to 2009. The
proportion of infants who were exclusively breastfed at four and six months increased slightly from 1998 to 2006 but was
far from the target for 2011 set in the Action Plan (Table 3). The proportion of infants breastfed at 12 months increased
significantly from 1998 to 2006 and was close to the target in the Action Plan. There are no recent national data available
on the proportion of infants who are breastfed.
A regional study using a relatively old dataset from participants in the adolescent part (Young-HUNT) of the Nord-Trøndelag
Health Study during the period 1995–1997, numbering 8817 girls and boys aged 13–19 years (89% of all students in junior
high schools and high schools in one county), found that higher levels of parental education, in particular the mother’s
education, was associated with healthier dietary habits among adolescents (19).
During the period 2010–2011, an assessment was made of the diet of 862 men and 925 women aged 18–70 years. The
method used was two randomly distributed 24-hour recalls and a food propensity questionnaire. This study, Norkost 3,
was conducted by the Department of Nutrition, University of Oslo, in collaboration with the Directorate of Health and the
Food Safety Authority (4).
The results showed a mean energy intake of 10.9 MJ per day for men and 8.0 MJ per day for women. The energy intake
decreased with increasing age for both men and women. On average, protein, fat and carbohydrates contributed 18%, 34%
and 43–44%, respectively, of the energy intake for both genders. Added sugar contributed 7% and both fibre and alcohol
approximately 2% of the energy intake in both groups. The energy percentages consumed from saturated fat, monounsaturated
fat and polyunsaturated fat were 13%, 12% and 6%, respectively, for both men and women. The energy percentage consumed
from protein, fat, monounsaturated fat, polyunsaturated fat and trans fat were in accordance with the Norwegian nutrition
recommendations. The dietary content of added sugar decreased substantially, but is still higher than recommended.
The energy percentage consumed from saturated fat was, however, above the recommended level, whereas the energy
percentage consumed from carbohydrates was below. The main sources of fat were butter, margarine, oil and meat.
Bread and sugar-sweetened squash and soft drinks were the most important sources of carbohydrates and added sugar

7
in the diet. The survey demonstrated some social inequalities in food and nutrient intake. Participants with a higher
education had a healthier diet than participants with a lower level of education, and non-smokers ate more fruit, berries
and vegetables compared to daily smokers (4).
In 2010, there was an increase of three percentage points for third-graders (eight-year-olds) who were overweight or
obese compared to 2008, on average from 16% to 19%. This was shown by figures from the Child Growth Study at
the Norwegian Institute of Public Health (20). It is, however, too early to say whether this increase reflects a trend, but
it is alarming and should be made a policy priority. The Child Growth Study is a nationwide study that started in 2008
to monitor growth trends among third-graders over time, and is the only study in Norway monitoring children’s height,
weight and waist circumference. It was conducted for the second time in 2010, and the next measurements are scheduled
for 2013 at the same schools. Almost 9 out of 10 pupils participated in the study in both 2008 and 2010. A total of 127
schools are taking part in this study, yielding data which are fed into the WHO Childhood Obesity Surveillance Initiative.
The results show that 19% of girls were defined as overweight and 3% were obese (total 22%), while 12% of boys were
defined as overweight and 5% were obese (total 17%) (20).
Weight increased in all adult age groups between the mid-1970s and 2000. The proportion of those overweight and
obese varies from county to county. The average body mass index and proportion of those overweight and obese are
lower in Oslo than in the four other counties (Oppland, Hedmark, Troms and Finnmark) where health studies have
been carried out. People aged 40 years with a high education level are less obese than those with a lower level
of education. In Oslo, the adult population tends to be heavier in eastern than in western districts, particularly the
women. Among immigrants in Oslo the prevalence of overweight and obesity varies with ethnic background. The
proportion of obesity in the immigrant population is highest among women from Turkey and lowest among men from
Vietnam. Women from Pakistan and Sri Lanka have the highest waist/hip ratio, as shown in a study among 3000
immigrants from non-western countries.
In the last 20–40 years an increasing proportion of adults were found to be obese. Adult men have increased evenly in
weight since the 1960s, while women have increased evenly in weight since 1985. The proportion of obese people rose
from 9–10% in 1985 to 13–22% around 2000, according to figures from health studies of adults. Approximately 8–14%
of the group aged 15–16 years are overweight or obese (21).
In the Directorate of Health’s study more boys than girls aged 15 years were obese. The Norwegian Institute of Public
Health’s youth studies among 15–16-year-olds show the link between overweight and socioeconomic factors. Among
immigrants aged 15–16 years in Oslo, the proportion of those overweight varies from 4% to 12%. The highest prevalence
of overweight was among young immigrants from other western countries, eastern Europe and the middle east/north
Africa, according to the youth part of the Oslo Health Study, which registered weight and height with the help of self-
reported questionnaires (22).
2.1.4 Actors and stakeholders in nutrition
As part of the development of the Action Plan, different stakeholders were invited to give their inputs in two public
hearings. The interaction between the public sector, private sector and nongovernmental organizations provided
a foundation for good programmes and measures. Experts, actors in the food industry and other private actors,
nongovernmental organizations and trade unions, university colleges and county authorities showed great interest in
the Action Plan and provided useful input. The dialogue was continued and the proposals, examples and experiences
that have been accumulated by these actors during the implementation of the Action Plan have been taking into
account during this evaluation.
2.2 Broader policy context
2.2.1 Public health policy context
Norway is a monarchy with a parliamentary form of government. There are three independent levels of government:
the national government, the county councils and the municipal authorities. The state level is responsible for secondary
care, which is delegated to four regional health authorities. The county authorities are responsible for, among other
things, dental care, public health, secondary education, energy delivery and communication. The municipal authorities
are responsible for health promotion, primary health care, care of the elderly, care of people with disabilities (including

8
mental disabilities), kindergarten and primary school education, social work (child protection and social protection),
water, local culture, local planning and infrastructure (23).
Life expectancy is among the highest in the world. Diseases of the circulatory system are the primary cause of mortality,
with cancer the second largest cause of death.
The health care system is organized on three levels, national, regional and local. Overall responsibility for the health care
sector rests at the national level with the Ministry of Health and Care Services, which is responsible for administering
primary health care, specialized health care, public health, mental health, medical rehabilitation, dental services,
pharmacies and pharmaceuticals, emergency planning and coordination, policies on molecular biology and biotechnology,
and nutrition and food safety. The Ministry of Education and Research is responsible for planning and partially subsidizing
the education of health personnel.
The Ministry of Health and Care Services has administrative responsibility for the following agencies: the Directorate
of Health, the Norwegian Board of Health Supervision, the Institute of Public Health, the Medicines Agency and the
Norwegian Scientific Committee for Food Safety. The Ministry of Agriculture and Food is responsible for the institutional
management of the Food Safety Authority.
The Directorate of Health is the central administration for the government, with legal authority, in the field of health and
social affairs. The Directorate contributes to the implementation of national health and social policy (for example, the
Nutrition Action Plan), and serves as an advisory body to central authorities, municipalities, regional health authorities,
voluntary organizations, the media and the public in general. An essential task for the Directorate is to develop and
strengthen preventive work and to widen the availability of services in the field of health and social affairs (for instance,
for nutrition).
The four regional health authorities have responsibility for specialist health care. They are financed by basic grants,
earmarked funds and activity-based funding.
The local level is represented by 429 municipalities which have responsibility for primary health care, including nursing
care. The aim of primary care is to improve the general health of the population and to treat diseases and deal with health
problems that do not require hospitalization and a high level of specialized care. Each municipality decides how best to
serve its population with primary care, which is for the most part publicly provided.
The main purpose of the Municipal Health Services Act (1982) (24) was to improve the coordination of the health and
social services at local level, to strengthen those services in relation to institutional care and preventive care, and to
pave the way for better allocation of health care personnel. The Act provides the municipalities with a tool to deliver
comprehensive health services in a coordinated way. In 1988, it was expanded and county nursing homes were transferred
to the municipalities.
The health care sector has undergone several important reforms in recent decades and nutrition is mentioned several
times in the Public Health Act (2012) and the National health and care services plan (2011–2015) (25).
2.2.2 Policy context for social inequalities
The evaluation includes a specific commitment to assess the achievement of the second goal of the Action Plan – to
reduce social inequalities in diet – both as a cross-cutting issue within the focus areas of nutrition and overall as a
public health goal. It is, therefore, important to have an overview of the policy context and situation with regard to social
inequalities when the Action Plan started.
In 2007, the National strategy to reduce social inequalities in health (2007–2017) was adopted by Parliament, with the
primary objective to “reduce social inequalities by levelling up” (11). The strategy, together with two others approved
by the government, forms part of Norway’s comprehensive policy to reduce social inequalities, promote inclusion and
combat poverty. The other two reports/strategies are concerned with: (i) employment, welfare and inclusion, and (ii) early
intervention for lifelong learning. The national strategy set out the guidelines for the government and ministries to reduce
social inequalities in health over the decade in question, although its measures are largely linked to the follow-up from

9
the other reports, for example, the Report on work, welfare and inclusion (26) and related action plans such as the Action
Plan against Poverty (27).
The four priority areas are:
• toreducesocialinequalitiesthatcontributetoinequalitiesinhealth
• toreducehealthinequalitiesinhealthbehaviouranduseofthehealthservices
• tointroducetargetedinitiativestopromotesocialinclusion,and
• todevelopknowledgeandcross-sectoraltools.
The national strategy emphasizes the development of public health policies that aim for a more equal distribution of
the positive factors affecting health, with a balance across structural universal or selective measures to downstream
universal or selective measures which seek to remedy or mediate the negative impacts of inequalities. Thus it is about
making the existing universal system more responsive and effective with regard to equity.
The national strategy to tackle social inequalities was developed in response to evidence about systemic inequalities in
health, as measured by large and growing differences in mortality among adults and at every stage of life. Education,
income, childhood conditions and work and the working environment were identified as some of the most important
mechanisms affecting the distribution of health in the population. In terms of nutrition, systematic inequalities in health
behaviour and access to health services were identified as important contributors to, in particular, perpetuating or
exacerbating inequalities in health.
An agreed conceptual framework is important for mapping the relationship between the broader social determinants of
health and social inequalities in diet. As part of global work on social determinants and equity in relation to priority public
health issues (such as harmful alcohol consumption, cardiovascular diseases and diabetes), inequalities in diet are seen
as being the result of differential exposure (that is, limited disposable income for ensuring a healthy diet), differential
vulnerability (poorer diet or less healthy food purchases due to limited income) and differential health outcomes (greater
risk and/or greater obesity and overweight) (28). In terms of overall food availability and the changing exposure of
different social groups to negative factors, however, it is also necessary to look outside the Action Plan on Nutrition to
the wider policy context and interventions designed to ensure that everybody has at least a minimum wage (which in
turn is found to be sufficient to meet minimal social and health needs), adequate social protection and/or lower rates of
early school drop-out. More structural and upstream action to improve food availability and access may, however, sit at
the level of socioeconomic context and position and changes to policies such as on taxation, subsidies and the pricing of
healthy food. These always need to be considered in relation to levels of income as well as the costs of other necessities
whose purchase may be prioritized over food (such as rent or fuel). The provision of education in nutrition and ensuring of
healthy foods in kindergartens and schools are also examples of measures that are independent of socioeconomic status.
3. Evaluation of the implementation of the Action Plan
3.1 General comments
The purpose of the evaluation was to review the national nutrition policy as well as progress and achievements in
nutrition, with a focus on evaluating the Action Plan. The evaluation was based on: (i) the quantitative review which
provided an update on current achievements in relation to the Norwegian diet, and (ii) the thematic matrix provided by
ministries with regard to their tasks defined in the Action Plan (see Annex 3), together with (iii) the extensive evaluation
week by the expert group that took place in Norway in April 2012.
3.1.1 Governance: implementation of the Action Plan
The Action Plan was developed and written with the purpose of gathering together existing and planned nutrition-related
activities in the various ministries. The structure of the Plan, with 2 goals, 5 strategies, 10 focus areas and 73 measures,
reflects the fact that it is as much a collection of activities in different sectors as it is a logical line between the different
levels.

10
The Action Plan was signed and involved activities by 12 different ministries. During the period of the Action Plan regular
meetings took place between the ministries, although there was considerable variation in their involvement. The Ministry
of Health and Care Services was involved in 59 of the 73 measures (Table 4) and was itself responsible for 33 of them.
The Ministry of Education and Research, the Ministry of Fisheries and Coastal Affairs and the Ministry of Agriculture and
Food were involved in 11–13 measures, while the other ministries were involved in 0–5 measures.
Table 4. Number of measures detailed in the Action Plan and assigned to different ministries
Ministry No. of measures
Health and Care Services 59
Education and Research 13
Fisheries and Coastal Affairs 11
Agriculture and Food 11
Labour and Social Inclusion 5
Local Government and Regional Development 4
Children and Equality 3
Finance 3
Environment 3
Foreign Affairs 2
Trade and Industry 1
The Ministry of Health and Care Services designated the Directorate of Health to be the secretariat for the Action Plan,
with the overall responsibility for overseeing its implementation. Besides carrying out the tasks presented in the national
budget, the Ministry of Health and Care Services each year writes a general allocation letter to the Directorate of Health,
describing all the prioritized activities in different fields (such as nutrition).
The Directorate of Health and Social Affairs (since 2008, the Directorate of Health) was established in 2002. The Nutrition
Council continued as an independent advisory board to the Directorate. In 2009, the Directorate was reorganized and
the responsibility for nutrition was shared between three different public health departments with the aim of it being
included in a broader public health perspective.
From the interviews with the various informants, it seemed that the implementation of the Action Plan went well,
particularly during the period 2007–2009. Several informants reported, however, that after 2009 there appeared to be
a loss of momentum. This appears to be validated by the fact that many activities, such as the development of national
dietary guidelines, were undertaken initially. One reason for the perception of loss of momentum could be explained by
the major reorganization of the Directorate of Health. Several informants indicated that this reorganization was not so
much to facilitate better implementation of the Action Plan as to improve coordination with public health in general. The
evaluation group did not evaluate or discuss the relevance of different models for organizing nutrition work.
3.1.2 Mechanism for monitoring implementation
The Action Plan did not detail a specific timeline or earmarked budget for each activity. For the indicators and targets
related to each activity for monitoring and evaluation purposes, it was found that there was not enough information on
socioeconomic status or ethnicity, age group, education or gender, or on other social determinants linked to health such
as:overweightandobesity,dietaryintake(saturatedfatandtransfat,fruitandvegetables,shandsalt);breastfeeding
andcomplementary feeding; and the trends in prevalence/incidence of diabetes mellitus in, for example, women of
childbearing age, or gestational weight gain or diabetes in pregnancy. The level of data disaggregation was, therefore,
too weak to construct a health equity profile with regard to nutrition.
An association of the determinants of health with regard to dietary behaviour (such as dietary intake) and the outcome
(prevalence of overweight/obesity, prevalence of diet-related noncommunicable diseases) is missing. Dietary surveys
that have been conducted are in line with international standards but they could have been linked more strongly with the

11
duration, timeline and priorities of the Action Plan, as a surveillance and monitoring system should feed directly into the
policy priorities defined in national policy.
Some informants reported that they had learned some lessons during the implementation process but they were not
aware of a structured reporting mechanism, although the county authorities have to report annually to the Directorate of
Health about their activities as a result of the letters they receive each year regarding their planning and implementation.
They felt that a structured reporting and monitoring mechanism could facilitate adjustments during the implementation
phase. With regard to monitoring the implementation of the Action Plan, a more robust mechanism for accountability
and reporting between sectors could strengthen collaboration and the exchange and/or dissemination of information
between various national authorities and at county level, supported by an appropriate integrated information system
and a surveillance system aligned with the policy priorities with defined roles for each actor and stakeholder during the
implementation. Another way of improving the monitoring of nutrition-related activities could be to improve the reporting
mechanisms on allocations to counties and the offices of the county governors.
The Dialogue Forum was mentioned as a reporting mechanism and was welcomed especially by the private sector,
although a more structured mechanism was sought by many to encourage ownership by the different sectors.
The Action Plan was perceived as a supportive tool for the informants, both by the authorities and by health professionals,
the private sector and civil society representatives. Most private stakeholders agreed that many of their initiatives did
not come about as a direct result of the Action Plan, as many of them had developed their own plans following the
endorsement of the WHO Global Strategy on Diet and Physical Activity in 2004 or even the long history of nutrition policy
in Norway (as described above).
3.1.3 Budget
As stated earlier, the Action Plan did not detail an earmarked budget for each of its activities. Such a budget is, however,
important to facilitate their implementation. Earmarking the budget in the policy development phase will entail an
assessment of the adequacy of the financial resources allocated to the policy for its implementation. If this shows that
the financial resources are restricted, the activities can be adjusted. A key issue is the need to identify appropriate funding
requirements for policy implementation in a detailed budget, together with a plan to manage the budget throughout this
implementation, so as to support the optimization of resources for this purpose. Detailed and accurate expenditure
reports are an essential tool for tracking the trends in expenditure that inform decision-making.
Several reasons were given for the non-availability of a detailed description of the budget allocation for the Action
Plan, the main one being that the Plan included activities in various sectors which thus impinged on different budgets. It
would be too simplistic to review the budget of the Ministry of Health and Care Services alone, as other ministries had
designated roles and probably specific budget allocations for implementation of the Plan. For example, the Ministry of
Education and Research is responsible for the free school fruit programme. Some informants stated that if funding for
nutrition (linked directly with the Action Plan) had been earmarked, it would have been easier to take implementation
forward. According to the Division of Public Health in the Directorate of Health, the resources spent on nutrition remained
relatively constant during the period of the Action Plan.
3.1.4 Communication
From reports by different informants, it became clear that the joint communication platform was much appreciated.
Although this platform had developed several communication strategies during the period of the Action Plan, it was
felt that a jointly defined media strategy for the Nutrition Council and the Directorate of Health would have been useful.
This was considered particularly important, as the current issues with communication by all the commercial actors to
the general public can cause misunderstanding and biased messages. It was also recognized that a communication
strategy in support of the Action Plan aimed at all target groups and local actors was necessary and should be
considered for future improvement.
In 2009, the Regional Office commissioned the report Health systems and health-related behaviour change: a review of
primary and secondary evidence from the Centre for Public Health Excellence at the National Institute for Health and
Clinical Excellence in the United Kingdom (29). This report aimed at identifying the characteristics of national, regional
and local health systems and services that produce and support changes in behaviour. It presented a review of the role

12
of policies and national programmes, including for the media (with evidence about mass media campaigns), as well as
marketing tools. Mass media campaigns help to set the social context, establish health leadership and communicate
health messages. There is evidence that such campaigns are not enough in themselves to promote changes in
behaviour. If, however, they are developed in line with the policy or government programme being implemented, they
can be effective in raising levels of awareness. With regard to nutrition, there is a body of evidence showing that
promotional campaigns, including media interventions, can increase awareness of what constitutes a healthy diet,
and may subsequently improve dietary intakes if they are reinforced by other measures that make healthier options
more available (29).
The Directorate of Health has used campaigns together with other measures, but it was felt crucial to use a mix of
communication tools and to ensure that the strategy is recognizable by means of an appropriate and consistent image,
such as an attractive logo (linked to the Directorate of Health). This should be supported by a high quality web site which
provides a clear point of contact for the general public.
Books, magazines and television programmes are an important source of information, and the active involvement of
media providers may improve the effectiveness of the policy implementation. In 2011, the Directorate conducted a mass
media campaign on keyhole labelling and collaborated with a smaller television channel (Utrop TV) on providing dietary
inputs and recommendations to minority populations.
The Matportalen web site, which has been set up by the public authorities with information about food and health, was
described by informants, specifically at local level, as a good source of information (30). It was renewed and relaunched in
spring 2011. A total of approximately 220 articles/answers to frequently asked questions about nutrition were published
during the period 2007–2011, an average of 44 published articles per year compared with only 10 per year in the period
2004–2006. The revised HelseNorge web site and the newly launched Helsedirektoratet web site (in December 2011)
provide continuous updates of articles on nutrition targeted at health services and mediators (31,32).
The authorities are respected and trusted by the general public. The National Nutrition Survey indicated in 2011 that
three out of four people (74%) have very great confidence in dietary advice from the Directorate of Health. The following
agencies provided material for the web site: the Norwegian Food Safety Authority, the Directorate of Health, the National
Institute of Public Health, the Scientific Committee for Food Safety, the National Veterinary Institute, the Bioforsk
Norwegian Radiation Protection Authority and the National Institute of Nutrition and Seafood Research.
As far as a communication strategy for minorities is concerned, the Directorate of Health organized a workshop on
diet and minorities in May 2011, with participants from different immigrant communities. The outcomes consisted of a
set of concrete ideas to be developed in dialogue with various minority groups. An example was cooperation with the
largest immigrant newspaper about a television programme featuring a local merchant cooking in consultation with a
nutritionist, both of whom had immigrant backgrounds.
3.1.5 Norwegian Nutrition Council
The Norwegian Nutrition Council was established in 1946. After various changes in its administration over the years,
in 2002 its staff became employees of the Directorate of Health and Social Affairs. The Council continued to exist as a
professional, scientific and independent advisory board to, in particular, the health authorities. During the period of the
Action Plan the Council consisted of 11 members who met, on average, four times a year. The Directorate served as the
secretariat for the Council.
During the period of the Plan, the Nutrition Council was responsible for a systematic review of the literature. This resulted
in the report Dietary advice for promoting public health and preventing chronic diseases (33), which provided an overview
for the health authorities of the updated national dietary guidelines and thus served as the basis for the national dietary
recommendations.
The external expert group heard from several current and former members of the Council. Many of them had strong
opinions about the Council, although some held a nostalgic view. Some felt that the Council should be replaced and its
functions taken over by the Directorate of Health. Others believed that the Council needed an even more independent
role, reflecting its role as an independent body under the Ministry of Health and Care Services.

13
As a result of these interviews, the expert group identified several issues needing some reflection with regard to the future
role of the Nutrition Council. These included: where the Council should be anchored organizationally (in the Directorate
of Health or in the Ministry of Health and Care Services), the background of and criteria for selecting Council members,
the mandate, the need for the Council to be kept updated, the provision of input by the Council on national and Nordic
nutrition recommendations and the Council’s role in communication.
3.2 Evaluation of focus areas and measures in the Action Plan
The Action Plan had 10 focus areas with 73 detailed measures and 5 main strategies to achieve them.
The five main strategies were:
• toimprovetheavailabilityofhealthyfoodproducts
• toincreaseconsumers’knowledge
• toimprovethequalicationsofkeypersonnel
• toensurethelocalbasisofnutrition-relatedwork
• tostrengthenthefocusonnutritioninthehealthcareservices.
The expert group was asked to evaluate whether these five strategies had been achieved through the implementation
of the proposed measures associated with the strategies. A preparatory meeting between the experts and members of
the Directorate of Health and the Ministry of Health and Care Services took place in April 2012 in the Regional Office in
Copenhagen. This meeting defined and prioritized the focus for the evaluation of the first four strategies, as described below.
3.2.1 Availability of healthy food products and improvement of consumers’ knowledge
The Action Plan mentioned a number of measures that could improve the availability of healthy food products and
discouragetheavailabilityofunhealthyfoodproducts.Theseincluded:thedevelopmentandreformulationofproducts;
theestablishmentofaforumfordialogue;increasedaccesstohealthyfoods(suchasvegetablesandfruitfromprimary
producers);increasedavailabilityofseafoodthroughstrengthenedcollaborationbetweenthegovernmentandtheprivate
sector(shing industryand retail);the provisionof healthyready-to-eat mealsfrom fastfood andkiosk outlets;the
introductionof taxation on, for example, non-alcoholic beverages;support for economicincentives; the regulationof
foodmarketingthroughthelabellingoffoodandsymbolsandhealthclaims;andvariousaccessissues,includingproduct
placement and display.
In addition, the Action Plan aimed to improve public knowledge about nutrition through information, communication and
educational approaches reaching all subgroups in the population, including new methods and channels of communication.
Measuresincluded:to develop a comprehensiveplanfor information and communicationonnutrition; to review and
specifytheofcial dietary guidelines; tocampaignfor the promotion of shconsumption; to publish a basiccookery
book;tocontinuetodeveloptheMatportalenwebsite;toawardanutritionprize;andtoestablishadialogueforumfor
information and communication.
The overall evaluation aims of the external expert group regarding these two strategies were to discover:
• goodexamplesofimprovedavailabilityofhealthyfoodproductsthroughouttheperiodoftheActionPlanandimportant
factorsforsuccess;
• goodexamplesofmeasuresthathavebeenabletoincreaseconsumers’knowledgeaboutnutrition;
• examplesof important barriers in theway of improving the availabilityof healthy food products andconsumers’
competenceregardingnutritionanddiet;
• thepotentialforimprovingtheavailabilityofhealthyfoodproductsandconsumers’competenceregardingnutrition.
Good examples of improved availability of healthy food products throughout the period of the Action Plan
and important factors for success
The keyhole labelling system, which was introduced as a joint Nordic health labelling initiative in June 2009, was
mentioned as a key tool in improving efforts to develop and reformulate products in some specific food groups (34).

14
Three consumer-oriented mass media campaigns were carried out during the period 2009–2011 to inform the population
about the keyhole labelling system. A home page was created, along with materials for consumers (folders in 12
languages) and for the food industry and education sectors. In just two years, the keyhole logo has become the best
known and most used logo in the grocery trade. By December 2011, approximately 1500 keyhole-labelled products were
available, in addition to fruits, vegetables, berries and fresh fish that could also be labelled with the logo.
A population survey in January 2012 of awareness and knowledge about the keyhole among consumers aged over 18
yearsshowedcontinuedpositiveprogress:98%kneworhadheardaboutthelogo;85%knewthatthelogorepresented
ahealthierchoice;manyknewthatthelogorepresentedlessfat,sugarandsaltandmoredietarybre;60%trustedthe
scheme;and50%thoughtthatitmadeiteasiertochoosehealthierfoods.
The private sector has also been involved in other initiatives for better food labelling, such as the bread scale (four
categories based on the whole grain and whole grain flour content), improved declaration of the content of food and
the introduction of guideline daily amounts. Independent of the Action Plan, the food industry has also developed
and increased the number of healthier products available. But there is more to be done, for example developing new
keyhole products and making bulk products (such as cheese) healthier. In addition, work is going on to develop a
national salt reduction strategy, including a dialogue with food producers with the aim of reducing the amount of salt
in their products.
The free distribution of fruit in schools, giving access to healthy foods such as vegetables and fruit from primary
producers in lower secondary schools (grades 8–10) and combined primary and lower secondary schools (grades 1–10),
was mentioned as a good example of improved availability of healthy food products, and suggestions were made as to
how this could become universal for all schoolchildren in grades 1–10. In 2007, the Ministry of Health and Care Services
and the Ministry of Education and Research jointly decided to make free fruit and vegetables available to all pupils in
lower secondary schools, thus increasing the availability of healthy food in schools. At 57% of the primary schools, pupils
can subscribe to a subsidized fruit and vegetables scheme but in 2011 only 18% of the pupils at these schools did so.
Informants also suggested that consideration should be given to the economic incentive of removing the value added tax
from sales of fruit and vegetables.
In conclusion, there appear to be examples of success regarding the increased availability of and access to healthy food.
Little progress has, however, been made regarding action on securing healthy ready-to-eat meals from fast food and kiosk
outlets, except perhaps for a few initiatives developed for people such as long-distance lorry drivers.
Good examples of measures that have been able to increase consumers’ knowledge about nutrition
During the period of the Action Plan, dialogue forums were used to communicate and consult with stakeholders. There
were two forums: one at national level between the authorities, nongovernmental organizations and relevant private
actors, and the other for cooperation between the food industry, the authorities, researchers and consumers.
It was seen as important for nutrition-related programmes to facilitate opportunities for information exchange, expert
discussion, consensus on challenges and effective measures, and coordination of measures and various subsidization
schemes. Nongovernmental organizations, the agricultural sector information offices and the Norwegian Seafood Export
Council actively provided information, courses, dietary advice and educational programmes devoted to diet and health.
Many of these organizations were committed to work with schools and kindergartens. There was a need for greater
clarity in regional and local public health efforts as regards certain aspects of partnering with private sector actors over
issues such as commercial interests and advertising.
Informants also considered it important to maintain a forum in which the authorities, the food industry, researchers
and consumers met to discuss topical issues concerning food, nutrition and health. The main objective of the forum
was to achieve a common platform and understanding of the efforts to achieve a healthier diet in the population. A
seminar was organized annually with the food industry and consumer organizations to discuss trends, disseminate
new knowledge and exchange information. Approximately 40–50 participants attended the meetings and different
themes were discussed at each meeting. Positive feedback was received from the participants in 2012 with regard to
these hearings.

15
These dialogue forums were referred to many times by informants, especially those from the private sector. The food
industry’s information offices continued to carry out information campaigns and other communication activities during
the period of the Action Plan.
The results of the interviews showed that all informants thought these forums were important in improving collaboration
with the Ministry of Health and Care Services and the Directorate of Health. All private sector informants agreed that they
should be continued and could be even more useful if smaller and more frequent meetings were held on specific topics
and based more on a real dialogue. This could help to strengthen synergies between different initiatives at different
levels.
As a direct communication tool to increase knowledge and skills for consumers, the Cookbook for all was published
in September 2007 (35). The book was given free to all pupils in lower secondary schools and to student teachers.
Municipalities could buy the book at cost of production for training purposes (for example, language courses for
immigrants or Good Food courses). The book was updated with the keyhole labelling scheme and new dietary advice and
was made available in bookshops for the general public. It was mentioned by the informants as a success story for staff
working in schools. In 2008, it received a prize for the most beautiful book used in primary and secondary education. The
recipes and cooking tips in the book are based on the national dietary guidelines. Table 5 presents an overview of the
number of books printed and distributed free to pupils, sold to municipalities at cost of production and sold in bookshops
during the period 2007–2011.
Table 5. Cookbook for all: numbers distributed or sold 2007–2011
Distributed or sold 2007 2008 2009 2010 2011 Total
To pupils, free 73 413 76 850 76 729 77 142 74 493 378 627
To municipalities, at cost of production 5 470 4 060 6 520 5 360 5 800 27 210
Through bookshops, at normal cost 8 381 337 2 031 1 445 949 13 143
An expert group appointed by the Nutrition Council to update the current dietary advice went through all the relevant available
research literature as the basis for their report Dietary advice to promote public health and prevent chronic diseases (33).
This report, which was developed using a robust systematic review methodology, is available online and will be translated
into English. Its launch in January 2011 gave rise to a broad debate and wide media coverage, as well as considerable
international interest and recognition. Informants mentioned the book as a good source for increasing competence in
nutrition. The Directorate of Health has translated the scientific dietary recommendations into more accessible information
using brochures, posters, online articles and lectures which have been disseminated to the county authorities, clinics,
doctors’ surgeries and other mediators. However, since the book was published it appears that not enough tools have been
developed to make the information accessible to the general population. For example, no food models such as food pyramids
or a food plate or other pictorial aids appear to have been developed to aid the widespread dissemination and uptake of the
guidelines (36). The health authorities have apparently chosen not to develop this kind of model.
Another tool to communicate good dietary practices, particularly targeting children, was the fish project Fiskesprell. This
was considered a good initiative for kindergartens to increase the availability of seafood through collaboration between
the government and the private sector (fishing industry and retail). The aim of the project was to increase knowledge
among kindergarten staff regarding the nutritional benefits of fish and other seafood. It also aimed to develop children’s
cooking skills by encouraging them to help with preparing the fish, and make them more positive towards eating fish by
enjoying the experience of a good taste. As part of the Action Plan, the Fiskesprell project was offered to all the counties
from autumn 2008, based in the Partnership for Public Health. Several informants raised the question of financing during
their interviews with the expert panel: two of the counties had decided not to participate, giving budgetary concerns as
the reason. This was not, however, an issue for other counties which had found the necessary funds.
A survey carried out to assess meals, physical activity and environmental health in kindergartens in the spring of 2011
showed that 37% of the administrators (n=1375) and 29% of the head teachers (n=1100) responded that at least one

16
member of their staff had participated in a Fiskesprell course.1 Among the head teachers who reported participation,
48% said that knowledge and experience from the course had been used to a large, or very large, extent. The survey also
showed that among the kindergartens in which staff had participated, a higher proportion served fish or fish products as
part of the warm meal at least once a month or more often, as compared with kindergartens that had not participated or
where participation was not known.
The Directorate of Health carried out several communication activities during the period of the Action Plan to improve
consumers’ awareness and the consumption of healthier products. These activities include the above-mentioned mass media
campaigns, collaboration with the Norwegian magazine Se og Hør [See and Hear] (with approximately one million weekly
readers) in the form of a 14-page report on healthy eating and recipes involving celebrities, and a workshop with participants
from different immigrant groups with the purpose of identifying specific ideas for communicating advice to such groups.
Although an evaluation of the impact of these initiatives is not available, some of the successful initiatives show that
progress has been made towards increasing knowledge about and competence in nutrition among consumers. It is,
however, difficult to infer causality between increased consumer awareness and the Action Plan. This can only be verified
by carrying out specific consumer research, including among different subgroups of consumers.
Examples of important barriers to improving the availability of healthy food products and consumers’
competence regarding nutrition and diet
Economic determinants such as the price of food and the cost of an affordable healthy food basket are key factors in
improving the availability of healthy food products, as shown in the WHO publication The challenge of obesity in the
WHO European Region and the strategies for response (37). From interviews with the expert panel, it appears that the
authorities have not developed an example of a minimum healthy food basket or what this would cost in, for example,
urban as opposed to rural areas. The National Institute for Consumer Research has, however, developed a reference
budget that includes a food basket in line with the dietary recommendations (38). This was first developed in 1987 and
revised in 2003 and 2007. For example, women aged 18–30 years would receive 9.4 MJ/day (protein 18 E%, fat 33 E%,
carbohydrates 49 E%) which would cost approximately NKr 1835 per month. It has also been calculated that a food
basket for a diet aimed at people with hypercholesterolemia (fat 25 E%, saturated fat 7 E%, carbohydrates 55%, protein
20 E%) would cost 40% more (NKr 2569 per month).
Certain products eligible to meet the keyhole criteria may cost more than the usual alternatives owing to the greater
expense of producing some of the healthier varieties of these products, although some keyhole-labelled products,
such as milk, yoghurt and skyr (a form of strained yoghurt), may cost the same. Added costs may create a barrier to
easier availability, particularly for those on low incomes. There is a need for more information as to which groups in the
population buy the keyhole-branded products. A consumers study or market surveys already available could provide a
more detailed picture of consumers’ behaviour, particularly if stratified by income groups.
Further, the overwhelming attention and focus in the media on diets from various self-designated experts can create
confusion and pose a particular challenge to promulgating the official dietary guidelines.
Price policies and regulations such as taxation (on, for example, non-alcoholic beverages), economic incentives and food
marketing regulations are difficult to implement owing to the natural conflict of interest between different stakeholders
and the political difficulties of adopting and implementing them. Informants from the private sector recognized that
the authorities believe that voluntary marketing regulations are not working, so the industry is anticipating mandatory
regulations from the state. While the food industry is not enthusiastic, it seems to accept that regulations are inevitable.
For many years, the health authorities have been proposing the use of price policies. Some reports and papers concerning
taxation have been published (by, for example, the Norwegian Agricultural Economics Research Institute) and constitute a
basis for the implementation of such initiatives. The strengthening of the regulatory framework to achieve healthier diets,
particularly for children, seems to be coming about with the proposal on the regulation of marketing of food to children,
which is currently under public discussion.
1 Participation in the course during 2010/2011: 4565 kindergarten staff (from 1991 kindergartens) and 401 others. During 2009/2010, 912 student teachers and 616
preschool teachers participated.

17
Potential for improving the availability of healthy food products and consumers’ competence regarding
nutrition: multisectoral collaboration
Norway has participated in an international dialogue, through the WHO Action Network on Marketing Food and
Beverages to Children, with other organizations and countries that had the same agenda or wished to have an
exchange about the measures related to regulation of food marketing proposed in the Action Plan. Through its
chairmanship of this Network, Norway has been instrumental in exchanging information with other Member States
and facilitating implementation of policies with regard to the marketing of food and beverages to children. Norway
has also participated in the EU High Level Group on Nutrition and Physical Activity and the European Food Safety
Authority meetings. In addition, the Nordic Council of Ministers is an important forum for dialogue between the Nordic
countries. The evaluation process showed that in Norway, more collaboration at national level between different
authorities would help to ensure that each sector develops a sense of ownership for the implementation of the Action
Plan.
3.2.2 Competence in nutrition – key personnel
Measures related to improving and securing nutrition-related knowledge, skills and competence in various key health
professional groups are linked to improving work in this area aimed at the prevention and early identification of overweight
and obesity and other nutrition-related noncommunicable diseases, as well as improving awareness at the local level and
in primary health care. Improving competence is also linked to the integration of nutrition in the curricula for professional
training and education.
The overall evaluation aims of the external expert group in assessing competence in nutrition efforts at local level were
to discover:
• good examples of measures to increase nutrition competence among key health personnel and other relevant
occupationalgroups;
• goodexamplesofadequatestandardsandroutinesfornutritioninthehealthcaresector;
• examplesof barriers in the wayof improving competence in nutritionand for establishing adequate routinesfor
nutritioninthehealthcaresector;
• thepotentialforimprovingcompetenceinnutritionandforestablishingadequateroutinesfornutritioninthehealth
care sector.
Good examples of measures to increase nutrition competence among key health personnel and other
relevant occupational groups
Informants involved with clinical nutrition presented evidence that a well-established nutritional structure in a hospital
went together with better nutritional care. A well-defined structure in a hospital was defined as the presence of a
multidisciplinary nutrition team, a resource person in the area of nutrition, guidelines for identifying patients at risk of
under-nutrition, assignment of responsibilities, and education for nursing staff.
Good examples of adequate standards and routines for nutrition in the health care sector
In 2006, the Norwegian Society of Clinical Nutrition and Metabolism asked the authorities for guidelines for the
prevention and treatment of under-nutrition. This resulted in the publication of guidelines in 2009 (39). Although
there is no regulatory framework requiring the full implementation of all action points in the guidelines, it has been
suggested that audits of the implementation of the guidelines carried out by health authorities could improve practice
in the Norwegian context.
The Directorate of Health is responsible for providing guidelines to the various medical disciplines. These are included in
the annual letter from the Ministry of Health and Care Services to the regional health authorities, which forms a central
management tool in the hospital sector. The regional health authorities are responsible for the implementation of these
guidelines. Since 2009, the Directorate of Health has instructed the regional health authorities to ensure that: (i) nutrition
isincludedinoverallspecialisthealthcareservices;(ii)hospitalshaveroutinesandthecompetencetointegratenutrition
intomedicaltreatment;and(iii)hospitalscansupportthemunicipalitiesonnutrition-relatedissues.

18
Examples of barriers in the way of improving competence in nutrition and for establishing adequate
routines for nutrition in the health care sector
A national survey of food and diet among leaders and health personnel in nursing homes was published in 2008 by
Østfold University College (40). This study showed that only 16% had written procedures to be used in the assessment of
patients’ nutritional status. There was, however, no national survey of nutritional status in nursing and care services. In
2010, a nationwide audit run by the Norwegian Board of Health Supervision identified major deficiencies in the daily work
to prevent and treat malnutrition in older people who received health and social services (41). There is still a significant
need for improvement in the health care services with regard to the formal procedures for assessing nutritional status,
night fasting, and knowledge about nutrition and about the daily practice of prevention, identification and treatment of
malnutrition.
It seems that more work is needed to integrate greater attention to nutritional issues in the education and training
curricula of health professionals and other related actors. University courses on human nutrition and clinical nutrition are
well standardized, but colleges and other institutions offering training up to bachelor level do not have a standard core
curriculum. Key issues for improvement are the lack of targeted nutritional education in training courses for health care
professionals and issues regarding the number of nutritionists being trained. The differences in academic knowledge and
skills between professional groups such as dieticians, nutritionists, clinical nutritionists and public health nutritionists
are unclear in terms of their training and certification.
There are not many opportunities for individual consultations about nutrition, and in primary care they seem to be carried
out predominantly by a handful of self-employed nutritionists working in the private sector. They are thus far too expensive
for people on low incomes.
There do not seem to be sufficient data to provide a picture of the dietary behaviour of certain population groups coherent
enough to be used by health professionals for response to and in dialogue with vulnerable groups such as pregnant
women and infants. Neonatal records, for example, could be included more often in routine data collection. Data on
antenatal health care (for example, maternal weight, height and weight gain) could be collected to ensure that this group
is covered. This could also allow sufficient disaggregation to provide useful data on inequalities and other issues, such
as infant feeding (including breastfeeding and complementary feeding) and monitoring tools for the diet and growth of
children aged 0–5 years.
Potential for improvement with regard to education and training
Only broad and inclusive multisectoral planning at the national level, including ensuring an appropriate geographical
distribution, will allow for effective coordination in scaling up the numbers of students and aligning professional education
in nutrition with national nutritional needs.
Overarching reforms must be undertaken at all levels in interventions aimed at increasing the number of health
professionals. Evidence demonstrates that simply increasing the student quota is not enough to address the shortage
of health professionals. Although it is important to increase the number of graduates, this must be done in tandem
with interventions targeted at multiple levels (42). Educational institutions need to increase their capacity and reform
their recruitment practices, teaching methods and curricula in order to improve the quality and social accountability
of graduates. Country-led efforts should be linked to international activities as a way of building on lessons learned
and successful examples of implementation. The inclusion of nutrition training in the curricula for undergraduate and
continuing education, especially for nurses and medical doctors, would probably significantly increase the capacity of
the health system to respond to nutrition-related health problems. There also appears to be a need for mapping current
nutritional competence among the health personnel in nursing care.
Self-perceived skills in nutritional knowledge among Scandinavian doctors and nurses have shown that insufficient
knowledge is the main barrier to good nutritional management in various clinical settings in Norway (43). This lack of
knowledge is evident in three main areas relating to good clinical nutrition practice: screening of patients on admission,
assessment of undernourished patients and initiation of nutrition treatment.

19
Key areas that could be addressed to increase competence in nutrition include:
• theauthorizedscopesofpracticeforvariouscategoriesofnutritionist;
• preserviceeducationtiedtohealthneeds(addingasocialinequalitiescomponenttonutritioneducation);
• in-servicetraining(suchasdistanceorblended2learning);
• thecapacityoftraininginstitutions;
• performancemanagement(appraisal,supervision,productivity);
• trainingofcommunityhealthworkers(in,forexample,centresforlearningandcoping)andeducationalproviders(in
kindergartens,andprimary-andsecondary-schoolteachers);
• identicationandselectionofandsupportforchampionsandadvocatesinthehealthworkforce;
• leadershipdevelopmentformanagersintheareaofnutritionatalllevels.
3.2.3 Nutrition efforts at local level
This area includes nutrition-related work at county and municipal level, including measures in schools and kindergartens.
The Action Plan aimed to establish a stronger basis for nutrition and dietary work at local level through ensuring local
bases for policy and making public health efforts more systematic. Locally-based nutrition-related work also involves the
promotion of healthy eating habits among children and young people in schools and preschools, since the responsibility
for these activities is largely devolved to the local level.
Following the increased emphasis on municipalities’ responsibilities for health promotion and disease prevention under
the new Public Health Act (44), which was developed after the end of the Action Plan, greater attention will be given to
this area in national public health activities.
The overall evaluation aims of the external expert group in assessing nutrition efforts at local level were to discover:
• goodexamplesoflocally-basednutrition-relatedworkthroughouttheperiodoftheActionPlanandimportantfactors
forsuccess;
• examplesofbarrierstolocally-basednutrition-relatedwork;
• thepotentialforimprovement.
Good examples of locally-based nutrition-related work throughout the period of the Action Plan and
important factors for success
A new section on planning in the Planning and Building Act (45) came into force on 1 July 2009. This incorporated public
health considerations: according to § 3–1 of the Act on duties and considerations in planning, plans should “promote
population health and counteract social inequalities in health, as well as help to prevent crime”.
The new Public Health Act of 2012 included provisions whereby the promotion of public health became a statutory
responsibility for counties. In 2006, the Health in Master Plans project was initiated by the Directorate of Health, with
the aim of improving the integration of public health considerations into the social components of municipal plans. By
2010, all the 30 project municipalities had developed Health in Master Plans, and the experiences from this project played
an important role in the development of the 2010 and 2012 Public Health Acts. The development work for the Health in
Master Plans project, with an emphasis on nutrition, was initiated in four pilot municipalities in three counties. All these
took steps to ensure that there was a political and organizational basis for nutrition-related work in their areas. Examples
of action included the adoption of nutrition programmes into the plan for a safe and healthy childhood and inclusion
of the Good Food training course in municipal and financial planning. In 2010, an evaluation of the Health in Master
Plans project referred to a survey conducted in all municipalities of their public health activities and how the work was
organized during the second year of the Action Plan (2008). The results showed that at the time, only a quarter of the
municipalities reported that nutrition-related work was an integral thematic area in their municipal plans. Some activities
relatedtothe Action Planwerefoundtobetakingplacein several counties andmunicipalities;othersinonlyoneor
two counties. Some activities were widespread partly because they were the result of national regulations (such as free
fruit and vegetable distribution in schools) or because the programmes were linked to national action supported by the
2 Education that combines face-to-face classroom methods with computer-mediated activities.

20
government and/or a commercial body. Even so, it seemed that the Action Plan was a driver for intersectoral collaboration
at the local level.
Other initiatives or activities seemed to arise because of the creativity or engagement of one or two key individuals in a
position to initiate nutrition activities who had drawn on the Action Plan as a key tool to enable them to carry out their
plans (for example, running a healthy living centre or a school food programme, or projects initiated at county level by a
public health adviser). All those interviewed who worked at the local level displayed great enthusiasm for the Action Plan
(and for being interviewed about it – all were very keen to engage with the evaluation) and specifically for its physical
manifestation as a written document that they could present and use in negotiation and advocacy. All those interviewed
wanted the Action Plan to be revised and the possibilities it offered to be strengthened and continued: none wanted it
to stop. It was, however, clear that at local level nutritional work was often driven by one or more local activists. In other
words, local nutrition activities appear to need a local champion, which at the same time make them vulnerable because
of their dependence on key individuals. Little evidence was found that nutrition activities had been started or continued
simply because the Action Plan had stated that this should happen. There needed to be someone with the skills, interest
and initiative. With some notable exceptions, informants working in nutrition said that they had felt that their status was
not high, and that the Action Plan had helped to raise their status and make their knowledge and skills more visible and
valued.
Particular barriers were also encountered in the education sector at local level through a lack of tools, expertise or
financial resources. The expert group repeatedly heard that there was a lack of teaching staff with appropriate training
in nutrition and food, insufficient nutrition-related content in the curriculum and not enough good, healthy food options in
schools. All those interviewed said it was important that all those involved in teaching and in the school food environment
should work together to promote and enable good understanding and practice related to healthy food.
The Action Plan was used to enable local professionals to advocate the monitoring of food and meals provided in
kindergartens so as to ensure that they complied with regulations referring to the guidelines for food and meals in
kindergartens (46) (revised as a result of the Action Plan). The informants were also clear that if the guidelines had been
stronger in their wording, by stating, for example, that food served in schools “must” instead of “should” be based on the
guidelines, greater compliance could be achieved at local level.
Other informants, who were not working directly in nutrition but, for instance, on child poverty, said that the Action Plan
had enabled them to include nutrition in their work programmes where previously this might not have been accepted
either by their line managers or those with whom they were working. These more unexpected spin-offs included examples
such as the Living Healthily courses for unemployed people, as well as the inclusion of ways to bring about and manage
healthy food and living among new immigrants in the New in Norway programme.
The informants highlighted the importance of a formal national policy document that works as a tool to drive action at
local level.
Action Plan generated/strengthened success stories
From 2009 to 2012, the Ministry of Education and Research carried out a project (Helhetlig Skoledag [Comprehensive
School Day]) testing various models in schools aimed at improving the coherence between school and the before- and
after-school programmes. Components of the programme included food in school, physical activity, help with homework
and various cultural activities. Provision of breakfast was one of several models for school food tested in a project
coordinated by the Directorate of Education. One of the informants interviewed had experience of breakfast provision,
while other schools tested lunch schemes although these were not discussed during the evaluation. The provision of
breakfast at primary schools was reported as being a successful example of a project looking at options for food provision
in the school setting, especially where teachers identified the children who needed it most (such as those who came
without eating first, or who brought unhealthy food). One school described making a contract agreement with the parents
that the children would eat it, thus engaging them too.
The findings from the Health Behaviour in School-Aged Children (HBSC) study (16) indicated that young people who
are overweight are more likely to skip breakfast, are less physically active and watch more television. Eating breakfast

21
regularly is associated with higher intakes of micronutrients, a better diet that includes fruit and vegetables and less
frequent use of soft drinks. Body mass index and the prevalence of overweight are, in general, lower in young people
who eat breakfast, which is also advocated as a way of improving cognitive function and academic performance.
Eating breakfast daily is less common among girls and in families with lower socioeconomic status and decreases
with age. The latest data from the HBSC 2009/2010 study (16) show that this is also the case among Norwegian girls.
In Norway, 76% of girls and 79% of boys aged 11 years reported that they ate breakfast every school day, which is
higher than the HBSC average of 71% but lowest among the Nordic countries (Sweden 86%, Denmark 82%, Iceland
81%, Finland 79%).
The informants indicated why they regarded school breakfasts as a success (even though very few schools offer breakfast):
the children could eat together, with adults (teachers) who knew them in a different way to their parents, sometimes
in classrooms so that they were in small groups. The teachers said that children were calmer and studied better when
they had breakfast at school. However, in the political debate concerning the provision of breakfast and lunch in schools,
breakfast is currently considered a family responsibility. Those working in education (teachers and trainers) or nutrition
promotion at county or municipal levels, as well as those leading national civil society alliances, all expressed a wish
to see meals provided in schools, in accordance with national guidelines, rather than food brought from home. A 2006
report mapping the situation and modelling five options for the costs of and potential for providing lunch in schools noted
that, owing to the principle of free education in Norway, it would be very difficult to implement a lunch model based on
out-of-pocket payments (47).
Potential for improvement
Public procurement guidelines are needed to ensure that food provided in school settings, as well as in other public
institutions such as care homes and hospitals, is in line with the Norwegian food-based dietary guidelines (48).
3.3 Findings in relation to social inequalities in dietary intake
Social inequalities in health persist in Norway. Examples of health problems that are unevenly distributed in the population
are cardiovascular diseases, overweight and obesity and type 2 diabetes. These conditions are linked to lifestyle and
behavioural factors such as diet, physical activity, harmful use of alcohol and tobacco use. There is consequently much to
indicate that social differences in lifestyle are a contributory factor in social inequalities in health.
The overall evaluation aims of the external expert group in relation to social inequalities in dietary intake were to discover:
• examplesintheActionPlanofstructuralmeasuresthathaveparticularlyfocusedonreducingsocialinequalitiesin
diet;
• examplesofimportantbarrierstoreducingsocialinequalityinnutritionanddiet;
• thepotentialforimprovement.
3.3.1 What the available data show
In terms of trends in social inequalities in diet, the available disaggregated data for adults were limited to sex and age
cross-linked with level of education (basic compared to university).
Among schoolchildren there does seem to have been a levelling-up of the social gradient in the consumption of fruit in
the period 2005–2009 when cross-linked with their parents’ socioeconomic status. Among girls, the greatest increase
was in families with a middle socioeconomic status (approximately 12%), whereas among boys the greatest increase
was in those from families with a lower socioeconomic status (approximately 19%, compared to 11% for those with a
middle socioeconomic status and 9% for those with the highest socioeconomic status). There are, however, limited data
regarding food availability and more upstream social determinants that affect health behaviour, such as food choices and
dietary intake.
3.3.2 Findings from interviews with key informants and related documentation
In sections 3.1–3.3, informants mentioned both universal and selective interventions, largely at the upstream/structural
and midstream/risk reduction levels, that can be understood as contributing to a reduction in social inequalities in diet.
These included the following measures.

22
• Thefreefruitschemeandotherprojectshavebeenintroducedinschoolstoincreasetheavailabilityofhealthyfood
in school settings.
• Thekeyholelabellinginitiativehasbeenintroduced,includingpre-testingwithawiderangeofstakeholderstosee
how they responded to the key messages as well as annual follow-up surveys which include information about level
of income, education and number of children living at home. The 2012 survey included a question on ethnicity derived
from the Statistics Norway surveys.
• Theproposedregulationson restricting the marketing ofunhealthyfoodsto children and young peoplewill,asa
universal measure, have a potential impact on social inequalities in diet by reaching all children without regard to
their socioeconomic background.
• Healthylivingcentres,particularlytheGoodFoodlowthresholddiet-relatedschemeandtheActiveintheDaytime
project, have a selective focus on the level of risk reduction and/or effect mediation. A report from Modum
municipality showed that approximately 60% of those attending the centres were unemployed or outside the labour
market, which is consistent with figures from 2010. Specific projects (particularly those with ethnic minorities and/
or migrants) included Romsås in Motion (which was in place before the Action Plan commenced), the cohort study
of pregnant women looking at ethnic diversity in response to the huge prevalence of gestational diabetes in ethnic
communities, and the materials about nutrition and diabetes produced by the Diabetes Association of Norway
using fruit, vegetables and foods consumed by different ethnic groups to communicate messages about healthy
eating.
• Targetedcommunicationinitiativeshavebeenundertaken,includingthetranslationofkeynutritioninformationinto
several languages (the keyhole labelling brochure was translated into 14 languages) and/or the use of oral as well as
print media. Key examples include the workshop on diet and minorities, the 2008 nutrition prize focusing on promoting
healthy diets among immigrants and cooperation with the largest immigrant newspaper about nutrition.
There is enough information to show that in principle there seems to be a good balance between social reform, risk
reduction and mediation at universal and selective levels. More information is, however, needed to say with certainty
whether the balance between upstream, midstream and downstream universal and selective interventions is right and/
or whether it is making a contribution to tackling social inequalities in diet. There has been a strong emphasis on the
implementation of upstream/structural interventions that are largely universal in focus. From the interviews with key
informants, it does, however, seem that the balance and coordination across each category (that is, improvements
in making universal interventions more responsive to the specific needs of some population groups, such as ethnic
minorities) could be strengthened.
Some initiatives could be improved. For example, some key informants called for the free fruit scheme to be available in
all schools instead of only some, “to move from being halfway there to being universal in coverage”. The scheme was
intended to be universal, but implementation seems to have been selective. In a research project offering free fruit in
schools, the impact on health inequalities was measured using data disaggregated by sex and parents’ education. The
offer of free fruit and vegetables at school increased fruit intake among pupils aged 10–12 years between 2001 and
2008, but vegetable intake did not increase significantly. The effect was the same for boys and girls, and for children of
parents with higher or lower education. The programme clearly had an effect both on boys and on children of parents
without a higher education. Related to this, some of the key informants, particularly those who worked with ethnic
groups or on selective initiatives, indicated that there needed to be greater mainstreaming of inequalities-sensitive
practice and/or systematization of initiatives, as there are many different specific and short-term projects. Some of the
key informants indicated the need for increased, or more sustained, funding to enable longer-term action and impact,
noting that funding is critical to avoid workers “burning out”. Nearly all those working with ethnic groups noted the
need for greater integration and linkage of inequalities-sensitive practice into the mainstream and universal system.
The keyhole labelling initiative is being monitored in different social groups by level of education, marketing legislation
and targeted materials. This monitoring exercise seems to be promising in terms of the potential health impact of tackling
social inequalities in diet.
In contrast, most of the key informants working with people who have lower levels of income and/or education and/or
belong to ethnic minorities, considered that there needs to be more deliberate and focused action to close gaps in diet
and/or in social inequalities that affect food choices.

23
The universal services are seen as fundamental to such action but some extra effort is required to make them responsive.
One informant noted that most immigrants have no idea how to use the health services – understanding what is available,
why it is important to use them and so on. On the other hand, immigrants have been identified as using services four times
as much as native Norwegians, although this also relates to the responsiveness and quality of the system. Such frequent
use is often the result of problems with communication, such as the unavailability of a translator or the complexity of
symptoms and/or co-morbidities.
The feedback from informants was that good intentions (as reflected in the second main goal of the Action Plan) are not
in question, but there seems to be a challenge in putting them into practice in terms of understanding what needs to be
done differently, doing it systematically and following up to see if there has been a reduction in social inequalities as a
result. Those working in the field of social inequalities do not necessarily see some of the key changes needed to make a
difference, or whether any changes that have been made appear to be closing the gaps. This last issue may also be linked
to whether programmes are being evaluated for their impact on inequalities and/or whether the right data are available
to make such an assessment.
Some projects and initiatives do focus on social inequalities in diet (in relation to socioeconomic characteristics such as
level of education, ethnicity and minority), although some of the key informants indicated that these are not necessarily
systematic, coordinated or documented, nor monitored for distribution of impact or effect.
An important consideration is the need to build up the competences of public health and clinical professionals who work
with migrants and different ethnic groups rather than focusing on culture. This needs to be done through elements in
undergraduate, postgraduate and continuing professional education courses.
Settings-based approaches, which are largely at the midstream and risk reduction level, are considered important in
tackling social inequalities in diet. They include health centres, health visitors, kindergartens (particularly because they
are cost-effective and have a wide reach), school health services and healthy living centres.
The evaluation of interventions with the purpose of assessing the distribution of impact, change and/or outcomes
seems to be a challenge as regards the impact of interventions on social inequalities, and also in the more systematic
use of disaggregated data on socioeconomic status and ethnicity. This is particularly the case with data for monitoring
the impact of various initiatives on different ethnic or minority groups as part of an overall mainstream and regular
monitoring effort.
There seem to be better data on different socioeconomic groups than on minority groups or by ethnicity. Data on ethnic
minority groups seem to be strong from the early part of this century, when some major studies provided the basis for the
Oslo Immigrant Health Profile. It is not clear what other national data are available or being collected. There is a need to
collect data on migrants and ethnic minority groups throughout the country.
Examples of barriers to reducing inequalities in nutrition and diet
The question of attribution is a challenge. Nutrition is part of a broader effort to strengthen public health overall, and
the Action Plan was introduced at the same time as a whole-government approach to tackling social inequalities. The
linkages and connections need to be analysed, to see what other macro-level policies in relation to, among other areas,
education and social protection that were put in place in the period 2007–2012 may also have contributed to a levelling-
up of inequalities across different social groups.
Potential for improvement
Table 6 provides an overview of examples of social reform identified during the interviews and in a review of key
documents that have either had a particular focus on reducing social inequalities in diet and/or generally or that aimed
to create a more enabling environment for supporting positive health behaviour.

24
Universal
Selective
Marketing legislation.
Keyhole labelling system for
food.
Fiskesprell in kindergartens.
Free fruit in schools programme. Legislation for the policy has to be
in place but it is delivered using a settings-based approach. This is
categorized as universal (as with Fiskesprell) because it is available to
all children in the relevant school settings but not selective in its focus
from an inequalities perspective.
Reduction in costs to families
associated with secondary
education (such as paper and
books) by gradually providing this
equipment free, and efforts to
increase attendance in secondary
schools, with the aim of creating
equal opportunities in later life.
Action to reduce the upper limit
on kindergarten fees by 18% in
2006 and introduction of pilot
projects allowing attendance at
kindergarten free at specified times
during the week for children living in
multiethnic or disadvantaged areas.
Testing of keyhole labelling with
selected groups (those with low
levels of education or low language
skills, migrant and ethnic groups)
so that a structural measure is
responsive to all groups.
Changes to primary care practice
among general practitioners
regarding nutrition and lifestyle
advice. For example, enabling doctors
to charge an hourly rate for situations
where they are giving lifestyle advice
(such as on diet), particularly for
people with type 2 diabetes or high
blood pressure not being treated with
medicine.
Antenatal cohort study among
women from ethnic minorities to
generate information in relation to
gestational diabetes and including a
targeted post-natal physical activity
and weight loss initiative.
Health information and
education campaigns such as
a cookbook and school health
promotion activities.
Targeted communication initiatives,
including translation of key nutrition
information into several languages
(the keyhole labelling brochure was
translated into 14 languages) and/or
use of both oral and print media.
Tailored health information for
different ethnic and/or minority
groups such as that produced by the
Diabetes Association.
Healthy living centres, particularly the Bra Mat low threshold diet-
related scheme and Active in the Daytime in Oslo and Nordland county.
These programmes are aimed at people who are unemployed, on sick
leave and/or from different ethnic minorities.
Table 6. Examples of social reform focusing on reducing social inequalities in diet
and/or generally or aiming to support positive health behaviour
Measure Social reform Risk reduction Effect mediation
(upstream or structural) (midstream) (downstream)

25
These interviews and documents indicated that monitoring of whether these interventions are making a difference to
social inequalities in diet remains a challenge. Key issues include the following.
• Thecollection,measurementandmonitoringofsex-andage-disaggregateddata,cross-linkedwithtwoorthreekey
and agreed socioeconomic determinants as well as ethnicity, need to be strengthened and perhaps a minimum set of
equity criteria developed.
• Someofthoseadministeringandimplementingtheuniversalmeasures,particularlyatthesocialreformlevel,need
to recognize that equity issues should be considered as part of the regular monitoring and assessment of effective
programme implementation. This is linked to the first issue, and it became apparent in discussions about health
services at all levels, both general and nutrition-related. There seems to be an implicit assumption that if a service or
intervention is intended to be universally available, then it is actually universally available and accessible in practice.
This assumption needs to be tested as part of good practice in ensuring that universal and/or effective coverage is
actually happening.
• Cananydifferences(such as changes in ratesorprevalence)be attributed to the intervention (socialreform,risk
reduction, effect mediation) and whether it is universal or selective? The further downstream and more selective an
intervention, the easier it is to measure and assess attribution.
• Istherateofchangefasterinmoredisadvantagedgroups?Thatisoneoftheideasbehindlevelling-upacrossthesocial
gradient so as to improve health faster among the population groups considered to have poorer health outcomes. There
is not enough information to answer this question, nor is there a quantitative target that would enable measurement of
whether the hoped-for change is being realized. Change does, however, seem to be in the right direction in some instances:
for example, more schoolchildren are consuming fruit, berries and vegetables at least once a day.
4. Overall recommendations of the evaluation
4.1 General recommendations
The Norwegian nutrition policy has increased knowledge on nutrition and health in the population. The main changes
in the diet have been as seen in other WHO European Member States: a reduction in the consumption of fat (mainly
saturated fat) and an increase in the consumption of vegetables, fruit and cereals. Diet and meal patterns are changing
rapidly, especially among the younger generation, and public health campaigns are losing ground to aggressive marketing
of foods high in fat, sugar and salt. Even though heart disease has almost halved during the past three decades, the
proportion of adult obesity in Norway is now as high as in the rest of Scandinavia: about 10%.
There are several challenges as well as positive trends in the current developments in diet. The content of saturated
fat is now significantly higher than recommended. The consumption of added sugars has decreased since 2000 but is
still higher than recommended. The content of dietary fibre has increased but is still lower than recommended. On the
positive side, the dietary content of protein, trans fat and polyunsaturated fat has remained at the recommended level
during the period of the Action Plan. Furthermore, the consumption of vegetables, fruit and berries has increased over
time, including during the period 2005–2010. Current dietary habits must be seen not only in relation to the period of the
Action Plan but also to work over several decades.
4.2 Specific recommendations regarding the Action Plan
The authorities, health professionals, private sector and civil society alike perceived the Action Plan with enthusiasm as
a supportive tool at local level for initiating and implementing nutrition-related activities. In particular, local professionals
used it to advocate the monitoring of food and meals provided in kindergartens for compliance with regulations referring
to the Directorate of Health’s guidelines for kindergartens, which were revised as a result of the Plan.
The allocation of measures between the various ministries showed that the Plan was primarily rooted in the context of
health. There are many good reasons why this is the case, but it could also be a challenge with regard to distributing
ownership and commitments to the other ministries involved. Ideally, sectors other than health should see how health-
related work contributes to achieving their objectives.

26
There were, however, no clear timeline, budgets, earmarked funding or targets/milestones for the different measures in the
Plan. Furthermore, the preciseness of the language describing the different measures varied from the specific, for example:
“1.4 Publish a basic cookery book for everyday use in the population” to the vaguer “4.8 Encourage school owners to strengthen
food and meal programmes in before- and after-school programmes for schoolchildren”. The content of the measures also
differs between those that were a continuation of previous activities, such as “7.5 Continue nutrition and diet initiatives
together with physical activity and anti-tobacco programmes as a priority focus in partnerships for public health”, and others
that were new activities, for example: “1.3 Implement a campaign to promote consumption of fish and other seafood”.
There is a need to strengthen the steering mechanism with regard to funding and financing mechanisms.
4.2.1 Core activities
According to the findings from interviews and other available material, many activities should be considered for
continued support. The observations of the expert group are based on the experience of the people, institutions and
health professionals involved and the likelihood of positive effects. These activities include the following:
• the distribution of free school fruit in lower secondary schools (grades 8–10) and combined primary and lower
secondaryschools(grades1–10),whichshouldbeextendedtoincludeprimaryschools;
• thecommonNordickeyhole labelling system, mentioned by various informants as one of the supportive tools for the
ActionPlan;
• the Fiskesprell sh project, implemented by most counties in kindergartens to improve the nutrition skills and
competence of kindergarten staff, which had positive effects on kindergarten children in terms of preparation skills
and taste preferences with regard to the consumption of fish.
Communication. The Dialogue Forum was acknowledged by all informants as an important step towards improving
collaboration with the Ministry of Health and Care Services and, especially, the private sector. All private sector
informants agreed that the Forum should continue, and that it could be even more useful if smaller and more frequent
meetings were held on specific topics and based more closely on a real dialogue. Other measures such as the
development of the Matportalen, Helsedirektoratet and HelseNorge web sites and the publication of the Cookbook
for all, were also popular.
Targeted communication initiatives, including the translation of key nutrition information into several languages and/or
the use of oral as well as print media, should be continued. Key examples include the workshop on diet and minorities, the
2008 nutrition prize focused on promoting healthy diets among immigrants, and cooperation with the largest immigrant
newspaper about nutrition.
Activities at local level. In the education sector, barriers were encountered in the form of a lack of available tools, expertise
or financial resources. It was repeatedly reported that there is a need for more teaching staff to receive appropriate
training about food and nutrition, the nutrition content in the curriculum could be improved, and the provision of good,
healthy food options in schools could be scaled up. Examples of nutrition programmes being adopted into the plan for a
safe and healthy childhood and the incorporation of the Good Food training course into municipal and financial planning
should be repeated more widely.
Key personnel and competence in nutrition. The range of domestic approaches that should be implemented or proposed
to address the projected shortage of nutritionists, especially in primary health care, could include both short- and longer-
term initiatives, legislative as well as programme development activities, and national as well as municipal or local
efforts. It was considered essential that those involved should represent a broad range of stakeholders.
Focus on social inequalities in diet. Although the Action Plan has two overarching policy priorities (social inequalities and
cross-cutting issues), informants felt that it was unclear how these priorities should be translated into action. This led to
the recommendation that policy action needs to be strengthened and reoriented from mainly universal coverage towards
a focus on the specific needs of low income groups and ethnic minorities.
Many of the other measures, such as the above-mentioned Good Food low threshold diet-related scheme at healthy living
centres, Fiskesprell in kindergartens, the free fruit scheme at schools and the keyhole labelling system, are important and
relevant measures for reducing inequalities in health.

27
4.2.2 Monitoring challenges
There appeared to be several challenges associated with the monitoring of nutrition-related issues, including a lack of
disaggregated data and of specific consumer investigations into changes in consumers’ knowledge and into the status
of nutrition in nursing and care services. There were also insufficient data to provide a coherent picture of dietary
behaviour among certain population groups that could be used by health professionals to respond to and in dialogue
with vulnerable groups such as pregnant women and infants. For example, neonatal records could be included more
frequently in routine data collection. Data on antenatal health care (such as maternal weight, height and weight gain)
could be collected to ensure that this group is covered and to allow for sufficient disaggregation so as to provide
useful data on inequalities and other issues, such as infant feeding. In terms of trends in social inequalities in diet,
the available disaggregated data for adults were limited to sex and age cross-linked with level of education (basic
compared to university).
4.3 Key priorities in nutrition policy
The Action Plan should be seen as an example of good practice in the application of the WHO Health 2020 policy
framework. The implementation of the Action Plan does, however, require a whole-government and whole-society
approach, and the emphasis on decentralization is creating some difficulties for the implementation of action plans at
local level. While the question of local autonomy is important in addressing multilevel governance, it is recognized that
empowerment and ownership both top-down and bottom-up may improve implementation.
In future policy-making related to nutrition, such as a new action plan, consideration should be given to the number of
action points, targets for action points and milestones, a time-line for implementation, a detailed budget and a more
structured reporting mechanism.
There is room for improvement with regard to ownership by the various ministries involved. One suggestion is to establish
a steering group for the Action Plan. The role and responsibility of the Nutrition Council should also be clarified. The
Directorate of Health is a key leader for public health policy at both national and European levels, so re-investment in
it would be crucial. As an example, the nutrition surveillance system allows for the monitoring of key challenges with
regard to nutrition. These priorities, for example the focus on vulnerable groups in data collection, need to be followed
up closely to ensure that they are indeed integrated within the nutrition surveillance system.
4.3.1 Increasing nutrition competence among consumers
It is important to garner more information about consumer behaviour and the role of incentives. For example,
research would be useful to validate how well the keyhole labelling system is able to affect various determinants
of behaviour.
The Directorate of Health could consider incentives for local policy-makers and organizations working with low
opportunity and/or ethnic and cultural minorities to encourage a balanced diet among social risk groups. An example
might be a booklet for local authorities offering examples of good practice in providing healthy nutrition in low
opportunity groups. The Directorate of Health could encourage this approach by rewarding good practice by local
authorities.
Further development of work on communication could include the production of pictorial aids, such as food pyramids or
food plates, for dissemination in support of the national guidelines. Training sessions for media professionals working
regularly with nutrition could also be considered.
More emphasis should be given to making healthier ready-to-eat meals available from fast food and kiosk outlets.
4.3.2 Visibility of nutrition activities at local level
The Action Plan was used by various actors at local levels, working in different contexts to achieve a number of outcomes.
This applied both to the written document, which could be used in negotiation with other local partners, and to its
existence as legislation enabling it to be used for advocacy and in education. As stated above, the Action Plan was
an important policy instrument at local level as wherever it needed implementation, it was crucial to train key staff to
increase their competence in nutrition.

28
There might be potential in increasing the number of individual nutrition consultations in primary care and making them
available in institutions. The healthy living centres could be one arena, but other parts of the health system could also
provide this service.
Healthy living centres, particularly the Good Food low threshold diet-related scheme and the Active in the Daytime
project, have a selective focus on the level of risk reduction and/or effect mediation. A report from Modum municipality
showed that approximately 60% of those attending the centres were unemployed or outside the labour market, which is
consistent with figures from 2010.
There were also examples of specific projects, particularly with ethnic minorities and/or migrants, such as Romsås
in Motion (which was in place before the Action Plan commenced), or the cohort study of pregnant women being
undertaken to look at ethnic diversity and in response to the huge prevalence of gestational diabetes. The Diabetes
Association of Norway has done important work in producing materials about nutrition and diabetes, using fruit,
vegetables and foods consumed by different ethnic groups to communicate messages about healthy eating.
The continuous implementation of projects such as these should be considered to ensure the sustainability and visibility
of nutrition activities at local level.
4.3.3 Increasing nutrition competence – health professionals
There is a need for improvement in the health care services with regard to formal written procedures for assessing
nutritional status, night fasting, and knowledge about nutrition and about daily practice in preventing, identifying and
treating malnutrition.
Nutrition-related work should be well-integrated in institutions at local level to ensure that the skills and status of
practitioners are more visible and valued, and to reduce the dependence on non-expert nutrition enthusiasts, which to
some extent appears to be the case today.
There is a lack of targeted nutritional education in training courses for health care professionals.
More emphasis needs to be placed on building up the competences of public health and clinical professionals working
with migrants and various ethnic groups and less on the present focus on culture. This needs to be done as part of
undergraduate, postgraduate and continuing professional education courses.
Only broad and inclusive multisectoral planning at the national level, including ensuring an appropriate geographical
distribution, will allow for effective coordination in scaling up the numbers of students and aligning professional education
in nutrition with national nutritional needs.
Competence regarding nutrition should be built up among schoolteachers through appropriate training in nutrition and
food. In addition, the nutrition content in curricula needs to be looked into, as well as the provision of good, healthy food
options in schools.
4.3.4 Strengthening action on social inequalities in diet
The following are recommendations in relation to both universal and selective interventions that could be extended and
or enhanced to make a greater impact on social inequalities in diet.
The overarching recommendation is that disaggregated data (at least sex and age) cross-linked to at least two or three
socioeconomic determinants (level of education, income, occupational status, ethnicity, etc.) should be collected more
systematically and routine analysis undertaken. Rather than seeking to have a massive data set for a possible new
nutrition action plan, it could be useful to develop a minimum indicator set (no more than three to five indicators) for
making assessments.

29
Further recommendations include the following.
• Thefruitschemeshouldbeexpandedtomakeituniversalandavailableinallschools.
Rationale/evidence is found in work by Bere et al. (49) about the impact on health behaviour and parents not being
willing to take up the subsidized scheme, together with evidence about early child development showing that
increased exposure in kindergartens and primary schools should mean that good eating habits are developed earlier,
are more entrenched and are better for learning.
• Work should be undertaken on costing a healthy food basket to identify the relative costs for all groups in the
population of a diet that is in accordance with the recommended guidelines.
Rationale/evidence: other interventions are important, particularly in relation to the effective adoption of healthy
behaviour. If it costs too much to eat healthily out of a lower family income, there will be less change and potentially
widening social inequalities with the higher income groups who can afford the cost.
• Existing structural measures should continue to be implemented, including keyhole labelling and price policies
(including taxes and subsidies) as well as other types of incentive.
Rationale/evidence: such measures seem to be having the desired effect but more evidence is needed about the
impact of taxes on unhealthy foods and the lowering or removal of taxes on healthier foods as well as about other
incentives and measures affecting price. This is important from a social inequalities perspective and relates to being
able to afford to live in a healthy way and to the healthy food basket (50).
• Aninventoryofnutritionprojectsand/orinitiatives(currentandpastveyears)shouldbedevelopedfocusingonsocial
inequalities and specific groups in the population defined by socioeconomic status, place of residence, ethnicity, etc.
Rationale/evidence: it would be useful to get an overview of the nutrition initiatives that could be classified as aiming
to reduce social inequalities in diet. This could be used to find out whether more selective initiatives are needed for
action on social inequalities in diet and nutrition, and whether more effort needs to be put into capturing the learning
from these initiatives in guidance and integrating it into mainstream practice and universal services for nutrition and
diet. Such an overview should also enable peer learning and exchange between different stakeholders looking to
do similar work. Examples of similar inventories or catalogues are A better life for children and adolescents through
diet and exercise. Nordic catalogue of initiatives and best practice for improved health and quality of life via diet and
physical activity (51).
• Anequity-focusedassessmentshouldbeundertakenoftheclinicalandpublichealthnutritionservicesofferedaspart
of the health system (at all levels) to identify whether there are gaps in relation to specific groups in the population,
including those with lower levels of education, migrants and ethnic minority groups.
Rationale/evidence: it was not clear from interviews with the key informants or from the available information
whether there is a focus on social inequalities in the nutrition services at the downstream/individual intervention
level. The obligation to provide equal health services to all, regardless of gender, economic circumstances, etc., is set
out to some extent directly in the health laws as well as in the general duty of the equal carrying out of public service
in the anti-discrimination legislation. According to the Patients’ Rights Act, patients can complain to the supervision
authorities, who work independently of political management dealing with complaints from the public and carrying
out systematic surveys of the health services.
• Anagreedsetofminimumcriteriashouldbedevelopedforevaluatingthesocialinequalitiesimpactofinterventions
implemented in the existing Action Plan and a possible new nutrition action plan.
Rationale/evidence: there is already a good set of data in the system and the generation of infinite data collection or
a call for a whole new set is not desirable.
• Asystemorprocessshouldbeputinplacetoensurethecollectionofrelevantdisaggregateddata(socioeconomic
status, ethnicity, etc.). A minimum set can be collected and accessed and used for monitoring and evaluation.
Rationale/evidence: from interviews with the key informants it is clear that a better use of existing data could help.

30
There seems to be a need for a greater mainstreaming of inequalities-sensitive practice and/or systematization of
initiatives in view of the many specific and short-term projects.
The proposed regulations restricting the marketing of unhealthy foods aimed at children and young people could
have an impact on social inequalities in diet by reducing the likelihood of some groups of children and young people
being more exposed, because of their socioeconomic background, to such marketing and therefore more differentially
vulnerable.
5. Future policy priorities
Several issues relating to monitoring should be considered. The current surveillance system does not allow for stratified
distribution between different social groups. In addition to the need for disaggregated data on diet, further consideration
should be given to monitoring and assessing the distribution of impact, change and outcome of the various measures
(such as keyhole-labelled products, communication efforts and fruit and vegetable schemes in schools) for the social
groups differentiated by socioeconomic status.
Regular consumer studies would provide a more detailed picture of consumers’ behaviour, including whether the keyhole
labelling system reaches all levels of the population.
There is also a need for an analysis of the linkages and connections with other macro-level policies in relation to education,
social protection and so on, and how they influence inequalities between different social groups.
Initiatives and projects aimed at reducing social inequalities in nutrition and diet should have a particular focus on
monitoring and documenting the distribution of impacts and effects.
Monitoring that measures process indicators should be carried out at district as well as provincial, national, regional and
global levels. Apart from ensuring that activities are being implemented in the agreed manner, it allows decision-makers
to stay aware of all the problems and constraints that may slow down progress and provides them with the information
they may need to refine their planning.

31
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34
Annex 1
LIST OF EXPERTS ON THE EVALUATION PANEL
WHO Regional Office for Europe
Caroline Bollars, Technical Officer, Nutrition,
Physical Activity and Obesity Programme, Division of
Noncommunicable Diseases and Life-Course
João Breda, Programme Manager, Nutrition,
Physical Activity and Obesity Programme, Division of
Noncommunicable Diseases and Life-Course
Sarah Simpson, Project Manager, European Office for
Investment for Health and Development
Rodrigo Rodriguez-Fernandez, Nutrition, Physical Activity
and Obesity Programme, Division of Noncommunicable
Diseases and Life-Course
International and national experts
Elizabeth Dowler, University of Warwick, Coventry, United
Kingdom
Charli Eriksson, Örebro University, Örebro, Sweden
Hanna Hånes, Norwegian Institute of Public Health, Oslo,
Norway
Aileen Robertson, Metropolitan University College,
Copenhagen, Denmark
Gun Roos, National Institute for Consumer Research,
Oslo, Norway
Harry Rutter, London School of Hygiene and Tropical
Medicine, London, United Kingdom
Grethe S Tell, Department of Public Health and Primary
Health Care, University of Bergen, Bergen, Norway
Dag Thelle, Research Centre for Epidemiology, University
of Oslo, Oslo, Norway
Suvi Virtanen, National Institute for Health and Welfare,
Helsinki, Finland and University of Tampere, Tampere,
Finland

35
Annex 2
LIST OF KEY INFORMANTS
Heidi Aagaard, Nurse and lecturer, nursing and care
sector
Anne Kathrine Owren Aarum, Senior adviser, Directorate
of Health
Tore Angelsen, Project leader, Information Office for Fruit
and Vegetables
Helga Arianson, County Medical Officer, Hordaland
County Governor’s office
Jon Olav Aspås, Director-General, Department of Public
Health, Ministry of Health and Care Services
Pernille Baardseth, Technological nutritionist, Norwegian
Institute of Food, Fisheries and Aquaculture Research,
Nofima AS
Sissel Lyberg Beckman, Head, Department of Public
Health, Ministry of Health and Care Services
Knut Berdal, Senior adviser, Ministry of Agriculture and
Food
Elling Bere, Professor, University of Agder
Ingunn Bergstad, Head, Nutrition and Dietetics Section,
Oslo University Hospital
Bodil Blaker, Senior adviser, Department of Public Health,
Ministry of Health and Care Services
Rune Blomhoff, Professor, University of Oslo, Member of
Nutrition Council
Geir Sverre Braut, Deputy Director-General, Norwegian
Board of Health Supervision
Magritt Brustad, Professor, Centre for Sami Health
Research, University of Tromsø
Kristi Wettre Brønner, Clinical nutritionist/dietitian,
Network of Nutritionists in Food Industry
Annechen Bahr Bugge, Researcher, National Institute for
Consumer Research
Vibeke Bugge, Nutritionist, Information Office for Eggs
and Meat
Anne Bærug, Head, Norwegian Resource Centre for
Breastfeeding
Lisbeth Dahl, Researcher, National Institute of Nutrition
and Seafood Research
Jorunn Vormedal Dalen, Academic Director, Food and
Environment, Confederation of Norwegian Enterprise,
Food and Agriculture
Cathrine Dammen, Head, Specialist Health Care
Department, Ministry of Health and Care Services
Astri Grydeland Ersvik, Nurse, Norwegian Nurses
Association and Association for Public Health Nurses/
Health Visitors
Øyvind Gievær, Senior adviser, Directorate of Health
Elin Glomnes, Leader, Norwegian Association for
Nutritionists
Anne Hafstad, Head, Healthy Public Policies Department,
Directorate of Health
Rut Harildstad, Senior adviser, Ministry of Fisheries and
Coastal Affairs
Helge Hasselgård, Managing Director, Grocery
Manufacturers of Norway
Brita Haugum, Leader, Dietitians’ Association
Paal Haavorsen, Academic Director, Rehabilitation
Enterprises Union
Ida Berg Hauge, Director, Information Office for Dairy
Products
Maren Hegna, Senior adviser, Ministry of Education and
Research
Tore Henriksen, Professor, University of Tromsø
Aase-Berit Hoffart, Adviser, Secretariat of the Parents’
Association for Children in Preschool, also representing
the Parents’ Association for Schoolchildren
Steinar Høie, Head, Food Policy, NHO Mat og Drikke
[NHO Food and Drink]
Gunstein Instefjord, Academic Director, Food and Trade,
Consumer Council
Øyvind Irtun, Professor, Norwegian Society of Clinical
Nutrition and Metabolism
Inger-Lise Fevang Jensen, Association for Teachers of
Food and Health in Schools
Anne Karen Jenum, Researcher and general practitioner,
University of Oslo
Geir Mo Johansen, Senior adviser, Ministry of Finance
Lars Johansson, Senior adviser, Directorate of Health
Jorunn Killingstad, Leader, Healthy Life Central
(Frisklivsentral)
Knut-Inge Klepp, Acting Deputy Director-General of
Health, Directorate of Health
Kathrine Kleveland, Leader of the Board, Farming
Women’s Association (NorgesBygdekvinnelag)
Gunn Harriet Knutsen, Adviser, Health and Quality,
Norwegian Seafood Federation
Berit Koen, Public health adviser, Municipality of Volda
Bernadette Kumar, Director, Norwegian Centre for
Minority Health Research
Geir Kvam, Secretary, Norwegian Transport Workers’
Union

36
Karen Lassen, Lecturer, Vestfold University College
Jorunn Lervik, Public health adviser, County Governor’s
Office of Sør-Trøndelag
Fedon Lindberg, Head, Dr Lindberg’s Clinic
Kaja Lund-Iversen, Nutritionist, Kostforum
Tove Løken, Senior adviser, Department of Specialist
Health Care, Ministry of Health and Care Services
Haakon Meyer, Professor, Head of Nutrition Council,
National Institute of Public Health and University of Oslo
Mette Helvik Morken, Associate Professor, University of
Bergen
Kari Hege Mortensen, Public health adviser (clinical
nutritionist), County authorities of Nordland
Mari Nes, Head of Department, Norwegian Research
Council
Joachim Nilsen, Senior adviser, Department of Public
Health, Ministry of Health and Care Services
Torunn Nordbø, Director, Information Office for Bread and
Grains
Kaare R Norum, Professor Emeritus, Former Head of
Nutrition Council, University of Oslo
Berit Nygaard, Special adviser, Norwegian Research
Council
Trond Nygard, Senior adviser, Department of Specialist
Health Care, Ministry of Health and Care Services
Arne Oshaug, Associate Professor, Oslo and Akershus
University College
Manuela Osmundsen, Head of Department, Akershus
University Hospital
Irene Teigen Paulsen, Nutritionist, Inter-municipal
Environmental Health
Guttorm Rebnes, Director, Information Office for Fruit and
Vegetables
Arnhild Haga Rimestad, Senior adviser, Ministry of Health
and Care Services
Gro Samdal, Head, Learning and Coping Centre
Unni Silkoset, Senior adviser, Norwegian Agency for
Development Cooperation
Vigdis Britt Skulberg, Clinical nutritionist, Health and
Welfare Administration, Municipality of Oslo
Merethe Steen, Head, Consumer Interests Section,
Norwegian Food Safety Authority
Eli Strande, Senior adviser, Department of Public Health,
Ministry of Health and Care Services
Janne Strømme, Clinical nutritionist, private clinic
Birger Svihus, Professor, Norwegian University of Life
Sciences
Britt Sørø, Leader, Institutional Catering, Norwegian
Association for Nutrition and Dietetics
Lasse Tenden, Head of analyses, Confederation of
Norwegian Enterprise, Food Service
Kjersti Toppe, Member of Parliament, First Vice-
Chairperson, Standing Committee on Health and Care
Services
Tone Torgersen, Senior adviser, Directorate of Health
Elisabeth Varland, Senior adviser, Ministry of Children,
Equality and Social Inclusion
Jorunn Borge Westhrin, Nutritionist, Public health
adviser, County authorities, Telemark County

37
Annex 3
INTERNAL GOVERNMENT MONITORING MATRIX
1. Communication about food and diet
Goals: Strengthen knowledge about food and diet and skills in preparation of healthy food in all population groups
Encourage enjoyment of food and motivate healthy changes in diet
Adapt public information and communication to minority language and at-risk groups
1.1 Develop and implement
a comprehensive plan
for information and
communication activities in
the nutrition area
Health & Care
Services;
Agriculture
&Food;
Fisheries &
CoastalAffairs;
Children,
Equality
& Social
Inclusion;
Education &
Research
A comprehensive plan was developed, but a lack of funding
for the specified activities meant that sub-plans and a
communication platform for the affected parties were developed
and implemented instead. Many measures in the Action Plan
also include communication, and these activities are presented
as part of those measures. The Directorate of Health has
developed communication strategies and plans for dietary
advice (see 1.2) and the keyhole labelling system (see 2.9) and
used focus groups in the design of communications activities.
In the summer of 2011 the expert group worked editorially with
the popular magazine Se og Hør (1 million readers a week),
producing 14 double-sided reports with tips for healthy eating
and recipes. Norway’s “cookery mum”, Ingrid Espelid Hovig, and
two other celebrities (one with an immigrant background) gave
their support.
In May 2011, a workshop was held on diet and minorities with
participants from different immigrant communities. This yielded
many ideas to be developed in dialogue with minority groups,
for example, cooperation with the largest immigrant newspaper
Participating ministries have shared
responsibility for implementing the
communication platform.
The Directorate of Health gave the highest
priority to implementation of the keyhole
labelling scheme and new dietary advice
(see 1.2 and 2.9). Many projects have been
published on the web.
The Media Profile Analysis (Retriever) covering
nutrition shows the following numbers of hits:
2009:10911;2010:23324;2011(upto4July):
22 417.
The Ministry of Agriculture & Food publishes
food and diet information on its web site linked
to keyhole labelling, dietary advice, etc.
The Directorate of Health continuously updates
nutritional articles on the Helsedirektoratet,
Matportalen and HelseNorge web sites. There
Focus area and goals Ministry Measures Comments
responsible

38
Focus area and goals Ministry Measures Comments
responsible
were 56 articles on the Helsedirektoratet web
sitein2003–2006;56in2007;49in2008;30
in 2009 and 30 in 2010. The Helsedirektoratet
web site was relaunched in December 2011
targeted at health services and mediators (see
1.2 and 2.9).
The media have focused strongly on low
carbohydrate/high fat diets since the summer
of 2011. The continuing debate on the merits
of such diets is challenging due to the variety
of opinion on low carbohydrates/high fats as
opposed to normal diets.
In February 2012, the Directorate of Health
invited selected executives, experts and
professionals to discuss and help with dietary
advice in future. A seminar on dietary advice
for journalists and workshops will be organized
with these people and with critics of dietary
advice.
about a TV programme where the local merchants cook in
consultation with a nutritionist, all with immigrant backgrounds.
The Ministry of Agriculture & Food marked World Bread Day, the
Week of Taste, Gane Fart [Palate Ride – a play on the word for
sleigh-ride] (a competition to find the best restaurant focusing
on local food traditions), the Year of the Potato and other media
initiatives. The Directorate of Health participated in 2008 in
the six-programme TV series Lyst & last [Pleasure and burden],
focusing on nutrition- and diet-related topics.
Since 2010, the Norwegian Seafood Council has increasingly
focused on the domestic market. For the first time it has run
commercials for salmon on TV.
A working group appointed by the National Nutrition Council
went through all the relevant available research literature as the
basis for the report Dietary advice for promoting public health and
preventing chronic diseases. The report has a thorough scientific
basis. It was developed through an open and transparent process
and network consultation and was launched at a large meeting in
January 2011.
The Directorate of Health publicized the specific dietary
recommendations from the report in brochures, posters,
online articles and lectures so as to disseminate advice and
information to county authorities, clinics, doctors’ surgeries and
other mediators. The launch of the report and dietary guidelines
created a broad debate and wide media coverage. The report
also drew broad international attention and recognition.
Health & Care
Services
1.2 Communicate official
dietary guidelines in specific
terms

39
Focus area and goals Ministry Measures Comments
responsible
The food industry’s information offices offer
generic information and were busy with
communications activities during the period of
the Plan.
The Ministry of Agriculture & Food participated
in the debate, particularly in relation to advice
relevant to agricultural and food policy, with
feature articles among other things. The
Ministry of Finance supported the MeetEat
conference in 2011. The goal of this conference
was to improve the dialogue between the
human and veterinary medicine and food
technological environments on diet and
nutrition.
The project was evaluated thoroughly in 2012.
Kindergarten staff have been asked to evaluate
the project along the way and an evaluation
survey is sent to all participating lower
secondary schools.
In a mapping of meals, physical activity and
environmental health in kindergartens in spring
2011, 37% of the administrators (n=1375) and
29% of the head teachers (n=1100) responded
that at least one member of staff in their
kindergarten had participated in a Fiskesprell
course.
Communication of dietary advice has been closely linked to the
keyhole labelling scheme, with the main focus on the scheme.
An unpublished population survey in January 2012 showed that
consumers know what is good for health in line with dietary
recommendations, but they do not know that these are the
government’s recommendations.
A Norstat survey in 2011 showed that three out of four people
(74%) have “very great confidence” in the Directorate of Health’s
dietary advice.
The Fiskesprell project was started in autumn 2008, with the
goal of increasing awareness of the nutritional benefits of
fish and other seafood and giving young people good taste
experiences. Through the project, staff in kindergartens and
schools are given advice on how to prepare and present
seafood, all with a youthful twist.
Fiskesprell is a collaborative project between the Ministries of
Fisheries & Coastal Affairs and Health & Care Services and the
Seafood Council, which together fund it with contributions from
the fish sales organizations. The Directorate of Health and the
National Institute of Nutrition and Seafood Research are partners
in the project.
Fisheries &
CoastalAffairs;
Health & Care
Services
1.3 Carry out a campaign to
promote the consumption of
fish and other seafood

40
Focus area and goals Ministry Measures Comments
responsible
Among the head teachers who reported
participation, 48% said that knowledge and
experiences from the course had been used to
a large, or very large, extent.
The survey also showed that among the
kindergartens where staff had participated
in a course, a higher proportion served fish
or fish products as part of the warm meal
once a month or more often, compared with
kindergartens that had not participated or
where participation was not known.
The project builds on positive experience with an earlier, similar
project funded by the Seafood Council. Under the Action Plan,
the counties were invited to participate in the Fiskesprell project
from autumn 2008, basing it in the Partnership for Public Health.
As the project is related to public health efforts in each county,
its basis and long-term perspective are ensured.
All counties participating in the project receive financial support
to organize courses for staff in primary schools, after-schools
and kindergartens, nurses and parents. The Directorate of Health
announces the funding for the counties each year.
Participation in Fiskesprell courses:
4565 kindergarten staff (1991 kindergartens) during 2010/2011,
and 912 student teachers + 616 pre-school teachers during
2009/2010.
Financial support to buy fresh produce and material given to:
2940 schools with 223 469 lower secondary school pupils (since
2008);
1480 schools with 48 507 primary school pupils during
2009/2010.
Registered for the school year 2010/2011:
1231kindergartenstaff(557kindergartens);
543 student teachers + 377 pre-school teachers + 70 students in
publichealth;
68233lowersecondaryschoolpupils(from900schools);
31 733 primary school pupils (from 970 schools).

41
Focus area and goals Ministry Measures Comments
responsible
The precursor of this book was positively
evaluated and is used by pupils even after they
have left school.
In 2008, the book received a prize for the most
beautiful book used in primary and secondary
education.
The Food Safety Authority is a national body,
whose aim is to ensure that food and drinking-
water are as safe and healthy as possible for
consumers.
The Cookbook for all was published in September 2007. It is
given free to all pupils in lower secondary schools and to student
teachers. Municipalities can buy it at production cost for training
purposes (language, Good Food courses, etc.). The book is updated
with the keyhole labelling and new dietary advice. It can also be
bought in bookshops.
In the cookbook, dietary advice from the Directorate of Health is
translated into recipes and practical cooking.
Cookbook for all: numbers distributed or sold 2007–2011
Distributed 2007 2008 2009 2010 2011 Total
or sold
To pupils,
free 73 413 76 850 76 729 77 142 74 493 378 627
To munici-
palities,
at cost of
production 5 470 4 060 6 520 5 360 5 800 27 210
Through book-
shops, at
normal cost 8 381 337 2 031 1 445 949 13 143
Matportalen is a web site with information about food and health
from public authorities. The following food administration agencies
provide material for the web site: Food Safety Authority, Directorate
of Health, National Institute of Public Health, Scientific Committee
for Food Safety, National Veterinary Institute, Norwegian Radiation
Protection Authority, National Institute of Nutrition and Seafood
Research and government food authorities in other countries. The
Matportalen web site was relaunched in spring 2011.
Health & Care
Services
Health & Care
Services;
Agriculture &
Food;Fisheries
& Coastal
Affairs
1.4 Publish a basic cookery
book for everyday use
1.5 Further develop the
Matportalen web site with
respect to nutrition and diet

42
Focus area and goals Ministry Measures Comments
responsible
The prize creates a good opportunity to
highlight important nutrition work. It was
not awarded in 2009 due to scarce human
resources.
The National Nutrition Council is behind the
award, which was first awarded in 1984.
Other important arenas for interaction are
through projects, conferences, meetings, etc.
Kost Forum is a consultative body consisting
of the National Association of Public Health,
The Norwegian Cancer Society, The Norwegian
Heart and Lung Patient Organization, The
Norwegian Diabetes Association and the
Norwegian Asthma and Allergy Association.
Kostforum is working to make it easier for
adults and children to make healthy food
choices. The Directorate of Health and the
A total of approximately 220 articles/answers to frequently
asked questions about nutrition were published during the
period of the Plan, an average of 44 articles a year, as against
approximately 10 a year for 2004–2006.
The prize is awarded, after the announcement of the chosen
subject, by the Directorate of Health in cooperation with the
National Nutrition Council. It was awarded in 2007, 2008, 2010
and 2011 and attracted positive press coverage. Annual issues
for the awards were:
2007: promoting healthy diets and a healthy environment for
children and young people locally, nationally and internationally
2008: promoting healthy diets among immigrants
2010: better food for the sick and elderly
2011: local nutrition – a healthy diet for children and young
people.
The purpose is to gather participants to exchange information,
discuss subjects, challenges and effective measures, and
possibly coordinate measures. Forums were held in autumn
2008 on the theme Low Threshold Services on Diet, and in 2010
on the theme Plan of Action for Nutrition: the final stage, new
guidelines, local nutrition programmes, etc.
Health & Care
Services
Health & Care
Services;
Agriculture
&Food;
Fisheries &
CoastalAffairs;
Children,
Equality
& Social
Inclusion;
Education &
Research
1.6 Award of the Nutrition
Prize
1.7 Establish a forum for
dialogue at national level
between authorities,
nongovernmental
organizations and relevant
private actors

43
Focus area and goals Ministry Measures Comments
responsible
agricultural and seafood information offices are
observers.
The Ministry of Agriculture & Food was present
as an observer in 2010, and there was good
feedback on the content and form.
Nofima is Europe’s largest institute for applied
research in the fields of fisheries, aquaculture
and food.
In 2011, the National Nutrition Council
submitted a strategy proposal for reducing
salt intake in the population, the key elements
being negotiations with the food industry
to reduce salt in their products, combined
with information to consumers. The Ministry
of Health & Care Services has asked the
Directorate of Health to prepare an action plan
for reducing salt intake in the population based
on the Council’s strategy.
See also sections 2.9 and 9.2.
Initiatives took place in various sectors.
In 2009, the Ministry of Fisheries & Coastal Affairs set up the
Marine Wealth Creation Programme: Business Cooperation for
Greater Adjustment of the Value Chains to the Market.
In 2006, a north Norwegian pilot project conducted by the
Foundation Norwegian Food Culture was set up to promote and
improve the use of local food in restaurants. It was intended to
spread the experience gained from the project.
Recirculation and Utilization of Organic By-products (RUBIN)
funds projects to increase the utilization of products from
fisheries and aquaculture as ingredients in consumer products
(feed, food, health food).
Agriculture &
Food;Fisheries
& Coastal
Affairs
2.1 Encourage the
development of healthy food
products and meals
2. Healthy food in a diverse market
Goals: Make it easier for consumers to choose foods with good nutritional composition in order to put together a healthy diet
Improve access to and promotion of healthy food products
Reduce the promotion of foods that contribute to an unhealthy diet, especially among children and younger people

44
Focus area and goals Ministry Measures Comments
responsible
Participants in the forum also meet through
cooperative projects such as the design and
implementation of the keyhole labelling
system, marketing, etc.
The Ministries of Fisheries & Coastal Affairs and Agriculture &
Food have been given support for a national centre for food with
14 food-related businesses outside Stavanger.
The Norwegian food industry is involved in the European
Technology Platform Food for Life. The Research Council’s Food
Programme is increasingly focusing on the development of
healthy and safe foods.
The Norwegian Institute of Food, Fishery and Aquaculture
(Nofima) is working on new research on healthy ingredients and
meals.
The purpose of the dialogue forum was to create a common
platform and understanding for promotion of a healthier diet.
The forum was established as a permanent series of meetings
during the period of the Plan and continued up to 2012. There
has been positive feedback. Approximately 40–50 participants
met each time. The themes have been as follows:
2007:expectations,formandcontentoftheforum;
2008: bread, labelling, communication and expertise in food and
nutrition;
2008: separate additional meetings on healthier foods in the fast
foodmarketwithselectedparticipants;
2009: advertising in schools, salt, palm oil, etc.
2010: status and challenges with regard to food and health in
generalandinfollowinguptheActionPlandietinparticular;the
keyholelabellingsysteminthefastfoodandcateringmarket;
2011: new policy documents, reform of coordination,
development in the diet, plans, summary dialogue arena.
Health & Care
Services;
Agriculture
&Food;
Fisheries &
CoastalAffairs;
Children,
Equality &
Social Inclusion
2.2 Establish a dialogue forum
for cooperation between the
food industry, authorities,
researchers and consumers

45
Focus area and goals Ministry Measures Comments
responsible
The report to parliament Agriculture and
food policy. Welcome to the table signals an
increased focus on fruits and vegetables.
In 2007, the Ministry of Agriculture & Food allocated funds to
local and regional initiatives through the counties.
Every year the Norwegian Farmers’ Union and the Norwegian
Farmers and Smallholders Union negotiate with the state on the
framework conditions for agriculture. In 2008, the Ministries
of Health and Agriculture & Food had a meeting in advance of
these yearly negotiations.
The Geitmyra food culture centre for children has been set up
in Oslo with funds from the Ministry of Agriculture & Food to
promote knowledge and use of fruit and vegetables, among
other things. In 2012, educational materials and programmes
were developed. The Ministries of Fisheries & Coastal Affairs
and Education & Research also support the centre.
Fruits and vegetables also have their place in the Nordic Council
of Ministers’ programme New Nordic Food II (2010–2014).
The vision is that the Nordic cuisine will inspire enjoyment,
innovation, taste and diversity, both at home and abroad.
See also 4.3.
On 1 January 2010, a regulation was introduced requiring the
labelling of fish products with consumer information (such as
for fresh fish, the catch and/or slaughter date). Work has been
started to determine the appropriate method for assessing the
quality of fresh fish, and to decide a standard for labelling fish
boxes and pallets so as to improve logistics and the flow of
information.
Agriculture &
Food
Fisheries &
Coastal Affairs
2.3 Promote the consumption
of fruit and vegetables by
stimulating better access to
high-quality products from
primary producers
2.4 Strengthen collaboration
between the authorities,
fisheries industry and retailers
to increase the availability of
good quality fish and seafood

46
Focus area and goals Ministry Measures Comments
responsible
Any introduction of a keyhole-labelled product
in the kiosk, petrol station and service market
and other food service industry premises or
restaurants is complex. Some of these products
(ready packed) are suitable for this market.
Since 2008, the transport company DHL has
been collaborating with nutrition students
and Everyday Cook to publish an overview of
nutrition-rated food services and restaurants
along the main trunk roads.
The project Nordic Young Health 2009–2010
focused on young consumers and the fast food
sector. The National Institute for Consumer
Research, Nofima and other Nordic research
institutions cooperated in the project. Main
results: the obstacles to healthy choices are
said to be structural barriers, the ease of
accessing unhealthy rather than healthy food,
and aggressive marketing with unhealthy foods
deliberately placed within easy reach. Many
of the respondents were open to healthier
alternatives.
To be considered in relation to measures in section 2.2.
The National Institute for Consumer Research report Food on the
go – opportunities and limitations for new and healthier eating
concepts in the fast food market, 2007 was supported financially
by the Directorate of Health.
There has been extensive interaction with industry and the
authorities in Denmark and Sweden on keyhole labelling in
general, and concerning the kiosk, petrol station and service
market.
Work is in progress on a report by the Food Safety Authority
and the Directorate of Health with suggestions for further work
on the keyhole labelling system in the kiosk, petrol station and
service market.
The Week of Taste has been held annually since 2005 to
increase awareness of the quality and joy of food, with a focus
on basic flavours. The Ministries of Agriculture & Food and
Fisheries & Coastal Affairs cooperate with the information
offices for agriculture and seafood, Nofima and the Norwegian
National Association of Chefs. In 2011, 26 cafeterias
participated.
The excise duty on non-alcoholic beverages was altered
in 2006/2007. Since 1 January 2007 the tax has applied to
sweetened drinks. Beverages without added sugar or sweetener
(such as pure water or juice) are exempt. In 2008, the tax was
increased by approximately 60% in real terms. Subsequently the
tax has been adjusted for general inflation.
Health & Care
Services;
Agriculture &
Food
Finance;
Health & Care
Services
2.5 Survey and follow up
ready-made food and meals
from restaurants and the
convenience store market
2.6 Restructuring of the tax on
non-alcoholic beverages

47
Focus area and goals Ministry Measures Comments
responsible
2.7 Study the possibilities of
using economic incentives to
promote a healthy diet
2.8 Work to improve the
labelling of food products,
including better nutrient
declarations
2.9 Aim to introduce symbol
labelling to make it easier to
put together a healthier diet
Health & Care
Services;
Finance
Health & Care
Services
Health & Care
Services;
Children,
Equality
& Social
The consumer price index for soft drinks increased from NKr 130
in 2008 to NKr 166 in February 2012.
Sales of soft drinks containing added sugar in 2007 were 60 litres
per capita per year. In 2011 they were 61 litres per capita per
year. There has been a small decrease in soda with artificial
sweeteners (2007: 44 litres per capita per year, 2011: 39 litres
per capita per year) and bottled water (2007: 24 litres per capita
per year, 2011: 17 litres per capita per year).
The Excise Committee submitted a report in 2007 mainly
focusing on how to use excise duties to tax products containing
sugar/sweeteners. A new tax would raise several questions
needing further consideration. The Ministry of Health & Care
Services continued this work, in consultation with the Ministry
of Finance, in 2012.
At the European level, the Norwegian government worked to
influence EU Regulation No. 1169/2011 on the provision of
food information to consumers. The Regulation introduced new
rules on mandatory declaration of nutrition, including energy,
saturated fat, sugar and salt. The declaration can take the form
of graphics or symbols. On the global level, Norway has worked
to influence Codex standards on food labelling to include added
sugars.
The keyhole labelling system was introduced in June 2009 as a
joint Nordic system for health labelling of food products. It is a
broad-based process encompassing industry, consumers, etc.
To be followed up by the Directorate of Health
and internationally.
Initiatives taken by retailers and
nongovernmental organizations to the Minister
of Health accelerated the process that led to
the decision. Nordic cooperation on the revision
of the criteria started in the autumn of 2011.

48
Focus area and goals Ministry Measures Comments
responsible
More knowledge is needed about the brand
and a broader selection of products. Nordic
cooperation is continuing. See also section 2.5.
Three consumer-oriented mass media campaigns were run
during the period 2009–2011. A home page was created and
materials developed for consumers (folders in 12 languages),
the food industry and the education sector. Annual surveys of
consumer awareness, knowledge and attitudes to the brand
since before it was launched as well as market analyses were
undertaken in 2009, 2010, 2011 and January 2012.
In August 2011, TNS Gallup found that in just two years, the
keyhole has become the best known and most used brand in the
grocery trade. A population survey on awareness and knowledge
of the keyhole symbol among all consumers aged over 18 years
(in January 2012) showed continued positive progress: 98%
knew or had heard of the brand, and 85% knew that the label
represented a healthier choice. Many also knew that the mark
represented less fat, sugar and salt and more dietary fibre. The
labelling system was trusted by 6 out of 10 people and 50%
thought the brand made it easier to make healthier choices.
As a result of a good dialogue with suppliers and traders on
the implementation of the scheme, industry and retailers have
contributed significantly to marketing. Communication is linked
to dietary advice.
A Nordic inspection campaign in 2011 showed that the keyhole
label is used properly.
Approximately 550 keyhole-labelled products (other than fruit or
vegetables) were on sale in 2010, and about 1500 in December
2011.
Inclusion;
Agriculture &
Food;Fisheries
& Coastal
Affairs

49
Focus area and goals Ministry Measures Comments
responsible
2.10 Follow up and continue
to develop rules for the use
of nutrition and health claims,
fortification of foods and food
supplements
2.11 Consider introduction
of restrictions on advertising
of unhealthy food aimed at
children and young people
Health & Care
Services
Health & Care
Services
The EU Commission’s work on developing nutrition profiles
has come to a stop. In meetings between (among others)
the Norwegian Minister of Health and the European Health
Commissioner, the Norwegian Government has tried to convince
the Commission to restart this work.
The Norwegian food and beverage industry adopted voluntary
guidelines for the marketing of foods and beverages to children
in 2007.
As a follow-up of the Action Plan, the National Health Care Plan
(2011–2015) and WHO’s recommendations on the marketing
of unhealthy foods to children, the Ministries of Health and
Children, Equality & Social Inclusion have established a
working group to consider the possible introduction of new
restrictions on the marketing of food and drink to children and
young people, including whether there is a need for specific
new legal measures. The work involves a description of the
extent of marketing of unhealthy foods to young people and the
development of a model for nutrition profiling.
In 2007, Norway was the initiator and driving force for WHO
to prepare recommendations on the marketing of food and
beverages to children. These recommendations were adopted
by a resolution proposed by Norway, with the support of many
countries, at the World Health Assembly in May 2010.
In 2008, the European network on reducing the marketing of
unhealthy foods and beverages towards children was set up.
These countries are working together to protect children’s health
by reducing the marketing of nutrient-poor and energy-dense
The regulations are being implemented
according to plan. Work on the nutrition profiles
is awaited in the EU.
Assessment work was completed in 2012.
The network will run through 2012, with the
possibility of an extension.
The network has contributed with knowledge
and experience to support efforts to develop
the WHO recommendations on the marketing
of food and beverages to children, and has
developed a code as an example of how such
marketing can be regulated. The network
is also working to develop a protocol for
monitoring the marketing of food to children.

50
Focus area and goals Ministry Measures Comments
responsible
See 2.5.
A simple questionnaire distributed in 2006
resulted in few but positive answers to the
newsletter.
The brochures Food for infants and How to
breastfeed your baby will be completely revised
when new recommendations on infant nutrition
are published.
foods and beverages to children. Currently, 20 WHO European
Member States are members. Norway (through the Directorate
of Health) chairs and is the secretariat for the network, which is
a collaborative activity with the Regional Office. See also 10.1.
Not initiated.
The Directorate of Health distributes annually 60 000 copies
of the brochures Food for infants and How to breastfeed your
baby. These brochures are revised when needed, most recently
in 2011. A newsletter was regularly distributed to child health
centres in the period 2007–2010.
A new web site for pregnant women (encouraging a healthy
lifestyle) was launched in 2010.
Health & Care
Services;
Children,
Equality &
Social Inclusion
Health & Care
Services
2.12 Draw up a summary of
knowledge about product
display and choice of foods at
various types of sales outlet
3.1 Offer updated information
material on breastfeeding,
infant and young child
nutrition
3. Nutrition in the early stages of life
Goals: mprove dietary guidance for women of childbearing age and pregnant women
Facilitate exclusive breastfeeding for a higher percentage of infants for the first six months of life and continued breastfeeding until at least 12 months
Facilitate a good diet for infants and young children
Strengthen guidance on breastfeeding, diet, food and meals for parents of infants and young children
Contribute to ensuring that marketing of breast-milk substitutes is strictly in line with international recommendations
Emphasize efforts towards women and children with a non-western background

51
Focus area and goals Ministry Measures Comments
responsible
3.2 Continue and further
develop the Baby-Friendly
Initiative in Norway
3.3 Facilitate the
incorporation of the entire
WHO Code of Marketing of
Breast-milk Substitutes into
Norwegian legislation and
ensure compliance with the
Code
3.4 Maintain established
maternity leave schemes
for women, and consider
the possibility of paid
breastfeeding breaks so that
all women who wish to may
breastfeed in accordance
with the health authorities’
Health & Care
Services
Health & Care
Services
Labour;
Children,
Equality
& Social
Inclusiona
Articles about infant and young child nutrition are continuously
developed and updated on the Directorate of Health,
Matportalen and HelseNorge web sites.
Courses were arranged for nurses working in child health
centres and midwives in all counties from autumn 2007 to
spring 2009 by the Resource Centre for Breastfeeding and the
Directorate of Health, in collaboration with the Norwegian
Nurses Organization. The main subject was an action plan for
a better diet, with emphasis on guidelines for skilled nursing
clinics.
National guidelines for perinatal care are being developed by
the Directorate of Health.
The government is considering offering paid breastfeeding
breaks for breastfeeding women. It is not clear when this will be
decided.
The Ministries of Labour, Health & Care Services and Children,
Equality & Social Inclusion have established an internal work
group considering breastfeeding breaks and distribution of
parenting leave between the parents.
Follow-up and evaluation is done through a
continuing randomized controlled study.
By the end of 2011, 109 out of 430
municipalities had introduced the project
Ammekyndige Helsestasjoner (certification of
breastfeeding practices at child health centres)
and 15 municipalities or urban districts had
been approved.
It is somewhat unclear.

52
Focus area and goals Ministry Measures Comments
responsible
In 2007, the Food Safety Authority and the
Directorate of Health published the report
Development in the baby food market – status
for 2007.
In 2007 and 2008, the Food Safety Authority
published Parts I and II of the report Analyses
of nutrients in baby food products 2006/2008.
In 2011, the Directorate of Health established a working group
to revise the recommendations on infant nutrition. This is a
comprehensive task. It is planned to complete new guidelines
for infant nutrition in 2013.
As soon as these guidelines are finished, guidelines for the
nutrition of premature babies will be started.
A new brochure about nutrition and physical activity in
pregnancy was published in 2009. The Directorate of Health, the
Food Safety Authority and the Institute of Public Health have
revised and updated information for pregnant women on the
Matportalen web site, in addition to their own web sites.
The Directorate of Health has had regular meetings with the
Food Safety Authority, distributed the newsletter Facts on food
for infants and monitored the baby food on the market.
Several registration systems have been considered and a choice
has been suggested but no system has yet established.
Health & Care
Services
Health & Care
Services
Health & Care
Services;
Agriculture &
Food
Health & Care
Services
recommendations during
working hours
3.5 Revise and develop
national recommendations
and guidelines on infant and
young child nutrition and
nutrition for premature babies
3.6 Strengthen guidance on
nutrition for pregnant women
by implementing professional
guidelines for maternity care
and publishing information
materials
3.7 Continue the measures
relating to the implementation
of the EC directives on infant
food in Norway
3.8 Work to establish
a system for national
breastfeeding statistics

53
Focus area and goals Ministry Measures Comments
responsible
3.9 Consider introducing a
nationwide programme of
free vitamin D supplements
for infants with non-western
backgrounds
4.1 Revise guidelines for food
in kindergartens.
Health & Care
Services
Health & Care
Services;
Education &
Research
A nationwide offer has been made since 2009 after testing in
eight well-baby clinics. This is based on a PhD thesis showing
that free vitamin D drops improve the vitamin D status for
infants of non-western immigrants.
The Guidelines for food in kindergartens were revised in 2007
and sent to all kindergartens and municipalities. Implementation
of the guidelines with supporting information was supported by
training and meetings at county level. The guidelines have been
described in central documents such as the National curriculum
regulations on the content and duties of kindergartens
(Chapter 3.2, Body, movement and health). In addition, the
guidelines are an integral part of ongoing work and information
efforts and are part of the Fiskesprell seafood project (see 1.3).
It has been suggested that the Institute of
Public Health should take over responsibility
for this project, but no decision has been taken.
Information is available in English, Norwegian,
Somali, Turkish and Urdu.
A mapping of meals, physical activity and
environmental health in kindergartens in spring
2011 showed that 90% of administrators and
70% of head teachers were aware of the
guidelines. This is far more than in 2005 when
36% and 21%, respectively, were aware of
them. Those directors who were aware of them
were asked how they had made use of the
guidelines: 71% said the guidelines had been
used during internal meetings with staff, 61%
said they were used for measures to increase
staff competence and 57% said they were
used for planning educational activities. Among
kindergartens where the head teacher was
aware of the guidelines, more healthy foods
were offered compared with kindergartens
without such awareness.
4. Healthy meals in kindergartens and schools
Goals: To help kindergartens, schools and before- and after-school programmes to promote healthy eating habits among children and adolescents through meals
in line with the health authorities’ recommendations
Help to ensure that children and adolescents acquire healthy eating habits
Emphasize efforts towards women and children with a non-western background

54
Focus area and goals Ministry Measures Comments
responsible
The mapping of meals, physical activity and
environmental health in kindergartens in spring
2011 showed that 60% of the administrators
and 46% of the head teachers had received the
booklet. Among the head teachers who had
received it, 80% felt that it had been useful
or very useful. In the kindergartens where
the head teachers had received the booklet,
some more healthy food products were served
compared with kindergartens where the head
teachers had not received the booklet.
Primary school (steps 1–7) participation in the
school fruit scheme, 2007–2011
Year Pupils with a fruit/ Schools with
vegetable scheme at a scheme (reduced or
reduced cost, steps normal rate) in steps
1–7a % 1–7 %
2007 25.6 57.2
2008 27.4 55.2
2009 19.6 59.3
2010 18.3 56.8
2011 18.4 57.1
a Percentage of total number of primary school children each
year who have access to fruit/vegetables, either through
subscription or with full or partial local sponsorship. The
proportion subscribing has always been larger than the
proportion with full or partial local sponsorship. The proportion
of local or municipal sponsorship has fallen each year, affecting
participation.
Material was developed and sent to all kindergartens
nationwide in 2008. The package of material entitled Good
food in the kindergarten includes a 61-page instruction booklet
with advice on diet, food and meals, celebrations, allergies and
hygiene as well as recipes, and two posters and two postcards.
There is great demand for the material.
The booklet has been printed in the following quantities: 18 000
in 2008, 10 000 in 2009 and 12 000 in 2011, totalling 40 000.
Since autumn 2007, Parliament has given grants to
municipalities to enable them to provide pupils in secondary
schools (steps 8–10) and combined schools (steps 1–10) with
free fruit and vegetables. This has been established in law since
2008.
Pupils in primary schools (steps 1–7) can subscribe to the school
fruit scheme, whereby the government subsidizes each fruit or
vegetable by NKr 1 so that the subscription costs NKr 2.50 per
school day. Registration, information and activities can be found
on the Skolefrugt.no web site, which has information about the
scheme in five languages other than Norwegian.
User surveys of the two schemes are carried out every semester.
A new web site has been developed together with simplified
registration, information in several languages, motivational
items such as t-shirts, book bindings and competitions, and
funding for model development and films to broaden the
subscription base and focus on fruits and vegetables. The work
Health & Care
Services;
Education &
Research
Education &
Research;
Health & Care
Services
4.2 Prepare and offer
educational tools and
information materials relating
to the revised guidelines
for food and meals in
kindergartens
4.3 Introduce a programme
for fruit and vegetables for
all pupils in primary and
secondary schools

55
Focus area and goals Ministry Measures Comments
responsible
Approximately 280 000 pupils attend schools
covered by the free scheme.
The TINE dairy cooperative and the Dairy
Products Information Office plan to increase
efforts in upper secondary schools with a
separate product portfolio.
Enrolment in the school milk scheme covers
99% of all primary schools (steps 1–7) and
combined primary- and lower secondary
schools (steps 1–10). In total, 50.7% of the
pupils in these schools participated in 2011,
a slight decrease on the previous years when
participation was 51.1% and 51.7% in 2010
and 2009, respectively. Semi-skimmed milk
is connected to the Directorate of Health’s guidelines for school
meals in primary and secondary schools.
Little opportunity to choose the fruit or vegetable is one of the
reasons given for low participation. It is difficult to get schools to
put work into a paid parental scheme in which only some of the
pupils participate, for example, by giving them a choice between
at least two fruits or vegetables. The response is greatest in the
first class and falls off as the pupils move up the school. Price
only seems to be significant for parents on the lowest household
incomes (reference: aspect of social inequality in health). Some
school staff and parents also gave the unfairness of the scheme
not being free in schools with steps 1–7 as a reason not to
participate.
It will be important to establish a fruit and vegetable programme
that reaches all pupils.
Meetings with representatives of the independent agricultural
sector Information Office for milk and the TINE dairy cooperative
are organized annually to discuss topical issues. Meetings are
also held with the relevant ministries (of Health & Care Services,
Education & Research and Agriculture & Food). The guidelines
for meals in primary and secondary schools, developed by the
Directorate of Health, form the basis of work and information
about the school milk scheme.
A new variety of milk with added flavour and a new online
registration form were launched in 2010. Work is continuing, and
planning has begun for a greater focus on milk in kindergartens.
Health & Care
Services;
Agriculture &
Food;Education
& Research
4.4 Promote increased
participation in the school
milk programme in primary
and secondary school

56
Focus area and goals Ministry Measures Comments
responsible
(1.5% fat) is the most popular of the milk
variants, chosen by 61% of the pupils.
Participation is greatest among the youngest
children. In lower secondary schools (steps
8–10), only 8% of the pupils enrolled in the
scheme in 2011.
A research group at the University of Bergen
(HEMIL-sentreet) has evaluated the Physical
Activity and Meals at School project (available
in Norwegian upon request).
Part one of the evaluation of the project about
coherence between school and the before- and
after-school programmes (Helhetlig Skoledag)
is available in Norwegian upon request.
Health-promoting schools have been a topic at
various meetings for public health advisers at
county level. It is also mentioned in the White
Paper on the National Health and Care Plan for
Norway (2011–2015).
A total of 400 primary and lower secondary schools and 18 upper
secondary schools received grants between 2004 and 2007 to
participate in the Physical Activity and Meals in School project.
Experience from the project was shared through presentations
and distribution of a guidance booklet and a DVD with examples
of best practice to all primary and lower secondary schools and
municipalities. A national conference was organized in 2007
and the county governors organized regional conferences in the
spring of 2008 to spread experience from the project.
A web site for sharing ideas and resources in the area of
physical activity was launched in 2009. This does not, however,
include measures relating to diet.
In the period 2009–2012, the Ministry of Education & Research
carried out a project testing various models in schools with
the purpose of improving the coherence between school and
the before- and after-school programmes (Helhetlig Skoledag).
Components of the programme include food in school, physical
activity, help with homework and various cultural activities.
Education &
Research;
Health & Care
Services
4.5 Disseminate experiences
from models developed in the
Physical Activity and Meals
in School project and collect
and spread know-how about
school breakfast programmes
in lower and upper secondary
schools

57
Focus area and goals Ministry Measures Comments
responsible
The need to revise the guidelines has been
discussed.
The evaluation of the Physical Activity and
Meals in School project showed that no
schools offered soft drinks during the project
period 2003–2006, and that access to cold
drinking-water improved.
The mapping exercise in 2008 on fruit,
vegetables, drinking-water and meals was
linked to a competition.
Local experiences with school breakfasts have not been
compiled and distributed, but some counties have tested models
for breakfast at school.
In 2007/2008, the Directorate of Education and Training carried
out a project with prolonged school days (Utvidet Skoledag) in
11 municipalities and 34 schools. Models for school meals were
included.
The guidelines for meals in school are part of the project
with prolonged school days in 2007/2008. Information about
the guidelines is available through ongoing work and various
projects (see 4.3 and 4.5), in relevant material and on relevant
web sites, including the Directorate of Health and Skolefrugt. It
was also available on an earlier web site (skolenettet.no), but
this web site was shut down and the material was not moved to
the web site of the Directorate of Education and Training.
Several high-level meetings have been held (between the
Ministry of Health & Care Services and the Ministry of Education
& Research), focusing inter alia on the guidelines.
In 2008, a joint letter from the Ministers of Health & Care
Services, Education & Research and Local Government &
Regional Development was sent to all county authorities
encouraging them to ensure that healthy foods and drinks were
made available in upper secondary schools. A competition was
used as a follow-up and a mapping exercise was carried out
(68% participation rate).
Health & Care
Services;
Education &
Research
Education &
Research;
Health & Care
Services
4.6 Continue the work of
spreading information about
the health authorities’
guidelines for meals in
primary and secondary
schools
4.7 Encourage school owners
to prevent access to soft
drinks and promote good
access to cold drinking-water

58
Focus area and goals Ministry Measures Comments
responsible
In 2011, the Directorate of Health carried
out a simple mapping (via e-mail) about the
follow-up to the initiative to ban soft drinks by
various county authorities. This showed that
six counties had taken the political decision to
offer healthy canteens, and three of these had
also taken the political decision not to allow
the sale of soft drinks (Rogaland, Vestfold and
Østfold).
The mapping of meals, physical activity and
environmental health in kindergartens in the
spring of 2011 showed that (according to the
administrators) 83% of the kindergartens
The same message has also been communicated through work
being carried out by the Directorate of Health, the Directorate of
Education & Training, county authorities and others.
Through the development and trial phases of the Health in
Master Plans (Helse i Plan) project, several counties have carried
out health promotion efforts in upper secondary schools. These
have emphasized the importance of the availability of food and
drinks. Some counties have developed networks for employees
in school canteens to share experiences.
The county of Oppland has a certification scheme for health-
promoting schools, who can apply for funds.
The Directorate of Education and Training is developing models
for better coherence between schools and the before- and
after-school programmes (Helhetlig Skoledag) (see 4.5). The
Directorate of Health’s guidelines for meals in schools is
included in this project.
This measure is part of the ongoing information and
communications work of the Directorate of Health.
The Directorate of Health has participated in a group planning
the project on coherence between schools and the before- and
after-school programmes (Helhetlig Skoledag) (see 4.5).
The Directorate of Health works with the Ministry of Health &
Care Services to inform municipal departments of environmental
health about the approval scheme in the regulations on
environmental health protection in kindergartens and schools so
Education &
Research;
Health & Care
Services
Health & Care
Services;
Agriculture &
Food;Fisheries
4.8 Encourage school owners
to strengthen food and meal
programmes in before- and
after- school programmes for
schoolchildren
4.9 Strengthen and coordinate
inspection of food and meals
in kindergartens, schools
and before- and after-school

59
Focus area and goals Ministry Measures Comments
responsible
were approved according to the regulations
on environmental health protection in
kindergartens and schools. However, about one
third of the kindergartens had not been subject
to supervision in the previous three years.
as to strengthen the supervision of kindergartens and schools,
including as concerns meals.
The Ministry of Agriculture and Food reports that a New Nordic
Food project highlights good systems for serving food and
information about children’s food and health.
& Coastal
Affairs
programmes
5.1 Establish a dialogue
between employers and
unions and the health
authorities to promote healthy
dietary habits
5.2 Assess how dietary
considerations can be
addressed at workplaces
Health & Care
Services
Health & Care
Services;
Labour & Social
Inclusiona
The Directorate of Health has initiated and participated in
several meetings with representatives of working life. Some of
the organizations have agreed to act as information channels for
the overall message from the Directorate.
Through the Workplace Health Promotion programme, the
Directorate of Health has established cooperation with the
Labour Inspectorate in Inner Østland, seven county councils
and the Nordic Academy for Public Health. In working with the
kiosk, petrol station and service market, contacts have been
established with the Confederation of Norwegian Enterprise and
other key players in working life, such as the Transport Workers
Union.
Included in 5.1 and 5.3.
The recommendations for food in cafeterias and restaurants
given by the Directorate of Health are the basis for food
See also 2.5.
Evaluation of the Workplace Health Promotion
programmeshowsthatitiseffective;60%of
the respondents feel that employees’ diets are
related to their jobs, and that available food
services are important to job satisfaction, the
work environment and productivity.
A follow-up of the programme is required,
preferably in the selected sectors.
There is a need to look at the relationship
between work, the Norwegian Labour and
Welfare Service, healthy living centres, health
services, etc.
5. Food and health in the workplace
Goals: Contribute to availability of healthy food and beverages in the workplace
Stimulate the motivation of employees to adopt healthy habits and make good food choices
Help employers to integrate dietary considerations in personnel policy

60
Focus area and goals Ministry Measures Comments
responsible
All initiatives regarding public health should be
made available on the Directorate of Health’s
web site.
Arrangements for a training workshop (or
workshops) for canteen staff should be updated
and possibly connected to the Good Food
training workshop in the long term.
An updated leaflet on food and health at work
will be presented.
provision. They are revised or developed according to new
dietary advice. Articles and advice are available on the web
sites and through lectures, etc. The Norwegian Labour and
Welfare Service Working Centre in Vest-Agder and Vest-Agder
County Council ran a Healthy Workplaces pilot project in 2007.
The future challenge is to encourage employees to be healthy.
To be considered in relation to measures 2.2 and 5.1.
Articles and materials have been published on web sites and
spread through ongoing work and lectures.
The Ministry of Agriculture & Food ran a canteen project during
The Week of Taste with menu suggestions and exhibitions
focusing on basic flavours and food quality (also in 2011).
The Information Office for Fruit and Vegetables have a
commitment called MORE (more fruit and vegetables), following
up initiatives and measures previously given to all counties in
collaboration with the Directorate of Health. MORE includes
advice and canteen courses (in collaboration with partner
companies) and information and programmes on the web site.
The Directorate of Health and the Information Office for Fruit
and Vegetables held a national training workshop on workplace
canteen meals in 2006 and another on high school canteens in
the counties of Telemark and Nord-Trøndelag in 2007. Both the
workshops were followed up in the counties afterwards with,
for example, local courses. Several counties have established
Health & Care
Services;
Agriculture &
Food;Fisheries
& Coastal
Affairs
5.3 Build competence and
ensure access to tools on
diet and health for groups
such as canteen employees,
trade union representatives,
managers and company
health service staff

61
Focus area and goals Ministry Measures Comments
responsible
The Association of Vocational Rehabilitation
Enterprises is an employer and interest
organization for approximately 100 enterprises
spread across Norway.
The Association of Vocational Rehabilitation
Enterprises provides services to more than
35 000 people annually.
experience forums for canteen staff in businesses and high
schools as a result of courses held by the Directorate of Health
and the Information Office for Fruit and Vegetables in the
counties during the period 1997–2006.
In 2007, the Ministry of Labour and Social Inclusion officially
requested the Directorate of Labour and Welfare to take the
initiative to motivate vocational rehabilitation enterprises to
include diet and physical activity in vocational rehabilitation (see
text, 5.4). Nutrition work in rehabilitation companies was a sub-
topic at a national conference for public health advisers in 2010.
The Directorate of Health has a continuing dialogue with the
Association of Vocational Rehabilitation Enterprises. The
Association, together with the weight loss and nutrition courses
firm Libra, has developed its own nutrition plan as part of its
internal training. The Association has increased the focus on diet
in its work as a result of the collaboration with the Directorate,
and has much information on its web site. The Directorate has
held exhibitions and lectures at the vocational rehabilitation
exhibition in 2010 and at relevant meetings of this group.
Regulations on work-related measures (in force since 1 January
2009), Chapter 3.1, make it possible to provide lifestyle
counselling as part of vocational rehabilitation. Together with
the high school in Akershus and the Association of Vocational
Rehabilitation Enterprises, the Directorate of Health has
developed a course in diet and living habits: 110 students,
primarily employees of the rehabilitation company with one
person from the Norwegian Labour and Welfare Service, have
completed their studies. The courses have been funded by the
Directorate of Health.
5.4 Motivate vocational
rehabilitation enterprises
to include diet and physical
activity in vocational
rehabilitation
Labour & Social
Inclusion;a
Health & Care
Services

62
Focus area and goals Ministry Measures Comments
responsible
The Good Food for Better Health scheme is
continuing. The evaluation of the first four
training courses showed that almost one
quarter of the people trained in the workshops
had implemented the programme in their own
municipalities. Almost everyone who attended
the workshops found the seminars valuable,
especially the material they were given.
Modum municipality has reported that
approximately 60% of the participants in the
courses are unemployed or outside the labour
market, which is consistent with figures from
2010.
See 5.4 and 6.8.
The low threshold dietary-related scheme Bra Mat for Bedre
Helse (Good Food for Better Health) was launched in 2008. In the
period of the Action Plan (2008–2011), the Directorate of Health
held training workshops in 16 of the 19 counties.
By December 2011, 135 healthy living centres had been
registered. Of these, 50 either had or planned to start Good Food
for Better Health courses. Guidelines for healthy living centres
were published in February 2011.
Cooperation and support have been given to Active in the
Daytime activities in Oslo and the county of Nordland. These are
locally organized activities for people who are wholly or partly
outside the workplace.
5.5 Develop and test low
threshold dietary schemes
for people on long-term sick
leave and others who are
periodically unemployed
Health & Care
Services
6.1 Consider how the
municipalities can provide
satisfactory services in
general and clinical nutrition
in the longer term
Health & Care
Services
The Directorate of Health has allocated funds to start the testing
of models for organizing and strengthening work in both general
and clinical nutrition. During the period of the Action Plan it
provided funding for five different models of how municipalities
can, in the long term, provide a satisfactory service. A meeting
was held in August 2011 with grant recipients. A preliminary
There is a need for better access to qualified
personnel in municipalities to assure the
quality of nutrition services. As an example,
only 8 of the 135 healthy living centres have
employed anyone with expertise in nutrition.
The Directorate of Health has recommended
6. Nutrition in health and social care services
Goals: Contribute to strengthening nutrition-related work in child health clinics and the school health service
Help patients in the primary health service and specialist health service receive individual dietary guidance
and treatment
Contribute to strengthening nutrition-related programmes in nursing and care services
Find out about patients’ or service recipients’ food and meals, diet and nutritional status and the qualifications
of health workers

63
Focus area and goals Ministry Measures Comments
responsible
that nutrition programmes should be anchored
in cross-sectoral planning. People with a
bachelor’s degree in nutrition can have key
skills in general and preventive nutrition. One
experienced clinical nutritionist employed at a
senior level in a municipality or county might
provide a model to ensure quality and improve
nutrition services in both general and clinical
nutrition. Expertise in food economics is also
a key competence for quality control of food
services in institutions.
The annual reports from the regional health
authorities in 2010 show that a continued
focus is needed. The instruction letter from
the Ministry of Health & Care Services
to the health authorities in 2012 states
that they should improve the nutritional
status of patients at risk of poor nutrition.
Documentation relating to nutritional status
must follow patients as they move between
treatment units or to another health service.
The Directorate of Health has prepared a plan
for implementation of the guidelines and is
working on a strategy on overweight.
report was sent to the Ministry of Health & Care Services in
December 2011, and a final report will be made available to the
Ministry when all the sub-reports are finalized.
Nutrition has been included as a specific theme in the contract
documents sent by the Ministry of Health & Care Services to the
regional health authorities annually since 2008.
Professional guidelines were published in February 2011 for
adults and for children and young people.
Health & Care
Services
Health & Care
Services
Health & Care
Services
6.2 A focus on nutrition
should be included in the
overall services offered in the
specialist health service
6.3 Prepare and implement
professional guidelines and
instructions for nutrition
therapy
6.3.1 Develop and implement
professional guidelines for

64
Focus area and goals Ministry Measures Comments
responsible
As for 6.3.1.
The Directorate of Health has presented
these guidelines at a number of conferences
and courses organized either by the regional
health authorities (for hospitals) or by county
governors (for nursing homes).
The university hospital in Bergen has made the
most progress in implementing the guidelines.
They conduct four point-prevalence surveys of
malnutrition and treatment annually.
The Nutrition and diet manual – guidance
for nutrition in health and care services was
published in spring 2012. The Directorate of
Health has prepared a plan for implementation.
As for 6.3.4.
Professional guidelines were published in February 2011.
Professional guidelines were published in June 2009.
The revision was started in 2009, based on the national
professional guidelines for the prevention and treatment of
nutritional deficiency, the Nordic nutrition recommendations
and the new national guidelines on nutrition. It will cover
institutions, youth health services, school health services,
healthy living centres, domiciliary health and care services, and
rehabilitation.
As for 6.3.4.
Health & Care
Services
Health & Care
Services
Health & Care
Services
Health & Care
Services
prevention and treatment of
overweight/obesity
6.3.2 Develop and implement
professional guidelines for
weighing and measuring at
child health clinics and in the
school health service.
6.3.3 Develop and implement
professional guidelines on
prevention and treatment
of patients with nutritional
deficiency and patients at
nutritional risk.
6.3.4 Revise and issue
guidelines for dietary
management in health care
institutions
6.3.5 Prepare instructions for
nutrition-related programmes

65
Focus area and goals Ministry Measures Comments
responsible
In 2011, the Directorate of Health held a
seminar on diet and minorities.
These indicators are not currently being
implemented in the specialist health services
except at Haukeland University Hospital. They
are not yet included in national statistics.
The nutrition and diet manual includes a chapter on nutritional
issues in various religions and cultures.
National professional guidelines for the prevention of nutritional
deficiency have proposed several quality indicators: for example,
the proportion of patients weighed, the proportion of patients at
nutritional risk and nutritional deficiency, and the proportion of
patients treated for nutritional risk or malnutrition.
A national survey of food and diet in nursing-homes was taken
among leaders and health personnel and published in 2008 by
Østfold University College. This study showed that only 16% had
written procedures for nutritional status, the night fast was too
long at two out of three nursing-homes, and the nursing-home
staff needed more knowledge about nutrition.
A survey of food and meals among residents of nursing homes
in Østfold County was published in 2010. This study showed
that most of the patients were satisfied with the food itself, but
there is a need for improvement regarding minimizing the night
fast, the content of servings and meals, and user involvement in
meal-related activities.
A national survey among employers in home care service was
published in 2012.
Health & Care
Services
Health & Care
Services
Health & Care
Services
in the nursing and care
services
6.3.6 Include diet in
developing a guide for health
personnel on communication
about health with speakers of
minority languages
6.4 Prepare suitable diet-
and nutrition-related quality
indicators in the health
institutions and domiciliary
services
6.5 Survey the food services
available to, and diet and
nutritional status of users of
nursing and care services

66
Focus area and goals Ministry Measures Comments
responsible
There is still a significant need for improvement
in the health and care services with respect
to written procedures on nutritional status,
night fasting, knowledge about nutrition
and knowledge about daily practice in the
prevention, identification and treatment of
nutritional deficiency.
See 5.5 and 6.1.
A healthy living centre is defined as a low
threshold group or individual structured
programme working on improving physical
activity, nutrition and antismoking. The number
of healthy living centres has doubled since
2009 to 135 in 2011. About 50 of these are
offering or planning Good Food courses, but
only 8 have staff with expertise in nutrition.
No national survey of nutritional status in nursing and care
services has been started.
In a nationwide audit in 2010, the Board of Health Supervision
identified: (i) major deficiencies in the daily work to prevent
and treat nutritional deficiency in older people who received
healthandsocialservices;and(ii)insufcientinformationabout
the nutritional status of patient medical records of elderly hip
fracture patients.
As for 6.8.
The Directorate of Health has made study visits to the National
Centre for Learning and Coping at Aker University Hospital and
the Centre for Learning and Coping in Bergen. Measures to
facilitate the uptake of the Good Food concept for learning and
coping have been introduced.
As for 5.5.
The low threshold diet-related scheme Good Food for Better
Health was launched in 2008. In the period 2008–2011 the
Directorate of Health held training workshops in 16 of 19
counties. Several healthy living centres are now offering Good
Food for Better Health courses. See also Guidelines for healthy
living centres.
Health & Care
Services
Health & Care
Services
Health & Care
Services
6.6 Ensure that food services
and facilitation of meals are
included in inspections of the
health services and nursing
care services
6.7 Develop further patient
training programmes through
centres for learning and
coping and by other means.
6.8 Continue to develop
low threshold diet-related
schemes

67
Focus area and goals Ministry Measures Comments
responsible
See 5.3, 6.3 and 6.8.
Good Food for Better Health material was developed in 2008 and
revised in 2011.
The Cookbook for all can be purchased at production cost by
municipalities.
Health & Care
Services
6.9 Develop information
materials and tools aimed at
changing habits, including
diet, for use by the health
service, patients and users
and relatives.
7.1 Emphasize the need to
take nutrition into account
as part of public health work
in county and municipal
planning
Health & Care
Services;
Environment
A new planning section of the Planning and Building Act came
into force on 1 July 2009. Public health considerations were then
incorporated into the Planning and Building Act. According to § 3-1
of the Act on Duties and considerations in planning under the Act,
plans should “(f) promote population health and counteract social
inequalities in health, as well as helping to prevent crime.” A new
public health law for counties came into force in 2010. The content
of that law was included in the new law for municipalities, county
governors and the state from 1 January 2012. By law, counties
have a statutory responsibility to promote public health.
All 30 municipalities in the development and trial project Health
in Master Plans have included public health considerations in the
municipal plan’s social component. Development work for Health
in Master Plans, with an emphasis on nutrition, was initiated in
four pilot municipalities in three counties. In the autumn of 2009,
This is followed up in the new public health
law and the national health and care plan
(2011–2015).
An evaluation of the Health in Master Plans
project (2010) refers to a survey conducted
among all municipalities in 2008 of their public
health efforts and how the work was organized.
The results showed that at the time only one
quarter of the municipalities reported that
nutrition-related work was integrated as a
thematic area in their municipal plans.
7. Diet in public health efforts at the local level
Goals: Contribute to a more solid basis for, and methods in, public health work, including nutrition-related work, in planning and budget systems in counties and municipalities
Contribute to systematic and interdisciplinary cooperation in nutrition as part of partnerships for public health in counties and municipalities
Contribute to publicizing various subsidy schemes and other programmes to support local public health efforts in general and dietary work in particular
Encourage the provision of healthy food and beverage alternatives in recreational arenas
Help the elderly receive offers of good and varied food at central meeting places

68
Focus area and goals Ministry Measures Comments
responsible
The Directorate of Health has not implemented
this measure because the assumptions were
changed.
According to information received by
the Directorate, the Regulation will be
revised again. The Directorate will monitor
developments.
Several universities and vocational colleges
offer programmes in public health. In 2011, five
of these institutions offered courses about the
Health in Master Plans project.
the municipality of Eidsberg adopted the inclusion of nutrition
programmes in the plan for a safe and healthy childhood. The
municipality of Volda has incorporated the Good Food training
course into municipal and financial planning. Final reports are still
to be received from the municipalities of Fauske and Vestvågøy.
In its annual official letter to county governors, the Ministry of
Agriculture & Food has included a sentence to the effect that the
governors should undertake work related to food and children.
The guidelines were updated in conjunction with the new
section on planning in the Act and were implemented at the
same time. Public health was included as a consideration
in the Act but not nutrition in particular. According to § 4 of
the Act on criteria for the assessment of significant impacts
on the environment and society, the plans and measures
should be assessed under the Regulation if they “i) may have
consequences for the population health or the distribution of
health in the population.”
The Ministry of the Environment planned to prepare a guide to
the criteria in § 4, but the Directorate of Health is not aware that
this work has been completed.
The Directorate of Health is working to build competence in
nutrition and has organized meetings with public health workers
at local and regional level to discuss this issue.
The Ministry of Education & Research commented that
facilitating competence-buillding, as requested in this measure,
is the responsibility of institutions in higher education.
Health & Care
Services
Health & Care
Services;
Education &
Research
7.2 Include examples of how
nutrition can be addressed in
guidelines for regulations and
environmental impact studies
pursuant to the Planning and
Building Act
7.3 Facilitate competence-
building in vocational college
programmes for public health
workers on how the Planning
and Building Act can serve as
a key instrument for laying a

69
Focus area and goals Ministry Measures Comments
responsible
No additional nutrition-related indicators
have been developed as a tool for municipal
planning, but this work is in progress.
Since 2009, some counties have merged their
resource groups in nutrition with other groups
(tobacco, physical activity, mental health,
substance abuse).
The assigned roles and responsibilities for
public health efforts at regional level, shared
between the county authorities and county
governors, have changed since 2010 with
implications for the organization and funding
of public health work, including the work of the
resource groups.
Until 2010 there was a national internet portal for municipal
health profiles which included health indicators as a tool in
municipal planning (kommunehelseprofiler). Birth weight and
the participation rate of schools in the fruit and vegetable
subscription scheme were included as nutrition-related
indicators available from existing data collections. Further
nutrition indicators were warranted.
With the new public health law of January 2012, a new web
portal for health indicators for each municipality has been
developed (folkehelseprofiler). According to the new law, the
Directorate of Health and the Norwegian Institute of Public
Health shall support local authorities in obtaining an overview of
the public health situation in the community.
In 2009, 18 out of 19 counties had resource groups in nutrition.
These groups were established in order to advocate and
constitute a resource network in relation to integrating nutrition
in partnerships for public health at county and municipal level.
The Directorate of Health organized annual meetings for the
resource groups from 2007 to 2010.
Health & Care
Services
Health & Care
Services
local foundation for nutrition
initiatives
7.4 Develop effective
indicators for nutrition and
public health for inclusion in
municipal health profiles
7.5 Continue nutrition and
diet initiatives together with
physical activity and anti-
tobacco programmes as a
priority focus in partnerships
for public health

70
Focus area and goals Ministry Measures Comments
responsible
A report about the Partnerships for Public
Health initiative is available in Norwegian from
the Directorate of Health.
Some reports are available as a result of Nordic
collaboration.
The ministries have been encouraged to
incorporate nutrition-related measures into
their work, where relevant.
Annual reports from the county governors, county authorities and
the Board of Health Supervision are reviewed and summarized
by the Directorate of Health with respect to nutrition
programmes. In addition, county and municipal meetings and
conferences are organized for the purpose of exchanging
knowledge, ideas, experience and models. The Directorate of
Health also contributes to the exchanges through its regular
work. In addition, there is Nordic cooperation in this field.
See 7.5.
Health & Care
Services;
Agriculture
&Food;
Fisheries &
CoastalAffairs;
Children,
Equality
& Social
Inclusion;
Labour;
Environment
Health & Care
Services;
Agriculture &
Food;Labour;
Fisheries &
CoastalAffairs;
Children,
Equality
& Social
Inclusion;
Environment
7.6 Collect, communicate
and, if necessary, develop
tools and models for nutrition
activities
7.7 Coordinate and channel
incentive funds from
various national food,
diet, physical activity and
health programmes to local
measures

71
Focus area and goals Ministry Measures Comments
responsible
See 1.4.
There is no evaluation of or documentation on
use of the material, nor whether schools and
teachers are aware of its existence.
Other relevant material is available online,
such as guidance on the subject of food and
health (home economics) at the Directorate of
Education.
Teaching material is available as part of the
annual Week of Taste project initiated by the
Ministries of Fisheries & Coastal Affairs and
Finance.
The project Den naturlige skolesekken [The
Natural Schoolbag], by the Ministries of
See 1.4.
The Cookery book for all was published in September 2007. It
is distributed free to pupils at the lower secondary level and
to teacher-training students. Municipalities can buy the book
at production cost for training purposes and it is also available
in bookshops. It is updated with information about keyhole
labelling and new dietary advice.
Teaching materials have been developed by the Directorate
of Health, in collaboration with the Directorate of Education
and Norwegian Food Safety Authority, for various grades on
nutrition, labelling, hygiene and keyhole labelling.
Health & Care
Services
Health & Care
Services;
Agriculture
&Food;
Fisheries &
CoastalAffairs;
Education &
Research
8.1 Offer a basic cookery
book free to pupils at the
lower secondary level and to
teacher-training students
8.2 Develop and offer
web-based educational
programmes for use in
primary schools
8. Capacity-building in nutrition-related issues
Goals: Contribute to consistent knowledge and skills in food, food preparation, diet and health among young people
Contribute to good qualifications in food, diet and health among teachers in food and health
Contribute to adequate knowledge about nutrition and social inequalities in diet and health among relevant health personnel groups, and empower them
to use this knowledge in their daily work
Contribute to more knowledge about the need for nutrition qualifications and how any needs can be covered

72
Focus area and goals Ministry Measures Comments
responsible
Education & Research and the Environment,
has integrated the learning objectives for the
subject of food and health. The focus area of
the project is primarily on the environment and
sustainability in general.
Teaching material is also available from all of
the information offices for fruit and vegetables,
eggs and meat, dairy products, seafood and
breads and cereals. This teaching material is
being used extensively.
Several ministries have received a letter from
the Association of Teachers in Food and Health
expressing their concern regarding the future
of the subject, its status and the possibilities of
reaching the learning objectives. For example,
there is no textbook for this subject in primary
schools.
Collaboration between the Directorate of Health and the
Directorate of Education and Training has highlighted the need
to strengthen the position of the subject Home Economics, Food
and Health. Concerns about this subject have been raised in
several political arenas. It is estimated that around 70% of the
teachers in food and health in primary and lower secondary
education do not have subject-specific training.
In 2007 and 2008, the Directorate of Health organized seminars
for student teachers in vocational colleges and universities.
A meeting was held in 2009 between the Directorate of
Health and the Directorate of Education and Training and
representatives from the Buskerud and Vestfold vocational
colleges as well as the Association of Teachers in Home
Economics, who are responsible for food and health in primary
and lower secondary schools, to discuss the challenges with the
subject.
Health & Care
Services;
Education &
Research;Local
Government
& Regional
Development
Health & Care
Services;
Education &
Research;Local
Government
& Regional
Development
8.3 Encourage the allocation
of resources for practical
training in food and health
8.4 Stimulate the
establishment of continuing
and further education
programmes in nutrition,
diet and food and health
and disseminate information
about them

73
Focus area and goals Ministry Measures Comments
responsible
8.5 Assess needs and
possibilities for strengthening
nutrition in relevant national
curricula
8.6 Ensure adequate
qualifications in diet and
nutrition in the nursing and
care sector
Education &
Research;
Health & Care
Services
An additional meeting was held in the autumn of 2010 between
the Directorate of Health and the Association of Teachers of
Home Economics, who are responsible for food and health in
primary and lower secondary schools.
Following publication of the report Kompetanse for kvalitet –
strategi for videreutdanning av lærere (2008–2012) [Competence
for quality – strategy for the further education of teachers
(2008–2012)], the government gave financial support for further
education programmes for teachers, including teachers of food
and health (home economics). Not all the student places in this
subject have been filled. The municipal authorities and school
heads decide which teachers and/or disciplines should get
further education.
The university sector in all six educational regions is supposed
to offer classes for student teachers enabling them to teach all
subjects in primary and lower secondary school.
In the development of the new regulation for teacher training,
the Ministry of Health & Care Services submitted input on
the need for better competence in health promotion among
teachers. This was not taken into account in the subsequent
regulations.
There is a need for more nutrition education for health care
professionals, especially doctors, nurses and social workers.
This is referred to in the white paper from the Ministry of
Education Education for the welfare state (Report No. 13
(2011–2012) to parliament).
An evaluation report on the education of pre-
school teachers is available from NOKUT (the
National Organization for Quality in Education).
A new national curriculum regulation for pre-
school education is under development.
See 8.4.
See the Ministry of Health & Care Services
publication Long-term care – future challenges.

74
Focus area and goals Ministry Measures Comments
responsible
The report from the Directorate of Health
estimates that 700 clinical nutritionists are
needed in the health and care services by
2020. In 2011, about 140 nutritionists were
employed, most of them in hospitals. Only 3%
were employed in municipal health and care
services.
In the budget for 2011–2012, the government
allowed for the number of students in clinical
nutrition to be increased by 20 (15 at the
University of Oslo and 5 at the University of
Bergen). In 2012, the University of Oslo planned
to admit 35 students and the University of
Bergen 15 to do Master’s degrees in clinical
nutrition. At the University of Bergen, however,
not all of the projected 13 students started in
2010, and in 2011 only 7 new Master’s students
started.
The Ministry of Education’s report Education for
the welfare state confirms that the government
will work to ensure that there is access to
clinical nutritionists in the whole country.
From 2010, a special effort was made to strengthen nutrition
competence in the nursing and care sector. In 2011, the
Directorate of Health announced funding opportunities for
municipalities to strengthen their competences in nutrition in
this sector as part of the Competence Lift 2015 project.
See also 6.1 and 6.5.
The survey on food and meals in nursing homes (6.5) showed
that the staff need increased access to nutrition expertise.
Reports were delivered to the Ministry of Health & Care
Services in 2009, 2010 and 2011 on the future needs for
clinical nutritionists. The reports describe how different groups
of personnel may be qualified to engage in various forms of
nutrition work and present different models for strengthening
competence in nutrition.
Feedback from the Ministry of Health & Care Services is needed
to follow up the measures in the ongoing work in the Directorate
of Health.
Health & Care
Services
Health & Care
Services
8.7 Consider future needs for
nutrition specialists in the
health service

75
Focus area and goals Ministry Measures Comments
responsible
Fifteen research projects are being carried out
in the programme related to nutrition. Some
examples are listed below (a complete list has
been requested from the Research Council).
• Thehealtheffectsofadietrichinplant-
based foods and fish. Focus on Nordic
foods.
• FruitsandVegetablesMaketheMarksIII:
How to improve adolescents’ eating habits?
• FoodandeatingamongyoungNorwegians.
A sociological analysis of teenagers’ food
ideologies and practices in an everyday
context.
The Research Council is coordinating
the Norwegian inputs to the planned EU
programme A Healthy Diet for a Healthy Life.
A workshop has been held where Norwegian
researchers drew up a letter with inputs to the
programme.
The Research Council and the Ministry of
Health & Care Services are members of
The Ministry of Health & Care Services allocated a budget for
2007–2010 to the research programme on public health at the
Research Council. Research on healthier diets was one of four
prioritized research areas, and 15 research projects received
funding. The Action Plan was also referred to in the general
allocation letter to the Research Council. A report for the
programme period is available.
The Ministry of Education & Research initiated a systematic
review of the effects of providing meals in schools and
kindergartens on health and learning, a description of existing
meal arrangements in schools and kindergartens in the different
Nordic countries, and an analysis of current knowledge about
the effect on health and learning by providing food in these
institutions, as well as identifying research gaps within this
field.
Health & Care
Services
9.1 Strengthen research on
the relationship between diet
and health
9. Research, monitoring and documentation
Goals: Provide increased knowledge about the links between diet and health
Provide knowledge about the status of and trends in diet and meal habits in Norway
Provide knowledge about factors that affect the food choices and dietary habits of the general population and various population groups
Provide knowledge about the effects of dietary measures to improve the national diet and reduce social inequalities in diet
Provide knowledge about the cultural and social significance of meals for health
Provide the basis for Norwegian food production that respects health concerns

76
Focus area and goals Ministry Measures Comments
responsible
the Management Board. The Directorate of
Health has one representative on the Strategy
Advisory Board.
Seven projects received funding on food and
health from the Food Programme during the
period of the Action Plan.
Two projects have been initiated by the
Programme: (i) HealthMeal: Possibilities and
Barriers for Increased Consumption of Fish
and Vegetables in Meals Eaten at Home
and Outside Home, by the Statens Institutt
for Forbruksforskning [National Institute for
Consumer Research], and (ii) Healthy Meals and
Prevention of Lifestyle Diseases, by Nofima.
A Research Council report in 2010 drew
attention to the status of and needs within
Norwegian research on food and health.
The report was written by NIFU-STEP and is
available (in Norwegian).
Nofima is working on new research on healthy
ingredients and meals. The Norwegian food
industry is involved in the research platform
Food for Life.
The Nordic Centre of Excellence programme (2007–2011) on
food products, nutrition and health is co-financed by NordForsk
and the Nordic research funding agencies.
The Ministry of Agriculture & Food allocated funds to the
Research Council’s Food Programme in 2007–2010.
The Ministry of Fisheries & Coastal Affairs allocated funds to
the Research Council’s Food Programme in 2007–2010. The
Ministry has raised its concern with the Council for the need
for more research on seafood and health. The Ministry also
supports food research through allocations to Nofima and the
National Institute of Nutrition and Seafood Research.
Agriculture
&Food;
Fisheries &
CoastalAffairs;
Health & Care
Services;Trade
& Industry
9.2 Promote research to
stimulate development of
better and healthier products

77
Focus area and goals Ministry Measures Comments
responsible
9.3 Continue and further
develop monitoring of the
population’s diet
9.4 Ensure expert studies
and updated official
recommendations
Health & Care
Services;
Agriculture &
Food;Fisheries
& Coastal
Affairs
The following data have been collected:
• infantfood(spedkost)(n=3000parentsinvited):dataon
infantsaged6and12monthscollectedin2006–2007;
• smallchildren’sfood(småbarnskost):dataonchildren
collectedin2009;
• nationwidesurvey(norkost)ofapproximately5000people
aged 18–70 years: pilot collection in 2009, main data
collectionin2010;reportpublishedin2012.
Data are also available from other national surveys such as
Statistics Norway’s Health Interview Survey. In 2008, 6500
people took part. The most recent survey was in 2012.
Methods for a pan-Nordic monitoring of trends in diet, physical
activity and overweight have been developed and validated.
Baseline data were collected in 2011. The overall focus for the
project is health promotion and prevention, where diet and
physical activity is one of five areas (74).
In early 2011, the National Council on Nutrition presented its
recommendations for revised national dietary guidelines and
recommendations (see 1.2).
Work is continuing on the development of pan-Nordic dietary
recommendations. The Directorate of Health is represented
on the steering committee, the reference group and one of the
expert groups (see 10.3).
The most recent findings are presented in a
separate document.
In 2000, data were collected about young
people’s food from approximately 2000
schoolchildren from grades 4 and 8, as well
as 400 children aged 4 years. The next data
collection is planned for 2013.
There is an ongoing process headed by the
Institute for Public Health to develop tools for
health indicators for municipalities (see 7.4).
The Scientific Committee for Food Safety
published the report Impact on health when
sugar is replaced with intense sweeteners in
soft drinks, ‘saft’ and nectar in 2007.
The Scientific Committee for Food Safety has
appointed a working group who assess the
benefits and risks of breast-milk. Their report
should be published in 2013.

78
Focus area and goals Ministry Measures Comments
responsible
Norway has participated actively in World Health Assemblies,
both in preparatory work and during the meetings.
The Directorate of Health has given its input to WHO’s
Maternal, infant and young child nutrition: draft comprehensive
implementation plan.
Norway has been represented in the EU’s High-Level Group on
Nutrition and Physical Activity and in the European Salt Action
Network since 2008.
The Directorate of Health is the secretariat for and chairs the
European network on reducing the marketing of unhealthy foods
and beverages towards children, in collaboration with the WHO
Regional Office for Europe. Twenty European countries are
involved.
The Directorate of Health was technically responsible for the
WHO Regional High-Level Consultation in the European Region
on the Prevention and Control of Noncommunicable Diseases,
held in Oslo on 25 and 26 November 2010, in preparation for the
high-level meeting on noncommunicable diseases held during
the United Nations General Assembly in September 2011. Civil
societies organized their own meetings and prepared their own
suggestions for resolutions on the day before the conference.
A resolution proposed by Norway on reducing the marketing of
Health & Care
Services
10.1 Participate actively in
WHO’s work on nutrition,
globally and regionally
10. Nutrition in an international perspective
Goals: Contribute actively in cooperation with other countries and international organizations on nutrition issues
Strengthen the focus on nutrition in aid and development cooperation
Raise awareness that breastfeeding and nutrition are important components in priority areas, such as action to improve child health and reduce child mortality

79
Focus area and goals Ministry Measures Comments
responsible
unhealthy foods and non-alcoholic beverages towards children
at the World Health Assembly in 2010 was approved.
At the first WHO Global Ministerial Conference on Healthy
Lifestyles and Noncommunicable Disease Control, held
in Moscow on 28 and 29 April 2011, the Regional Office
consulted Member States and other key stakeholders on the
report and presented the final version at the same conference.
The Norwegian Minister of Health chaired the round-table
discussion on nutrition.
Norway chaired the bilateral group within the Standing
Committee on Nutrition for 10 years up to 2010.
The Ministry of Agriculture & Food was observer during a
meeting with the World Cancer Research Fund in London where
the associations between cancer and intake of meat were
debated. Representatives of Norwegian meat producers also
participated.
A Nordic working group (linked to the Nordic Council of
Ministers for Fisheries and Aquaculture, Agriculture, Food
and Forestry and the Nordic Working Group for Diet, Food &
Toxicology) has initiated project collaboration on monitoring,
communication and evaluation of the keyhole labelling system,
communication measures towards children, examples of best
practice and training of teachers in food and health. This
initiative is a follow-up to the Nordic Action Plan for Better
Health and Quality of Life.
ForeignAffairs;
Health & Care
Services
Health & Care
Services
10.2 Contribute actively to the
work of the United Nations
Standing Committee on
Nutrition
10.3 Contribute actively to
Nordic and Nordic-Baltic
cooperation

80
Focus area and goals Ministry Measures Comments
responsible
The Ministry of Agriculture & Food participated in the survey of
food and children initiated by the Nordic Council of Ministers
(New Nordic Food).
The Directorate of Health participates in a Nordic network on
physical activity, nutrition and obesity with the Danish Board of
Health (Sundhedsstyrelsen) and Swedish National Public Health
Institute (Statens Folkhälsoinstitut). The Nordic School of Public
Health is the administrator.
A project group appointed by the Minister of Development Aid
has submitted a report on food security and hunger.
In 2008, the Norwegian Agency for Development Cooperation
and the Directorate of Health arranged a seminar on nutrition
and development.
The United Nations Department of the Ministry of Foreign
Affairs has been active in writing a new strategy for the World
Food Programme, and has participated in the high-level meeting
on the food supply crisis. Norway is a board member of the
World Food Programme.
An internal status report with suggestions for measures to
strengthen nutrition-related programmes in development aid
was drawn up in 2009.
The white papers on Environment and Development and Global
Health include points on food security, environment, health and
nutrition. Nutrition in development aid will be anchored in white
papers and focus areas.
Health & Care
Services;
Foreign Affairs
10.4 Ensure that nutrition
measures and assessment of
nutritional consequences are
included as an element in aid
and development cooperation

81
Focus area and goals Ministry Measures Comments
responsible
The Ministry of Foreign Affairs and the Norwegian Agency for
Development Cooperation were active in the development of the
United Nations Secretary-General’s Global Strategy on Maternal
and Child Health (including nutrition-related issues).
The Ministry of Foreign Affairs and the Norwegian Agency
for Development Cooperation contributed to the World Food
Programme’s new HIV/AIDS policy, which includes support for
the provision of nutritional products to HIV-infected persons.
Norway is involved in the international initiative on increasing
the focus on nutrition in developing countries – Scaling Up
Nutrition (SUN) – which was launched in April 2010.
a Social inclusion was transferred from the Ministry of Labour to the Ministry of Children & Equality in 2008.

Evaluation of the Norwegian Nutrition Policy with
focus on the Action Plan on Nutrition (2007-2011)
The WHO Regional Office for Europe
The World Health Organization (WHO) is a
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created in 1948 with the primary responsibility
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Evaluation of the Norwegian Nutrition Policy with
focus on the Action Plan on Nutrition (2007-2011)
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Evaluation of the Norwegian nutrition policy with a focus on the Action Plan on Nutrition 2007–2011
Evaluation of the Norwegian Nutrition Policy with
focus on the Action Plan on Nutrition (2007-2011)
Evaluation of the Norwegian nutrition policy with
a focus on the Action Plan on Nutrition 2007–2011
World Health Organization Regional Office for Europe
UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark
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