Public Policies on Healthy Diet: Analyzing the Portuguese Experience

Abstract

In Portugal, public policies promoting a healthy diet have gained prominence in recent years, reflecting a growing concern with the population’s health status and its individual, social, economic, and political impact. These policies aim to mitigate the impact of inadequate eating habits as a determinant of health and the population’s disease burden. Based on a document analysis, the main objective of this article is to explore public healthy diet policies in Portugal following the 2017 implementation of the Estratégia Integrada para a Promoção da Alimentação Saudável (Integrated Strategy for the Promotion of a Healthy Diet), which is the primary guiding instrument for these policies. Among the most impactful legislative measures found in this sector, we highlight the reformulation of food products, food taxation, food marketing regulation, food incentives, and food labeling. Despite significant progress in promoting healthy diets, some challenges still remain, particularly the growing prevalence of behavior-related chronic non-communicable diseases, like obesity, such as the maintenance of a set of health determinants related to inadequate nutrition. Thus, the continuity and deepening of such policies, combined with continuous impact assessments, are crucial to ensuring a healthier future.

1. Introduction

Health is a fundamental right, and good health ensures the human and economic development of the population, which, in turn, guarantees prosperity and security. To achieve this, healthy public policies must involve a dual commitment: placing health at the top of the political agenda and emphasizing the determinants of health as the focus of intervention [1,2,3].

One of the concerns of governments is to ensure adequate health conditions and the quality of life of the population, identifying the risk factors that mostly influence the disease burden, which is crucial for the implementation of public policies that promote health as a “planned and managed process aimed at encouraging and assisting in improving the health status of the population, allowing individuals and communities to increase control over the determinants of health and, in doing so, improve their health.” [4] (p. 43).

In recent decades, technological, scientific, social, and economic development, alongside advancements in public health and medicine, have resolved many of the health issues that society faced. However, today, societies encounter new and more complex circumstances due to increased life expectancy, an aging population, and the higher incidence and prevalence of chronic diseases [5,6]. These developments pose new challenges to health systems, necessitating comprehensive public health policies to address these issues to improve the health of the population [7]. This is reflected in the improvement of care quality and population health, with political change projects now almost universally incorporating concepts and indicators that go beyond the financial sustainability of systems, such as impacts on life expectancy, infant mortality rates, or the prevalence of certain diseases [8].

Given the importance of individual health and well-being and the fact that a population’s health status is influenced by a wide range of factors beyond direct healthcare control, the World Health Organization (WHO), inspired by the Alma Ata Declaration (1978) and United Nations conferences on health promotion, proposes the motto health in all policies. This approach seeks collaboration among various actors, governmental and non-governmental, to maximize health benefits and minimize any adverse public policy effects on health determinants, promoting synergies to improve population health [9,10]. Similarly, the European Union, in article 129 of the Amsterdam Treaty, prioritizes public health, mandating that both the EU and member states ensure a level of human health protection across all policies by promoting an integrated approach that considers the health impacts of public policies across different sectors [11].

Typically, quality and health gains are the two primary goals of health policies. A policy that promotes quality and achieves significant health gains is the most sustainable [12]. Addressing health determinants requires healthy public policies and intersectoral collaboration between political authorities and public mobilization [6].

The growing evidence of the link between a healthy diet and good health, as well as the association between poor diets and chronic diseases with significant individual, social, economic, and political impacts, has placed health policies, especially those promoting a healthy diet, at the center of the public and political agendas, both internationally and nationally. Numerous guidelines for adopting healthy policies have been issued by major international organizations of which we are members, including the World Health Organization (WHO), the European Union (EU), and the Organization for Economic Co-operation and Development (OECD).

In Portugal, in 1979, the creation of the Serviço Nacional de Saúde (National Health Service) underscored concerns about health promotion and disease prevention [13]. This focus is also reflected in various national health plans and in the Health Framework Law. When it comes to promoting a healthy diet, there were some efforts starting in 1995 within school health programs and obesity prevention programs. However, it was only in 2012 that the Programa Nacional para a Promoção da Alimentação Saudável (National Program for the Promotion of a Healthy Diet) was approved. This program was specifically designed to provide an integrated response to public health strategies addressing obesity and promoting a healthy diet [14] and becoming one of the priority national health programs.

Until then, Portugal was one of the few European countries without a coordinated and cross-sectional program aimed at improving the nutritional status and health of the population by addressing one of its main determinants—nutrition. Within the framework of this National Program, in 2017, the XXI Constitutional Government, inspired by international guidelines and considering the impact of poor diets on individual health and the national economy, approved the Estratégia Integrada para a Promoção da Alimentação Saudável (Integrated Strategy for the Promotion of Diet) through Order No. 11418/2017. The aim was to encourage adequate food consumption and improve citizens’ nutritional status, which directly impacts chronic disease prevention and control [15].

More recently, in 2023, the Directorate-General for Health published the National Program for the Promotion of a Healthy Diet 2022–2030, reinforcing the importance of promoting healthy diets and preventing and controlling all forms of malnutrition, especially overweight and obesity. This remains a health priority, especially given projections for 2030 in Portugal that suggest that inadequate dietary habits may surpass smoking as the leading risk factor [16].

It was mainly after the Strategy approval that legislative initiatives and specific programs promoting healthy diets gained momentum. Consequently, this date is set as the starting point for this investigation.

Following the Strategy approval, major public policies in the sector have focused on food marketing regulation, dietary incentives, food labeling, food taxation, and food and beverage reformulation. Therefore, this article aims to explore public policies for promoting healthy diets in Portugal after 2017 and, specifically, to identify the legislative measures promoting healthy diets and evaluate their implementation.

2. Materials and Methods

To support the premise of this study, which focused on identifying and evaluating the implementation of public policies on healthy diets in Portugal, bibliographical research and an analysis of reports from the main international and national institutions in the sector were carried out.

3. Results

In Portugal, the first steps in this area were taken in the 1980s with the first National Health Plan, which served as one of the initial approaches to health promotion. However, it was only in 2017 that the Estratégia Integrada para a Promoção da Alimentação Saudável (Integrated Strategy for the Promotion of a Healthy Diet) was approved, marking the beginning of a greater number of legislative initiatives aimed at promoting a healthy diet.

According to the latest available data on the main health risk factors, in Portugal, inadequate dietary habits were the fifth leading risk factor contributing to the loss of healthy life years. Analyzing the top eighteen factors, it is evident that eight are related to poor nutrition. It is also noteworthy that the three factors that most contributed to the loss of healthy life years (elevated blood glucose, high BMI, and high blood pressure) are directly linked to dietary habits [17]. The central role that inadequate nutrition and other related factors play in the risk of losing healthy life years is also evident in terms of mortality. Poor dietary habits were the third leading risk factor contributing to the total number of deaths in Portugal in 2021 [17] and the second leading risk factor in 2023 [18].

The following sections outline the measures and results achieved in terms of actions implemented to align with the defined Strategy, focusing on food marketing, incentives, labeling, reformulation, and taxation.

3.1. Public Healthy Diet Policies in the Context of Food Marketing

Marketing plays a central role in food choices, as it influences how consumers perceive, select, and consume food, directly impacting social consumption patterns. To mitigate the harmful impact of food marketing, various governments, including the Portuguese government, are urged to restrict the promotion of foods that contribute to unhealthy diets, reduce children’s exposure to such marketing, and diminish its influence by providing the best possible protection, particularly in the realm of digital marketing [19,20,21].

In this context, in 2019, Portugal implemented legislative measures (Law No. 30/23 April 2019 and Order No. 7450-A/21 August 2019) aimed at introducing restrictions on food and beverage advertising, targeted at children under 16 years old, for products high in energy, salt, sugar, and trans-fatty acids [22,23].

In terms of results, by 2024 (five years after the policy’s implementation), the following were observed:

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There is still widespread exposure to advertising for foods with an inadequate nutritional profile, as around 20% of the analyzed advertisements feature appealing and attractive content for children, and more than 65% of the advertised products are unhealthy. However, there has been an increase in the percentage of food products that meet the defined nutritional profile criteria, particularly in food categories recognized for their nutritional value (such as solid and liquid yogurts, breakfast cereals, and flavored milk) [24].

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Regarding food advertising near schools, no advertisements for unhealthy food products were found within a 100 m radius of a school vicinity, as mandated by law. However, when food advertisements were assessed within a broader perimeter (500 m around school vicinities), a significant presence of advertising for unhealthy food products was identified [24].

3.2. Public Healthy Diet Policies in the Context of Food Incentives

Food incentive policies are essential for promoting healthy diets, as they contribute to improving the food environment and facilitate the selection and consumption of healthier foods and beverages. In this sense, incentives should be created to encourage the acquisition of healthy foods and the implementation of nutrition and food policies, particularly in school settings [18,25].

In Portugal, some legislative measures have been adopted in this regard, both in schools and in other public institutions. Notably, these include the regulation of the conditions for limiting unhealthy products in spaces designated for bars, cafeterias, and buffets operated by institutions under the Ministry of Health, aiming to implement measures to promote overall health and, specifically, the adoption of healthy eating habits (Ordinance No. 11391/28 December 2017); the promotion of the consumption of fruits, vegetables, bananas, milk, and dairy products in schools (Ordinance No. 113/1 May 2018); the establishment of new guidelines for school menus and cafeterias (Circular No. 3097/DGE/August 2018); the definition of criteria for selecting and acquiring food products, promoting the sustainable consumption of locally produced goods in public canteens and cafeterias (Law No. 34/22 May 2019); and the establishment of rules to be taken into account for preparing menus and selling food items in buffets and vending machines in public education establishments under the Ministry of Education (Ordinance No. 8127/17 August 2021).

In terms of implementation results, the following was found in 2023:

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Regarding the implementation of legislation on food offerings in schools, it was observed that food products such as soft drinks, cookies, pastries, and sweet and salty snacks are no longer part of the food offerings in 90% of the schools analyzed within the public education network. Although some products—such as cereal bars, cookies, and ice creams—remain available in a small number of schools, it is noteworthy that schools are opting for products with the best nutritional profile within each category [26].

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Regarding vending machines, there is greater difficulty in offering healthy food options. In the evaluation conducted in 2023, vending machines, which are available in 31% of schools, offer products that do not comply with the legislation. In addition to products that should not be available in a school context—such as cookies, biscuits, cereal bars, single-serving cereals, and chocolates—there was also a noticeable absence of several products that should be mandatory, such as fruit, bread, and plain milk [26].

3.3. Public Healthy Diet Policies in the Context of Labeling

According to the WHO, labeling policies are essential in promoting good eating habits, providing clear, accurate, and accessible information on the constitution and nutritional composition of foods so that consumers can make conscious and informed decisions about food purchases and consumption, and it is also expected that measures will be taken to regulate nutrition and health claims to avoid false or erroneous information [27]. In fact, nutrition labeling on the front of food packages can support more healthful purchase decisions and encourage favorable reformulation [28].

In Portugal, the regulation of nutrition and health claims on food labels follows the guidelines established by the European Union, mainly Regulation (EC) No. 1924/2006, which guarantees that claims made on food are clear, truthful, and scientifically based, protecting consumers from misleading information and promoting informed choices.

With regard to labeling, a measure was taken recently, but it is optional to apply: the implementation of the Nutri-Score system as a public health and healthy eating promotion measure that is optional for operators to apply (Ordinance No. 3637/4 April 2024). So far, Portugal’s position regarding the preferred format to be adopted remains unclear [29].

The optional nature of the Nutri-Score labeling implementation was decided by the Minister of Agriculture, following strong criticism from the food sector, which argued that the mandatory use of this labeling system classified some national food products unfavorably compared to other products, such as olive oil, which had negative impacts on the industry and exports of certain traditional food products.

This option led the Ordem dos Nutricionistas (Portuguese Association for Nutritionists) and DECO (Portuguese Association for Consumer Protection) to express support for the adaptation and improvement of the labeling system, considering it an effective tool for promoting healthy food choices. However, they acknowledged the complexity of its implementation, taking into account cultural factors, the protection of traditional products, and the need for consumer nutritional education. Both organizations believe that the absence of a uniform nutritional labeling system could hinder informed food choices and harm public health.

Comparisons with other European countries reveal a diversity of approaches. Countries such as France, Belgium, Germany, the Netherlands, and Luxembourg have implemented this system. In contrast, countries like Italy, Romania, Poland, and Spain have shown resistance or have repealed policies related to Nutri-Score. This reflects divergences regarding the effectiveness of this type of labeling in different European cultural and food contexts.

In terms of implementation results, when 2743 products available on the Portuguese market were analyzed (breakfast cereals, charcuterie and similar products, packaged bakery and pastry products, dairy products, desserts, and drinks), it was found that 25% of these already have a simplified nutritional labeling system, and 40% use Nutri-Score, but the majority use other methodologies, such as the Reference Intake Label (31%) and Traffic Light Labeling System (28%) [30].

3.4. Public Healthy Diet Policies in the Context of Food Taxation

Food taxation, i.e., the use of taxes and fiscal incentives on foods and beverages, is a powerful tool for shaping dietary behaviors, with taxation schemes being among the most effective and rapid measures to achieve results [31,32].

In Portugal, measures have been implemented to additionally tax sugar-sweetened beverages, and variable taxes are applied to food products (Value-Added Tax): reduced rate (6%), intermediate rate (13%), and standard rate (23%). This difference reflects the priority to facilitate access to basic food items, while less essential or more harmful products are taxed at higher rates. So far, no subsidies have been implemented for healthier foods.

Regarding the taxation of sugar-sweetened beverages, some legislative measures have been implemented: Law No. 42/28 December 2016 on the State Budget for 2017, which introduced the taxation of non-alcoholic beverages with added sugar or other sweeteners, and Law No. 71/31 December 2018 on the State Budget for 2019, which introduced a revision to the Special Tax on the Consumption of Sugary and Sweetened Beverages, creating new taxation tiers. In terms of implementation outcomes, the following were observed:

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Between 2017 and 2023, there was a 36% decrease in the proportion of beverages falling into the highest tax tier (sugar content equal to or greater than 8 g/100 mL) [25];

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Between 2019 and 2023, there was a 54% increase in the beverages that fall into the lowest tax tier (sugar content less than 2.5 g/100 mL), suggesting that the soft drinks currently most consumed by the Portuguese have a significantly lower sugar content [30].

3.5. Public Healthy Diet Policies in the Context of Food and Drink Reformulation

Lastly, but no less important, are food reformulation policies as a way to encourage the production, development, and consumption of healthier food options. The reformulation of foods and beverages brings benefits to individuals, public health, and businesses.

At the individual level, reformulation improves the nutritional quality of foods and helps individuals consume healthier diets. At the public health level, by reducing the excessive consumption of fats, sugars, or salt in processed products, individuals improve their diets, which reduces the risk of chronic diseases, disabilities, and deaths related to inadequate diets. Finally, at the business level, reformulation leads to the development of products with a better nutritional profile, offering companies the opportunity to enhance their brand and reach more consumers, especially those interested in taking an active role in their health. Additionally, these products may avoid being subject to fiscal measures aimed at unhealthy products and may face fewer marketing restrictions and trade barriers [32,33].

Since 2016, the Portuguese Ministry of Health has collaborated with the food industry, developing a series of protocols aimed at reducing the levels of salt, sugars, and trans-fatty acids in various foods and beverages:

(i)

A protocol between the Directorate-General of Health, the Association of Portuguese Sugar Refiners, and the Industrial Association of Distribution Companies to limit the net weight of individual sugar portions to 5/6 g (2016);

(ii)

A protocol between the Directorate-General of Health and the Associations of Bakery, Pastry, and Similar Industries to reduce the salt content in bread and the trans-fatty acid content in pastry products;

(iii)

A protocol between the Directorate-General of Health, the Association of Portuguese Sugar Refiners, the Industrial Association of Distribution Companies, and the Portuguese Association of Distribution Companies to reduce the grammage of individual sugar portions to 4 g (2017);

(iv)

A commitment between the Directorate-General of Health, the National Institute of Health, the Portuguese Association of Distribution Companies, and the Federation of Portuguese Agri-Food Industries to reformulate certain nutrient-rich foods that pose health risks, such as salt, sugar, and trans-fatty acids (2019);

(v)

A protocol between the Directorate-General of Health, the National Institute of Health, and Nielsen for monitoring the commitment to reformulating foods and beverages (2019).

In terms of implementation outcomes, the following were observed:

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Between 2018 and 2021, there was an overall reduction of 11.5% and 11.1% in the average salt and sugar content, respectively, of the products covered by this commitment (crisps and other snacks, breakfast cereals, and pizzas (salt) and breakfast cereals, yogurts and fermented milks, chocolate milk, and soft drinks and nectars (sugar)). Overall, the average salt content of the products covered went from 1.14 g per 100 g in 2018 to 1.01 g per 100 g in 2020. In the same period, the average sugar content went from 7.46 g per 100 g to 6.36 g per 100 g [34];

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Compared to the targets set under this protocol, around 50% of the food product categories analyzed met or exceeded these values. With regard to sugar content, three of the categories covered by this agreement (“soft drinks”, “chocolate milk”, and “yoghurts”) achieved the reduction target set for the year 2022 in 2018. With regard to salt content, two of the categories (“breakfast cereals” and “pizzas”) also achieved the reduction target set for 2022 in 2018 [34].

4. Discussion

When we analyze the measures, it seems that there has been a clear choice to take regulatory measures, i.e., to adopt policies that impose restrictions or rules that aim to regulate behaviors and practices, protecting the collective interest, namely tax policy measures, which are considered to be the most effective and have the shortest-term results. However, up until now, the only option in this area has been to tax harmful foods, while there is a lack of tax relief for healthy foods.

According to the Food-EPI study on the degree of implementation of public policies to promote healthy diets, published in 2021, Portugal achieved a moderate or high degree of implementation in 77% of the indicators (56% and 21%, respectively), standing out positively compared to other European countries in the implementation of policies that contribute to healthier dietary habits. A number of measures have been identified that are internationally considered good practice, namely measures that promote the reformulation of food products, measures to regulate food advertising aimed at children, measures related to pricing policies, or measures aimed at regulating the food offer in different public spaces [35,36]. In the same vein, the ranking World Obesity Atlas (2023) highlights Portugal as the eighth most prepared country to combat obesity, which is due to the set of health promotion measures that have been developed, examples of which are those aimed at legislating food marketing or reformulation [37].

Although Portugal is the eighth best-prepared country in the World Obesity Atlas, the healthcare policies do not ensure a nutritionist-to-patient ratio in the National Health Service that allows for proper nutritional education and adequate clinical follow-up.

Notwithstanding this promising data, the projections are worrying, and it is predicted that by 2035, the percentage of adults with obesity in Portugal will be around 39%, an increase of 2.8% per year, which, in addition to the direct negative impact on health, will also be reflected in the increase in health expenditure to mitigate problems caused by obesity, which will be equivalent to 2.2% of GDP in 2035 [36]. Similarly, when analyzing health determinants, inadequate nutrition remains at the top of the list [17,18].

Thus, it is essential to reinforce and monitor the effect of these measures, which contribute to the prevention of a wide range of diseases, with obesity being the most widely publicized among the preventable diseases through nutrition.

High body mass indexes interfere with individual and collective health and have a number of social and economic implications. Firstly, excess weight contributes to an increase in the burden of disease and the cost of medical treatments for associated chronic illnesses. It also contributes to a decrease in school performance, and, in the long term, lower educational attainment negatively affects the socio-economic status of individuals and the human capital of countries. Similarly, obesity and its consequences affect productivity with a negative impact on the labor market, particularly due to the increased risk of absences from work and unemployment. Finally, at the macroeconomic level, all of these factors can negatively affect GDP and create conditions for greater budgetary pressure, as individuals with obesity tend to seek healthcare services more frequently, often presenting more severe clinical conditions, and require more medication than those with a healthy weight.

Studies assessing the impact of excess weight on healthcare expenses in Portugal estimate that it accounts for 10% of the total health budget, which is above the European average [38,39,40,41]. Given this, it can be assumed that the promotion of healthy diets is a determining factor in promoting health status and preventing disease, improving the quality of life, and reducing avoidable costs, which is why countries must be empowered to make decisions in this area.

This research presents certain limitations that should be acknowledged. The analysis focused predominantly on documentary and institutional sources, which may not fully capture the complexity of the on-the-ground implementation of public policies promoting healthy eating. The absence of primary data—particularly through interviews with stakeholders or direct observation of implementation contexts—may limit the deeper understanding of the facilitating mechanisms and the barriers encountered.

Despite these limitations, the research provides a solid foundation for future research that may complement and expand the existing knowledge on the topic, and, in this regard, future research should focus on an in-depth analysis of the actual impact of public policies promoting healthy eating implemented in Portugal, incorporating not only epidemiological and public health indicators but also the social, economic, and cultural determinants that influence their effectiveness. The analysis of perceptions and experiences of the various stakeholders—including policymakers, healthcare professionals, and citizens—is also crucial for identifying facilitators and barriers to policy implementation. Additionally, comparative studies with other European contexts may provide a valuable basis for identifying best practices and strengthening intercontextual learning, thereby contributing to the continuous improvement of national policies.

5. Conclusions

The majority of chronic diseases have a behavioral origin, and there is a strong correlation between inadequate dietary habits and their growth. This highlights the importance of implementing public healthy diet policies. Strategies should be comprehensive, with a particular focus on health education, the promotion of literacy, and measures aimed at modifying the food environment, ranging from self-regulation to the adequate use of taxation.

In this context, the justification for government intervention is strong, and, in Portugal, there has been a strengthening of legislative action in this field following the implementation of the Estratégia Integrada para a Promoção da Alimentação Saudável (Integrated Strategy for the Promotion of a Healthy Diet) in 2017. Despite the recognition of the problem and the implementation of a wide range of programs, plans, and strategies to promote healthier diet habits, it can still be seen that among the first ten health determinants, seven of them are related to inadequate diet habits, as well as the growing rates of obesity and other chronic diseases associated with poor diet habits, which shows that the responses generated have not fully met the challenges and efforts needed to be stepped up in this area.

It can, therefore, be seen that there is still significant room for progress in defining public healthy diet policies. A set of priority actions should be considered, such as expanding the food reformulation plan to include other food categories, reassessing the tax system based on nutritional criteria—namely by creating tax incentives or subsidies for the consumption of healthy foods—implementing and strengthening food and nutrition literacy programs and projects, as well as other initiatives, such as improving access to nutritional care and expanding the nutrition teams in the National Health Service.