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Systematic Review| Volume 50, ISSUE 8, P813-823, September 2018

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Key Characteristics of Public Health Interventions Aimed at Increasing Whole Grain Intake: A Systematic Review

Published:August 01, 2018DOI:https://doi.org/10.1016/j.jneb.2018.05.013
Key Characteristics of Public Health Interventions Aimed at Increasing Whole Grain Intake: A Systematic Review
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      Abstract

      Objective

      To identify characteristics of successful public health interventions aimed at increasing whole grain consumption.

      Methods

      The Preferred Reporting Items for Systematic Reviews and Meta-analyses framework, guided by higher-quality interventions with greatest effect size, was adopted to conduct a systematic literature review.

      Results

      Of 8,500 initial records, only 8 interventions with demonstrated reach (up to national populations) and effectiveness (increasing consumption 8–27 g/d) were eligible for synthesis. Their characteristics included multiple stakeholder involvement, specified target intakes in dietary guidelines, manufacturer codes of practice, product reformulation, evidence-based educational resources, social media, and community events with tasting and preparation opportunities. Empowerment of food service providers was also linked to success.

      Conclusions and Implications

      Successful interventions require multifaceted strategies across multiple aspects of the food system, underpinned by multiple stakeholder partnerships. Uniform capture of interventions using an online, searchable, public domain resource may provide a strategy to enable health professionals globally to plan local interventions across cultural settings, drawing on best practice guidelines developed from interventions with demonstrated reach and effectiveness.

      Key Words

      Introduction

      A risk assessment of the Global Burden of Disease
      • Forouzanfar MH
      • Afshin A
      • Alexander LT
      • et al.
      Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.
      Lancet. 2016; 388: 1659-1724
      attributed 71% of deaths in 2015 to behavioral risks, with 53% of these risks attributable to dietary risks.
      • Forouzanfar MH
      • Afshin A
      • Alexander LT
      • et al.
      Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.
      Lancet. 2016; 388: 1659-1724
      The authors suggested that a policy focus to promote increased intake of vegetables, fruit, whole grain (WG), nuts and seeds, and ω-3 from seafood may have a comparatively larger effect than focusing on the sugar and fat components of diets.
      • Forouzanfar MH
      • Afshin A
      • Alexander LT
      • et al.
      Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.
      Lancet. 2016; 388: 1659-1724
      In support of such a focus, large observational studies
      • McKeown NM
      • Jacques PF
      • Seal CJ
      • et al.
      Whole grains and health: from theory to practice—highlights of the Grains for Health Foundation's Whole Grains Summit 2012.
      J Nutr. 2013; 143: 744S-758S
      suggested that WG consumption may mitigate cardiovascular disease (CVD), weight gain, type 2 diabetes, and cancer and enhance the gut microbiome. In 2016 alone, at least 6 meta-analyses
      • Aune D
      • Keum N
      • Giovannucci E
      • et al.
      Whole grain consumption and risk of cardiovascular disease, cancer, and all cause and cause specific mortality: systematic review and dose-response meta-analysis of prospective studies.
      BMJ. 2016; 353: i2716
      , 
      • Benisi-Kohansal S
      • Saneei P
      • Salehi-Marzijarani M
      • Larijani B
      • Esmaillzadeh A
      Whole-grain intake and mortality from all causes, cardiovascular disease, and cancer: a systematic review and dose-response meta-analysis of prospective cohort studies.
      Adv Nutr. 2016; 7: 1052-1065
      , 
      • Chen GC
      • Tong X
      • Xu JY
      • et al.
      Whole-grain intake and total, cardiovascular, and cancer mortality: a systematic review and meta-analysis of prospective studies.
      Am J Clin Nutr. 2016; 104: 164-172
      , 
      • Ma X
      • Tang WG
      • Yang Y
      • Zhang QL
      • Zheng JL
      • Xiang YB
      Association between whole grain intake and all-cause mortality: a meta-analysis of cohort studies.
      Oncotarget. 2016; 7: 61996-62005
      , 
      • Wei H
      • Gao Z
      • Liang R
      • Li Z
      • Hao H
      • Liu X
      Whole-grain consumption and the risk of all-cause, CVD and cancer mortality: a meta-analysis of prospective cohort studies.
      Br J Nutr. 2016; 116: 514-525
      , 
      • Zong G
      • Gao A
      • Hu FB
      • Sun Q
      Whole grain intake and mortality from all causes, cardiovascular disease, and cancer: a meta-analysis of prospective cohort studies.
      Circulation. 2016; 133: 2370-2380
      were published reviewing WG consumption and reduced risk of noncommunicable diseases and all-cause mortality. In quantifying a dose-response of WG intake to mortality, Zong et al
      • Zong G
      • Gao A
      • Hu FB
      • Sun Q
      Whole grain intake and mortality from all causes, cardiovascular disease, and cancer: a meta-analysis of prospective cohort studies.
      Circulation. 2016; 133: 2370-2380
      showed that for every 16-g/d increase in WG, the relative risks of CVD, cancer, and total mortality decreased.
      • Zong G
      • Gao A
      • Hu FB
      • Sun Q
      Whole grain intake and mortality from all causes, cardiovascular disease, and cancer: a meta-analysis of prospective cohort studies.
      Circulation. 2016; 133: 2370-2380
      Despite strong evidence of the health benefits of WG for many years, consumption in most countries remains below recommendations. For example, intake in Australia and the US ranges from 20 to 27 g/d,
      • Albertson AM
      • Reicks M
      • Joshi N
      • Gugger CK
      Whole grain consumption trends and associations with body weight measures in the United States: results from the cross sectional National Health and Nutrition Examination Survey 2001-2012.
      Nutr J. 2016; 15: 8
      , 
      • Galea LM
      • Dalton SMC
      • Beck EJ
      • Cashman CJ
      • Probst YC
      Update of a database for estimation of whole grain content of foods in Australia.
      Journal of Food Composition and Analysis. 2016; 50: 23-29
      with recommended intakes at 48 g/d.

      US Department of Health and Human Services and US Dept of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. 2015.http://health.gov/dietaryguidelines/2015/guidelines/. Accessed June 15, 2018.

      , 

      Grains and Legumes Nutrition Council. Whole Grain Daily Target Intake Statement. http://www.glnc.org.au/codeofpractice/whole-grain-daily-target-intake-statement/. Accessed June 15, 2018.

      These recommendations are not new; initiatives to improve WG intake exist

      Oldways Whole Grains Council. Whole Grains Council kicks off 6th annual Whole Grains Challenge. https://oldwayspt.org/news-media/press-releases/whole-grains-council-kicks-6th-annual-whole-grains-challenge. Accessed September 12, 2017.

      , 

      Oldways Whole Grains Council. Whole Grain Sampling Day. https://wholegrainscouncil.org/get-involved/whole-grain-sampling-day. Accessed September 12, 2017.

      , 

      Oldways Whole Grains Council. 2018 Whole Grains Council Conference. https://oldwayspt.org/events/2018-whole-grains-council-conference. Accessed September 12, 2017.

      , 

      PhilRice. Brown rice made affordable. http://www.philrice.gov.ph/brown-rice-made-affordable/. Accessed June 15, 2018.

      , 

      Agricultural Credit Policy Council. #BROWN4good. http://www.acpc.gov.ph/1479-2/. Accessed June 15, 2018.

      , 

      PhilRice. Be Riceponsible.http://www.philrice.gov.ph/campaign/be-riceponsible/. Accessed June 15, 2018.

      , 

      Health Hub. Healthy Hawker Food Programme. https://www.healthhub.sg/live-healthy/24/healthyhawkerfood. Accessed September 9, 2017.

      yet it remains low. Evidence-based health promotion initiatives are needed.
      This systematic literature review aimed to determine key characteristics of public health interventions that increased WG consumption at a national level, to inform government agencies and other groups that promote WG intake.

      Methods

      This review used the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines
      • Moher D
      • Liberati A
      • Tetzlaff J
      • et al.
      Preferred reporting items for systematic reviews and meta-analyses: thePRISMA statement.
      PLoS Med. 2009; 6
      and was registered with PROSPERO (Registration No. CRD42017056563). Researchers included a student researcher (RS), an expert working with a nonprofit organization promoting grains (MB), and an academic researcher with significant experience in grains research and systematic reviews (EB). Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Science Direct, Scopus, PubMed, and Web of Science databases were searched using the terms (grain OR “whole grain” OR wholegrain OR whole-grain) AND (“public health” OR epidem* OR population OR community OR cohort OR “health promotion”) AND (increas* OR rais* OR escalat* OR improv* OR promot* OR chang*) AND (eat* OR diet* OR consum* OR intake OR input) in February, 2017. In addition, gray or unpublished literature meeting the search criteria was sourced as referenced. Although original PROSPERO registration included a review of purchase intent, the lack of quantifiable measures of intent meant that this aspect was not included.

      Eligibility Criteria

      The characteristics of population (humans) intervention (public health initiatives aimed at increasing WG intake), comparator (no intervention), outcome (change in WG consumption), and study design (not specified) formed the basis for the research question What are the key characteristics of public health initiatives aimed at increasing WG intake? Inclusion criteria were (1) reported in English, (2) humans, (3) grain related, and (4) published in peer-reviewed journals or independent gray literature. Studies were excluded if (1) participants were provided with food (such as randomized control trials) with no subsequent assessment for elective WG intake; (2) the intervention was aimed at reducing another macronutrient (eg, fat), inadvertently resulting in increased WG consumption; (3) WG as 1 of many foods or nutrients included in the intervention was not quantified in the outcome; (4) the study tested the acceptability of WG reformulated foods (5) or only assessed an increase in knowledge of WG after the intervention; (6) they were not scalable to a public health level; and (7) WG consumption was not recorded at both baseline and after the intervention.

      Study Selection, Data Collection, and Synthesis

      The identified studies were screened (based on the title for the first screening and the abstract for the second screening) by the primary author (RS) and checked for eligibility (full article) by 2 independent reviewers (RS and EB) as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses process.
      • Moher D
      • Liberati A
      • Tetzlaff J
      • et al.
      Preferred reporting items for systematic reviews and meta-analyses: thePRISMA statement.
      PLoS Med. 2009; 6
      Eligible studies were reviewed in full and characteristics were extracted into a predesigned table. All authors reviewed the summary and synthesis of results. The quality of the studies was assessed using the Critical Appraisal Skills Program: Cohort Studies checklist.

      Critical Appraisal Skills Programme. CASP Cohort Study Checklist 31.05.13http://docs.wixstatic.com/ugd/dded87_5ad0ece77a3f4fc9bcd3665a7d1fa91f.pdf. Accessed June 15, 2018.

      Data were qualitatively synthesized on a narrative basis at a group level. Higher-quality studies guided the discussion and were used to develop recommendations for future interventions. When possible, effect size was reported.

      Results

      Study Selection

      Initial electronic database searches retrieved 8,496 records (Figure). Gray literature searches retrieved a further 20 interventions. After screening, 8 interventions were included in the final synthesis (Table 1). All interventions were published in peer-reviewed journals,
      • Arts J
      • English C
      • Greene GW
      • Lofgren IE
      A nutrition intervention to increase whole grain intake in College students.
      Topics Clin Nutr. 2016; 31: 222-231
      , 
      • Brownlee IA
      • Kuznesof SA
      • Moore C
      • Jebb SA
      • Seal CJ
      The impact of a 16-week dietary intervention with prescribed amounts of whole-grain foods on subsequent, elective whole grain consumption.
      Br J Nutr. 2013; 110: 943-948
      , 
      • Burgess-Champoux TL
      • Chan HW
      • Rosen R
      • Marquart L
      • Reicks M
      Healthy whole-grain choices for children and parents: a multi-component school-based pilot intervention.
      Public Health Nutr. 2008; 11: 849-859
      , 
      • Egger G
      • Wolfenden K
      • Pares J
      • Mowbray G
      Bread: it's a great way to go: increasing bread consumption decreases laxative sales in an elderly community.
      Med J Australia. 1991; 155: 820-821
      , 
      • Ha EJ
      • Caine-Bish N
      Interactive introductory nutrition course focusing on disease prevention increased whole-grain consumption by college students.
      J Nutr Educ Behav. 2011; 43: 263-267
      , 
      • Mancino L
      • Kuchler F
      • Leibtag E
      Getting consumers to eat more whole-grains: the role of policy, information, and food manufacturers.
      Food Policy. 2008; 33: 489-496
      , 
      • Van Kleef E
      • Vrijhof M
      • Polet IA
      • Vingerhoeds MH
      • De Wijk RA
      Nudging children towards whole wheat bread: a field experiment on the influence of fun bread roll shape on breakfast consumption.
      BMC Public Health. 2014; 14
      except for a Danish intervention.

      Greve C, Nees RI. The evolution of the whole grain partnership in Denmark.http://www.fuldkorn.dk/media/179349/the-evolution-of-the-whole-grain-partnership-in-denmark.pdf. Accessed September 19, 2017.

      , 

      Mejborn H, Ygil KH, Fagt S, Trolle E, Christensen T. Wholegrain intake of Danes 2011–2012. http://www.food.dtu.dk/∼/media/Institutter/Foedevareinstituttet/Publikationer/Pub-2013/Rapport_Fuldkornsindtag_11-12_UK.ashx. Accessed September 19, 2017.

      Fig 1
      FigurePreferred Reporting Items for Systematic Reviews and Meta-analyses flow diagram detailing the review filtering process. CINAHL indicates Cumulative Index to Nursing and Allied Health Literature; WG, whole grain.
      Table 1Characteristics of Eligible Research Studies Aimed at Increasing Whole Grain Intake (n = 8)
      ReferenceTitleParticipantsCountrynTypeIntervention DetailsOutcomes
      Arts et al
      • Arts J
      • English C
      • Greene GW
      • Lofgren IE
      A nutrition intervention to increase whole grain intake in College students.
      Topics Clin Nutr. 2016; 31: 222-231
      		A nutrition intervention to increase WG intake in college studentsUS98College students (aged 18–24 y, BMI >18.5 kg/m2)Increased awareness: point of selection signage and text messaging. 6-wk intervention, 6-mo follow-upWG intake increased from baseline to follow-up (23 ± 31 to 31 ± 43g; P = .008) (40%)
      Brownlee et al
      • Brownlee IA
      • Kuznesof SA
      • Moore C
      • Jebb SA
      • Seal CJ
      The impact of a 16-week dietary intervention with prescribed amounts of whole-grain foods on subsequent, elective whole grain consumption.
      Br J Nutr. 2013; 110: 943-948
      		The impact of a 16-wk dietary intervention with prescribed amounts of WG foods on subsequent, elective WG consumptionUK266Aged >18 y, BMI >25 kg/m2Prescribed WG 16-wk intervention (group 1: 60 g/d for 16 wk; group 2: 60 g/d for 8 wks followed by 120 g/d for 8 wk) on subsequent, elective WG consumption (1, 6, and 12 mo after intervention)Control: 16–19 g WG intake (baseline, 1, 6, and 12 mo); intervention: WG intake at 47.1, 44.2, and 36.3 g/d (1, 6, and 12 mo). WG consumption significantly higher (approximately double) (P < .001) after intervention
      Burgess-Champoux et al
      • Burgess-Champoux TL
      • Chan HW
      • Rosen R
      • Marquart L
      • Reicks M
      Healthy whole-grain choices for children and parents: a multi-component school-based pilot intervention.
      Public Health Nutr. 2008; 11: 849-859
      		Healthy WG choices for children and parents: a multicomponent, school-based pilot interventionUS150Parent–child pairs (child aged 10 y)Power of 3: Get Healthy with Whole Grain Foods:

      5-lesson classroom curriculum (identify WG foods, enhance selection, tasting and preparation, menu-planning skills, goal-setting, and advocacy for peers and family members

      School cafeteria menu modifications to increase availability of WG foods (menu planning, product procurement, training, and quality control)

      Family-oriented activities (newsletters and bakery and grocery store tours) to increase availability in home environment      		WG consumption increased by 1 serving (P < .001), more WG foods were available in the cafeteria (P < .001), the ability to identify WG foods increased (P = .06), parenting role modeling increased (P < .001), and enabling behaviors (P < .05) were significantly greater
      Egger et al
      • Egger G
      • Wolfenden K
      • Pares J
      • Mowbray G
      Bread: it's a great way to go: increasing bread consumption decreases laxative sales in an elderly community.
      Med J Australia. 1991; 155: 820-821
      		Bread: it's a great way to go: increasing bread consumption decreases laxative sales in an elderly communityAustraliaRetirement community, aged >55 yCommunity organization strategy: media, community events, bread pricing, social marketing campaign

      Patient education strategy: pamphlet distributed to all patients aged >55 y attending general practitioner medical practice      		58% increase in whole-meal/WG bread sales (χ2 = 67; P < .010).
      Ha, and Caine-Bish
      • Ha EJ
      • Caine-Bish N
      Interactive introductory nutrition course focusing on disease prevention increased whole-grain consumption by college students.
      J Nutr Educ Behav. 2011; 43: 263-267
      		Interactive introductory nutrition course focusing on disease prevention increased WG consumption by college studentsUS80Healthy college students (aged 18–24 y)Interactive introductory nutrition course focusing on disease prevention

      Three 50-min/wk sessions for spring session

      Lectures, interactive feedback, hands-on activities. Approximately 4 h spent on WGs      		WG intake increased from 10 to 33 g (P < .001) whereas total grain intake remained the same (87 g)
      Mancino et al
      • Mancino L
      • Kuchler F
      • Leibtag E
      Getting consumers to eat more whole-grains: the role of policy, information, and food manufacturers.
      Food Policy. 2008; 33: 489-496
      		Getting consumers to eat more WG: the role of policy, information, and food manufacturersUSUS populationQuantification of WG consumption in 2005 Dietary Guidelines for Americans, media attention, increased availability, and reformulation of existing products to include more WG23% increase in sales of WG breads and baked goods and 27% increase in sales of WG pasta
      Mejborn et al

      Mejborn H, Ygil KH, Fagt S, Trolle E, Christensen T. Wholegrain intake of Danes 2011–2012. http://www.food.dtu.dk/∼/media/Institutter/Foedevareinstituttet/Publikationer/Pub-2013/Rapport_Fuldkornsindtag_11-12_UK.ashx. Accessed September 19, 2017.

      and Greve and Nees

      Greve C, Nees RI. The evolution of the whole grain partnership in Denmark.http://www.fuldkorn.dk/media/179349/the-evolution-of-the-whole-grain-partnership-in-denmark.pdf. Accessed September 19, 2017.

      		WG intake of Danes 2011–2012 and the Evolution of the Whole Grain PartnershipDenmarkDanish populationWG PPP between regulatory authorities (legitimacy, specified target intakes of WG in dietary guidelines, codes of practice for product labeling, educational materials), national nongovernmental organizations (legitimacy, research, evidence, awareness, public relations, and communication activities) and industry (increased availability of new/reformulated products with higher WG, clear, consistent product labeling, marketing, and communications).WG consumption increased from 36 to 63 g/d/10 MJ (75%)
      Van Kleef et al
      • Van Kleef E
      • Vrijhof M
      • Polet IA
      • Vingerhoeds MH
      • De Wijk RA
      Nudging children towards whole wheat bread: a field experiment on the influence of fun bread roll shape on breakfast consumption.
      BMC Public Health. 2014; 14
      		Nudging children toward whole wheat bread: a field experiment on the influence of fun bread roll shape on breakfast consumptionThe Netherlands1,113Schoolchildren (aged 9–13 y)National School breakfast event in which schoolchildren were free to choose type (white/whole wheat) and number or bread rolls in regular/fun shapes, respectivelyPresenting fun-shaped whole-wheat bread rolls alongside regular-shaped white bread rolls almost doubled consumption of whole-wheat bread (P = .001)
      BMI indicates body mass index; WG, whole grain.
      Note: Bolded references in the first column show intervention outcome measured in increased sales (which does not necessarily correlate with increased consumption).

      Study Characteristics

      Interventions dated from 1991
      • Egger G
      • Wolfenden K
      • Pares J
      • Mowbray G
      Bread: it's a great way to go: increasing bread consumption decreases laxative sales in an elderly community.
      Med J Australia. 1991; 155: 820-821
      to 2016
      • Egger G
      • Wolfenden K
      • Pares J
      • Mowbray G
      Bread: it's a great way to go: increasing bread consumption decreases laxative sales in an elderly community.
      Med J Australia. 1991; 155: 820-821
      and were conducted in Australia,
      • Egger G
      • Wolfenden K
      • Pares J
      • Mowbray G
      Bread: it's a great way to go: increasing bread consumption decreases laxative sales in an elderly community.
      Med J Australia. 1991; 155: 820-821
      the US,
      • Arts J
      • English C
      • Greene GW
      • Lofgren IE
      A nutrition intervention to increase whole grain intake in College students.
      Topics Clin Nutr. 2016; 31: 222-231
      , 
      • Burgess-Champoux TL
      • Chan HW
      • Rosen R
      • Marquart L
      • Reicks M
      Healthy whole-grain choices for children and parents: a multi-component school-based pilot intervention.
      Public Health Nutr. 2008; 11: 849-859
      ,
      • Ha EJ
      • Caine-Bish N
      Interactive introductory nutrition course focusing on disease prevention increased whole-grain consumption by college students.
      J Nutr Educ Behav. 2011; 43: 263-267
      , 
      • Mancino L
      • Kuchler F
      • Leibtag E
      Getting consumers to eat more whole-grains: the role of policy, information, and food manufacturers.
      Food Policy. 2008; 33: 489-496
      the UK,
      • Brownlee IA
      • Kuznesof SA
      • Moore C
      • Jebb SA
      • Seal CJ
      The impact of a 16-week dietary intervention with prescribed amounts of whole-grain foods on subsequent, elective whole grain consumption.
      Br J Nutr. 2013; 110: 943-948
      The Netherlands,
      • Van Kleef E
      • Vrijhof M
      • Polet IA
      • Vingerhoeds MH
      • De Wijk RA
      Nudging children towards whole wheat bread: a field experiment on the influence of fun bread roll shape on breakfast consumption.
      BMC Public Health. 2014; 14
      and Denmark.

      Greve C, Nees RI. The evolution of the whole grain partnership in Denmark.http://www.fuldkorn.dk/media/179349/the-evolution-of-the-whole-grain-partnership-in-denmark.pdf. Accessed September 19, 2017.

      , 

      Mejborn H, Ygil KH, Fagt S, Trolle E, Christensen T. Wholegrain intake of Danes 2011–2012. http://www.food.dtu.dk/∼/media/Institutter/Foedevareinstituttet/Publikationer/Pub-2013/Rapport_Fuldkornsindtag_11-12_UK.ashx. Accessed September 19, 2017.

      The number of participants varied between 80
      • Mancino L
      • Kuchler F
      • Leibtag E
      Getting consumers to eat more whole-grains: the role of policy, information, and food manufacturers.
      Food Policy. 2008; 33: 489-496
      and national populations (the US
      • Mancino L
      • Kuchler F
      • Leibtag E
      Getting consumers to eat more whole-grains: the role of policy, information, and food manufacturers.
      Food Policy. 2008; 33: 489-496
      and Denmark

      Greve C, Nees RI. The evolution of the whole grain partnership in Denmark.http://www.fuldkorn.dk/media/179349/the-evolution-of-the-whole-grain-partnership-in-denmark.pdf. Accessed September 19, 2017.

      , 

      Mejborn H, Ygil KH, Fagt S, Trolle E, Christensen T. Wholegrain intake of Danes 2011–2012. http://www.food.dtu.dk/∼/media/Institutter/Foedevareinstituttet/Publikationer/Pub-2013/Rapport_Fuldkornsindtag_11-12_UK.ashx. Accessed September 19, 2017.

      ). When settings were specified, they included primary schools,
      • Burgess-Champoux TL
      • Chan HW
      • Rosen R
      • Marquart L
      • Reicks M
      Healthy whole-grain choices for children and parents: a multi-component school-based pilot intervention.
      Public Health Nutr. 2008; 11: 849-859
      , 
      • Van Kleef E
      • Vrijhof M
      • Polet IA
      • Vingerhoeds MH
      • De Wijk RA
      Nudging children towards whole wheat bread: a field experiment on the influence of fun bread roll shape on breakfast consumption.
      BMC Public Health. 2014; 14
      colleges
      • Arts J
      • English C
      • Greene GW
      • Lofgren IE
      A nutrition intervention to increase whole grain intake in College students.
      Topics Clin Nutr. 2016; 31: 222-231
      , 
      • Ha EJ
      • Caine-Bish N
      Interactive introductory nutrition course focusing on disease prevention increased whole-grain consumption by college students.
      J Nutr Educ Behav. 2011; 43: 263-267
      and a retirement community.
      • Egger G
      • Wolfenden K
      • Pares J
      • Mowbray G
      Bread: it's a great way to go: increasing bread consumption decreases laxative sales in an elderly community.
      Med J Australia. 1991; 155: 820-821
      One intervention was conducted with overweight adults who consumed <1 serving/d of WG (20 g in that study).
      • Brownlee IA
      • Kuznesof SA
      • Moore C
      • Jebb SA
      • Seal CJ
      The impact of a 16-week dietary intervention with prescribed amounts of whole-grain foods on subsequent, elective whole grain consumption.
      Br J Nutr. 2013; 110: 943-948
      Some interventions focused on education, using point of selection signage and text messaging,
      • Arts J
      • English C
      • Greene GW
      • Lofgren IE
      A nutrition intervention to increase whole grain intake in College students.
      Topics Clin Nutr. 2016; 31: 222-231
      extension of the knowledge base on WG (through lessons and hands-on activities); influenced the surrounding environment, and created supporting networks.
      • Burgess-Champoux TL
      • Chan HW
      • Rosen R
      • Marquart L
      • Reicks M
      Healthy whole-grain choices for children and parents: a multi-component school-based pilot intervention.
      Public Health Nutr. 2008; 11: 849-859
      , 
      • Ha EJ
      • Caine-Bish N
      Interactive introductory nutrition course focusing on disease prevention increased whole-grain consumption by college students.
      J Nutr Educ Behav. 2011; 43: 263-267
      Other interventions prescribed WG foods for a time to familiarize consumers with WG-containing foods,
      • Brownlee IA
      • Kuznesof SA
      • Moore C
      • Jebb SA
      • Seal CJ
      The impact of a 16-week dietary intervention with prescribed amounts of whole-grain foods on subsequent, elective whole grain consumption.
      Br J Nutr. 2013; 110: 943-948
      made consuming WG foods fun,
      • Van Kleef E
      • Vrijhof M
      • Polet IA
      • Vingerhoeds MH
      • De Wijk RA
      Nudging children towards whole wheat bread: a field experiment on the influence of fun bread roll shape on breakfast consumption.
      BMC Public Health. 2014; 14
      or promoted other beneficial effects.
      • Egger G
      • Wolfenden K
      • Pares J
      • Mowbray G
      Bread: it's a great way to go: increasing bread consumption decreases laxative sales in an elderly community.
      Med J Australia. 1991; 155: 820-821
      Interventions influencing increased WG consumption on a national scale were multifactorial, incorporating multiple stakeholders and multiple strategies.

      Greve C, Nees RI. The evolution of the whole grain partnership in Denmark.http://www.fuldkorn.dk/media/179349/the-evolution-of-the-whole-grain-partnership-in-denmark.pdf. Accessed September 19, 2017.

      , 

      Mejborn H, Ygil KH, Fagt S, Trolle E, Christensen T. Wholegrain intake of Danes 2011–2012. http://www.food.dtu.dk/∼/media/Institutter/Foedevareinstituttet/Publikationer/Pub-2013/Rapport_Fuldkornsindtag_11-12_UK.ashx. Accessed September 19, 2017.

      Policy reformulation and increased product availability that influenced WG availability
      • Mancino L
      • Kuchler F
      • Leibtag E
      Getting consumers to eat more whole-grains: the role of policy, information, and food manufacturers.
      Food Policy. 2008; 33: 489-496
      ,

      Greve C, Nees RI. The evolution of the whole grain partnership in Denmark.http://www.fuldkorn.dk/media/179349/the-evolution-of-the-whole-grain-partnership-in-denmark.pdf. Accessed September 19, 2017.

      , 

      Mejborn H, Ygil KH, Fagt S, Trolle E, Christensen T. Wholegrain intake of Danes 2011–2012. http://www.food.dtu.dk/∼/media/Institutter/Foedevareinstituttet/Publikationer/Pub-2013/Rapport_Fuldkornsindtag_11-12_UK.ashx. Accessed September 19, 2017.

      , 

      Grains and Legumes Nutrition Council. GLNC Code of Practice. https://www.glnc.org.au/codeofpractice/about-the-code/. Accessed September 19, 2017.

      were part of the solution, but many other factors such as regulated specific target intakes in national dietary guidelines, codes of practice for manufacturers, and clear and consistent public relations and communication activities were employed in the Danish Wholegrain Public Private Partnership (Danish PPP).

      Greve C, Nees RI. The evolution of the whole grain partnership in Denmark.http://www.fuldkorn.dk/media/179349/the-evolution-of-the-whole-grain-partnership-in-denmark.pdf. Accessed September 19, 2017.

      , 

      Mejborn H, Ygil KH, Fagt S, Trolle E, Christensen T. Wholegrain intake of Danes 2011–2012. http://www.food.dtu.dk/∼/media/Institutter/Foedevareinstituttet/Publikationer/Pub-2013/Rapport_Fuldkornsindtag_11-12_UK.ashx. Accessed September 19, 2017.

      Whole Grain Intake Outcomes

      Two study outcomes were presented as increased sales in bread and WG products
      • Egger G
      • Wolfenden K
      • Pares J
      • Mowbray G
      Bread: it's a great way to go: increasing bread consumption decreases laxative sales in an elderly community.
      Med J Australia. 1991; 155: 820-821
      , 
      • Mancino L
      • Kuchler F
      • Leibtag E
      Getting consumers to eat more whole-grains: the role of policy, information, and food manufacturers.
      Food Policy. 2008; 33: 489-496
      and another as increased consumption of bread rolls.
      • Van Kleef E
      • Vrijhof M
      • Polet IA
      • Vingerhoeds MH
      • De Wijk RA
      Nudging children towards whole wheat bread: a field experiment on the influence of fun bread roll shape on breakfast consumption.
      BMC Public Health. 2014; 14
      Five interventions demonstrated an increase in WG intake (grams per day). The college awareness intervention resulted in an 8-g/d (0.5-serving) increase from baseline to 31 g/d at 6 months’ follow-up (after a 6-week intervention).
      • Arts J
      • English C
      • Greene GW
      • Lofgren IE
      A nutrition intervention to increase whole grain intake in College students.
      Topics Clin Nutr. 2016; 31: 222-231
      The 16-week prescribed WG
      • Brownlee IA
      • Kuznesof SA
      • Moore C
      • Jebb SA
      • Seal CJ
      The impact of a 16-week dietary intervention with prescribed amounts of whole-grain foods on subsequent, elective whole grain consumption.
      Br J Nutr. 2013; 110: 943-948
      and Power of 3 school intervention
      • Burgess-Champoux TL
      • Chan HW
      • Rosen R
      • Marquart L
      • Reicks M
      Healthy whole-grain choices for children and parents: a multi-component school-based pilot intervention.
      Public Health Nutr. 2008; 11: 849-859
      both resulted in an increased intake of approximately 16–36 g/d (1 serving) at 12 months’ follow-up. Meanwhile, the college nutrition course
      • Ha EJ
      • Caine-Bish N
      Interactive introductory nutrition course focusing on disease prevention increased whole-grain consumption by college students.
      J Nutr Educ Behav. 2011; 43: 263-267
      increased consumption by 23–33 g/d (about 1.5 servings) and the Danish PPP

      Greve C, Nees RI. The evolution of the whole grain partnership in Denmark.http://www.fuldkorn.dk/media/179349/the-evolution-of-the-whole-grain-partnership-in-denmark.pdf. Accessed September 19, 2017.

      , 

      Mejborn H, Ygil KH, Fagt S, Trolle E, Christensen T. Wholegrain intake of Danes 2011–2012. http://www.food.dtu.dk/∼/media/Institutter/Foedevareinstituttet/Publikationer/Pub-2013/Rapport_Fuldkornsindtag_11-12_UK.ashx. Accessed September 19, 2017.

      resulted in a national average increase in consumption from 36 g/10 MJ/d in 2000–2004 to 63 g/10 MJ/din2014.

      Quality Assessment

      Based on an assessment using the Critical Appraisal Skills Program quality rating tool

      Critical Appraisal Skills Programme. CASP Cohort Study Checklist 31.05.13http://docs.wixstatic.com/ugd/dded87_5ad0ece77a3f4fc9bcd3665a7d1fa91f.pdf. Accessed June 15, 2018.

      (Table 2), the intervention by Burgess-Champoux et al
      • Burgess-Champoux TL
      • Chan HW
      • Rosen R
      • Marquart L
      • Reicks M
      Healthy whole-grain choices for children and parents: a multi-component school-based pilot intervention.
      Public Health Nutr. 2008; 11: 849-859
      was the most robust, meeting all rating criteria including accounting for confounding factors. Three further studies met other cohort rating criteria: a college-based intervention increasing awareness,
      • Arts J
      • English C
      • Greene GW
      • Lofgren IE
      A nutrition intervention to increase whole grain intake in College students.
      Topics Clin Nutr. 2016; 31: 222-231
      a prescription of WG via a 16-week intervention,
      • Brownlee IA
      • Kuznesof SA
      • Moore C
      • Jebb SA
      • Seal CJ
      The impact of a 16-week dietary intervention with prescribed amounts of whole-grain foods on subsequent, elective whole grain consumption.
      Br J Nutr. 2013; 110: 943-948
      and the Danish PPP.

      Greve C, Nees RI. The evolution of the whole grain partnership in Denmark.http://www.fuldkorn.dk/media/179349/the-evolution-of-the-whole-grain-partnership-in-denmark.pdf. Accessed September 19, 2017.

      , 

      Mejborn H, Ygil KH, Fagt S, Trolle E, Christensen T. Wholegrain intake of Danes 2011–2012. http://www.food.dtu.dk/∼/media/Institutter/Foedevareinstituttet/Publikationer/Pub-2013/Rapport_Fuldkornsindtag_11-12_UK.ashx. Accessed September 19, 2017.

      Table 2Critical Appraisal Skills Program Cohort Study Checklist
      Broad IssueAppraisal QuestionArts et al
      • Arts J
      • English C
      • Greene GW
      • Lofgren IE
      A nutrition intervention to increase whole grain intake in College students.
      Topics Clin Nutr. 2016; 31: 222-231
      		Brownlee et al
      • Brownlee IA
      • Kuznesof SA
      • Moore C
      • Jebb SA
      • Seal CJ
      The impact of a 16-week dietary intervention with prescribed amounts of whole-grain foods on subsequent, elective whole grain consumption.
      Br J Nutr. 2013; 110: 943-948
      		Burgess-Champoux et al
      • Burgess-Champoux TL
      • Chan HW
      • Rosen R
      • Marquart L
      • Reicks M
      Healthy whole-grain choices for children and parents: a multi-component school-based pilot intervention.
      Public Health Nutr. 2008; 11: 849-859
      		Egger et al
      • Egger G
      • Wolfenden K
      • Pares J
      • Mowbray G
      Bread: it's a great way to go: increasing bread consumption decreases laxative sales in an elderly community.
      Med J Australia. 1991; 155: 820-821
      		Ha, and Caine-Bish
      • Ha EJ
      • Caine-Bish N
      Interactive introductory nutrition course focusing on disease prevention increased whole-grain consumption by college students.
      J Nutr Educ Behav. 2011; 43: 263-267
      		Mancino et al
      • Mancino L
      • Kuchler F
      • Leibtag E
      Getting consumers to eat more whole-grains: the role of policy, information, and food manufacturers.
      Food Policy. 2008; 33: 489-496
      		Mejborn et al

      Mejborn H, Ygil KH, Fagt S, Trolle E, Christensen T. Wholegrain intake of Danes 2011–2012. http://www.food.dtu.dk/∼/media/Institutter/Foedevareinstituttet/Publikationer/Pub-2013/Rapport_Fuldkornsindtag_11-12_UK.ashx. Accessed September 19, 2017.

      and Greve and Nees

      Greve C, Nees RI. The evolution of the whole grain partnership in Denmark.http://www.fuldkorn.dk/media/179349/the-evolution-of-the-whole-grain-partnership-in-denmark.pdf. Accessed September 19, 2017.

      		Van Kleef et al
      • Van Kleef E
      • Vrijhof M
      • Polet IA
      • Vingerhoeds MH
      • De Wijk RA
      Nudging children towards whole wheat bread: a field experiment on the influence of fun bread roll shape on breakfast consumption.
      BMC Public Health. 2014; 14
      Are the results of the study valid?1. Did the study address a clearly focused issue?YesYesYesYesYesYesYesYes
      2. Was the cohort recruited in an acceptable way?YesYesYesYesNoYesYesYes
      3. Was the exposure accurately measured to minimize bias?YesYesYesYesCannot tellYesYesYes
      4. Was the outcome accurately measured to minimize bias?YesYesYesYesYesYesYesYes
      5. (a) Have the authors identified all important confounding factors?NoCannot tellYesCannot tellCannot tellNoCannot tellYes
      (b) Are confounding factors considered in the design/analysis?NoCannot tellYesNoNoNoCannot tellNo
      6. (a) Was the follow-up of subjects complete enough?YesYesYesCannot tellYesNoYesNo
      (b) Was the follow-up of subjects long enough?YesYesYesYesYesYesYesNo
      What are the results?7. What are the results of this study?40%
      indicates increase; WG, whole grains. Notes: Bolded values indicate interventions whose outcome is measured by an increase in sales (which does not necessarily correlate with an increase in consumption).
      WG (P = .008) (to 31 g/d)      		100%
      indicates increase; WG, whole grains. Notes: Bolded values indicate interventions whose outcome is measured by an increase in sales (which does not necessarily correlate with an increase in consumption).
      WG (P < .001) (to 36 g/d)      		100%
      indicates increase; WG, whole grains. Notes: Bolded values indicate interventions whose outcome is measured by an increase in sales (which does not necessarily correlate with an increase in consumption).
      WG (1 serving) (to 16 g/d) (P < .001)      		58%
      indicates increase; WG, whole grains. Notes: Bolded values indicate interventions whose outcome is measured by an increase in sales (which does not necessarily correlate with an increase in consumption).
      WG bread sales (P < .010)      		> 200%
      indicates increase; WG, whole grains. Notes: Bolded values indicate interventions whose outcome is measured by an increase in sales (which does not necessarily correlate with an increase in consumption).
      WG (P < .001) (to 33 g/d)      		23% and 27%
      indicates increase; WG, whole grains. Notes: Bolded values indicate interventions whose outcome is measured by an increase in sales (which does not necessarily correlate with an increase in consumption).
      WG bread and pasta sales      		> 75%
      indicates increase; WG, whole grains. Notes: Bolded values indicate interventions whose outcome is measured by an increase in sales (which does not necessarily correlate with an increase in consumption).
      WG (to 63 g/d/10 MJ      		100%
      indicates increase; WG, whole grains. Notes: Bolded values indicate interventions whose outcome is measured by an increase in sales (which does not necessarily correlate with an increase in consumption).
      whole-meal bread rolls
      8. How precise are the results?LowLowLowLowLowLowLowLow
      9. Do you believe the results?YesYesYesYesYesYesYesYes
      Will the results help locally?10. Can the results be applied to the local population?YesYesYesYesYesYesYesYes
      11. Do the results of this study fit with other available evidence?YesYesYesYesYesYesYesYes
      12. What are the implications of this study for practice?Education setting, age 18–24 yUnrealistic: food provisionEducation setting, school, good, detailed protocolElderly population, laxation as driverEducation setting, age 18–24 yPolicy important driver to
      indicates increase; WG, whole grains. Notes: Bolded values indicate interventions whose outcome is measured by an increase in sales (which does not necessarily correlate with an increase in consumption).
      WG supply      		Public private partnerships show successEducation setting, school
      ↑ indicates increase; WG, whole grains.Notes: Bolded values indicate interventions whose outcome is measured by an increase in sales (which does not necessarily correlate with an increase in consumption).

      Discussion

      Characteristics of successful interventions include multiple stakeholder involvement, specified target intakes in dietary guidelines, codes of practice for labeling WG foods, reformulation of foods to contain more WG, evidence-based educational resources, social media campaigns to increase awareness and extend the WG knowledge base, and community events that provide tasting and preparation opportunities. Empowerment of food service providers, both in the home and outside it, is also paramount.
      Successful interventions include multiple stakeholder involvement, specified target intakes in dietary guidelines, and codes of practice for labeling WG foods.
      Public health interventions aimed at increasing WG intake have been undertaken in a variety of settings and employed various strategies. Interventions in education settings (schools
      • Burgess-Champoux TL
      • Chan HW
      • Rosen R
      • Marquart L
      • Reicks M
      Healthy whole-grain choices for children and parents: a multi-component school-based pilot intervention.
      Public Health Nutr. 2008; 11: 849-859
      , 
      • Van Kleef E
      • Vrijhof M
      • Polet IA
      • Vingerhoeds MH
      • De Wijk RA
      Nudging children towards whole wheat bread: a field experiment on the influence of fun bread roll shape on breakfast consumption.
      BMC Public Health. 2014; 14
      and colleges
      • Arts J
      • English C
      • Greene GW
      • Lofgren IE
      A nutrition intervention to increase whole grain intake in College students.
      Topics Clin Nutr. 2016; 31: 222-231
      , 
      • Ha EJ
      • Caine-Bish N
      Interactive introductory nutrition course focusing on disease prevention increased whole-grain consumption by college students.
      J Nutr Educ Behav. 2011; 43: 263-267
      ) took advantage of a captive audience and recognized that lifelong eating habits may be instilled in young learners. Contrary to adult perceptions, children were accepting of WG foods,
      • Chu YL
      • Warren CA
      • Sceets CE
      • Murano P
      • Marquart L
      • Reicks M
      Acceptance of two US Department of Agriculture commodity whole-grain products: a school-based study in Texas and Minnesota.
      J Am Diet Assoc. 2011; 111: 1380-1384
      with equal
      • Tritt A
      • Reicks M
      • Marquart L
      Reformulation of pizza crust in restaurants may increase whole-grain intake among children.
      Public Health Nutr. 2015; 18: 1407-1411
      or greater
      • Van Kleef E
      • Vrijhof M
      • Polet IA
      • Vingerhoeds MH
      • De Wijk RA
      Nudging children towards whole wheat bread: a field experiment on the influence of fun bread roll shape on breakfast consumption.
      BMC Public Health. 2014; 14
      enjoyment of WG foods when they were made more appealing. The characteristics of successful interventions in education settings included curriculum modifications to extend the WG knowledge base, tasting and preparation opportunities, menu planning, and involvement of both peers and family members.
      • Burgess-Champoux TL
      • Chan HW
      • Rosen R
      • Marquart L
      • Reicks M
      Healthy whole-grain choices for children and parents: a multi-component school-based pilot intervention.
      Public Health Nutr. 2008; 11: 849-859
      Equally important characteristics of successful school interventions were education and capacity building of food service personnel and families who provided food.
      • Burgess-Champoux TL
      • Chan HW
      • Rosen R
      • Marquart L
      • Reicks M
      Healthy whole-grain choices for children and parents: a multi-component school-based pilot intervention.
      Public Health Nutr. 2008; 11: 849-859
      , 
      • Cohen JFW
      • Rimm EB
      • Bryn Austin S
      • Hyatt RR
      • Kraak VI
      • Economos CD
      A food service intervention improves whole grain access at lunch in rural elementary schools.
      J Sch Health. 2014; 84: 212-219
      ,
      • Roth-Yousey L
      • Barno T
      • Caskey M
      • Asche K
      • Reicks M
      Whole-grain continuing education for school foodservice personnel: keeping kids from falling short.
      J Nutr Educ Behav. 2009; 41: 429-435
      Finally public relations campaigns such as family activities and WG events that normalized WG consumption contributed to the success of these interventions.
      • Burgess-Champoux TL
      • Rosen R
      • Marquart L
      • Reicks M
      The development of psychosocial measures for whole-grain intake among children and their parents.
      J Am Diet Assoc. 2008; 108: 714-717
      In other settings, successful interventions provided WG foods to low-WG consumers, enabling familiarization with different WG foods.
      • Brownlee IA
      • Kuznesof SA
      • Moore C
      • Jebb SA
      • Seal CJ
      The impact of a 16-week dietary intervention with prescribed amounts of whole-grain foods on subsequent, elective whole grain consumption.
      Br J Nutr. 2013; 110: 943-948
      Although this approach increased long-term elective consumption,
      • Brownlee IA
      • Kuznesof SA
      • Moore C
      • Jebb SA
      • Seal CJ
      The impact of a 16-week dietary intervention with prescribed amounts of whole-grain foods on subsequent, elective whole grain consumption.
      Br J Nutr. 2013; 110: 943-948
      the cost and involvement of health professionals and/or food industry professionals (distribution of promotions and free samples) are unrealistic at a national level.
      Changes in policy and manufacturing codes of practice have led to increased WG foods entering the food supply.
      • Mancino L
      • Kuchler F
      • Leibtag E
      Getting consumers to eat more whole-grains: the role of policy, information, and food manufacturers.
      Food Policy. 2008; 33: 489-496
      , 

      Grains and Legumes Nutrition Council. Code of Practice Encourages Addition of 100 000 tonnes of Whole Grain to Australian Food Supply.http://www.glnc.org.au/wp-content/uploads/2011/10/GLNC-Media-Release_WGBD_INDUSTRY_2016-11-10.pdf. Accessed August 17, 2017.

      However, increased awareness and engagement of industry alone do not necessarily correlate with increased WG consumption. For example, in Australia, the proportion of the population who met target intakes appeared to have remained at 30% over the past 5 years
      • Galea LM
      • Beck EJ
      • Probst YC
      • Cashman CJ
      Whole grain intake of Australians estimated from a cross-sectional analysis of dietary intake data from the 2011–13 Australian Health Survey.
      Public Health Nutr. 2017; 20: 1-7
      , 
      • Suthers R
      • Broom M
      • Beck E
      Whole Grain Consumption in Australia Intake, Demographics, Barriers and Facilitators.
      University of Wollongong, Australia2017
      although nonprofit and industry partners promoted daily target intakes for the past decade,

      Grains and Legumes Nutrition Council. Whole Grain Daily Target Intake Statement. http://www.glnc.org.au/codeofpractice/whole-grain-daily-target-intake-statement/. Accessed June 15, 2018.

      and more recently (July, 2013), a voluntary Code of Practice for WG Ingredient Claims was provided to the food industry.

      Grains and Legumes Nutrition Council. GLNC Code of Practice. https://www.glnc.org.au/codeofpractice/about-the-code/. Accessed September 19, 2017.

      In the US, changes to dietary guidelines, media attention, a WG stamp, and reformulation of products resulted in greater availability of WG products.
      • Mancino L
      • Kuchler F
      • Leibtag E
      Getting consumers to eat more whole-grains: the role of policy, information, and food manufacturers.
      Food Policy. 2008; 33: 489-496
      A small but significant increase in WG intake was realized from 17 g/d in 2003–2004 to 26 g/d in 2013–2014.

      US Department of Agriculture. Food patterns equivalents intakes by Americans: what we eat in America, NHANES 2003–2004 and 2013–2014.https://www.ars.usda.gov/ARSUserFiles/80400530/pdf/DBrief/17_Food_Patterns_Equivalents_0304_1314.pdf. Accessed July 17, 2017.

      A combination of initiatives appears to be required for improvement.
      Based on this review, the most successful intervention to increase WG consumption was the Danish PPP, which increased national WG consumption from 36 g/d/10 MJ (2000–2004) to 63 g/d/10 MJ (2014):

      Greve C, Nees RI. The evolution of the whole grain partnership in Denmark.http://www.fuldkorn.dk/media/179349/the-evolution-of-the-whole-grain-partnership-in-denmark.pdf. Accessed September 19, 2017.

      , 

      Mejborn H, Ygil KH, Fagt S, Trolle E, Christensen T. Wholegrain intake of Danes 2011–2012. http://www.food.dtu.dk/∼/media/Institutter/Foedevareinstituttet/Publikationer/Pub-2013/Rapport_Fuldkornsindtag_11-12_UK.ashx. Accessed September 19, 2017.

      a 75% increase over a decade. The Danish PPP was a multifactorial, multiple-stakeholder intervention with multiple characteristics that proved to be successful. Specifically, this success included 3 types of stakeholders in the partnership:
      • 1.
        Regulatory authorities responsible for specifying target intakes of WG in dietary guidelines; and codes of practice for manufacturers to abide by with product labeling and educational materials;
      • 2.
        Nongovernmental organizations responsible for maintaining the evidence base supporting the health benefits of WG and raising awareness through public relations campaigns and communication activities;

        Greve C, Nees RI. The evolution of the whole grain partnership in Denmark.http://www.fuldkorn.dk/media/179349/the-evolution-of-the-whole-grain-partnership-in-denmark.pdf. Accessed September 19, 2017.

        and
      • 3.
        Industry responsible for the increased availability of new or reformulated products with higher WG content, clear and consistent product labeling, specified by regulatory authorities, and marketing and communications.
      The Danish PPP operated within the 5 key action areas of health promotion as specified in the Ottawa Charter

      World Health Organization. The Ottawa Charter for Health Promotion. http://www.who.int/healthpromotion/conferences/previous/ottawa/en/. Accessed June 15, 2018.

      but differed from other interventions in this review in that the goal of building healthy public policies was critical to the success of that public health intervention on a national scale. Not only did a specified target intake in dietary guidelines prove beneficial, a code of practice endorsed by the government rather than industry or nongovernment organizations alleviated consumer skepticism.
      • Williams P
      Consumer understanding and use of health claims for foods.
      Nutr Rev. 2005; 63: 256-264
      A final characteristic of successful interventions to increase WG intake was the use of social media and the Internet.
      • Arts J
      • English C
      • Greene GW
      • Lofgren IE
      A nutrition intervention to increase whole grain intake in College students.
      Topics Clin Nutr. 2016; 31: 222-231
      , 
      • Rees G
      • Bakhshi S
      • Surujlal-Harry A
      • Stasinopoulos M
      • Baker A
      A computerised tailored intervention for increasing intakes of fruit, vegetables, brown bread and wholegrain cereals in adolescent girls.
      Public Health Nutr. 2010; 13: 1271-1278
      Internet-based interventions were convenient and flexible and enabled the instantaneous and inexpensive distribution of nutrition education; many people already used it as a source of health information.
      • Brug J
      • Oenema A
      • Kroeze W
      • Raat H
      The internet and nutrition education: challenges and opportunities.
      Eur J Clin Nutr. 2005; 59: S130-S137
      Any WG intervention needs a coordinated and comprehensive integrated contribution from all sectors (academia, government, trade and industry, and advocacy groups), disciplines (from plant geneticists through growers, product developers, distributors, and food service personnel), and, importantly, consumers.
      • Hauge DA
      • Melroe S
      • Maschoff B
      • Hermann M
      • Marquart L
      Whole grains in schools: a supply chain approach.
      Nutrition Today. 2015; 50: 135-141
      , 
      • Jacques P
      • Hauge D
      • Voth K
      • Hermann M
      • Maschoff B
      • Marquart L
      Overcoming the challenges of translating the US Dietary Guidelines into healthier grain-based foods.
      Nutrition Today. 2013; 48: 254-259
      Together, these stakeholders can influence the food supply chain, resulting in successfully developing healthier products with taste, convenience, and culture characteristics that the consumer demands while product innovation and renovation costs are minimized and risks are shared.
      • Hauge DA
      • Melroe S
      • Maschoff B
      • Hermann M
      • Marquart L
      Whole grains in schools: a supply chain approach.
      Nutrition Today. 2015; 50: 135-141
      , 
      • Jacques P
      • Hauge D
      • Voth K
      • Hermann M
      • Maschoff B
      • Marquart L
      Overcoming the challenges of translating the US Dietary Guidelines into healthier grain-based foods.
      Nutrition Today. 2013; 48: 254-259
      Viewed from the perspective of food systems, a fully functional supply chain influences the food environment, which ultimately influences consumer behavior;

      High Level Panel of Experts 2017. Nutrition and food systems: a report by the High Level Panel of Experts on Food Security and Nutrition of the Committee on World Food Security, Rome.www.fao.org/fileadmin/user_upload/hlpe/hlpe_documents/HLPE_Reports/HLPE-Report-12_EN.pdf. Accessed April 16, 2018.

      hence, this approach needs to be adopted when considering public health interventions. However, a national food strategy would be required to provide a coordinated and comprehensive improvement in the food system to serve the health needs of the population better while making it economically viable, equitable, and resilient.

      Leib EB, Beyranevand LJ, Clippinger E, Ristino L, Moses A. Blueprint for a national food strategy. http://foodstrategyblueprint.org/wp-content/uploads/2017/03/Food-Strategy-Blueprint.pdf. Accessed April 23, 2018.

      This review yielded limited published information on successful public health interventions aimed at increasing WG consumption. Furthermore, there was a lack of consistent and standardized measurement of WG intake, both at baseline and after the intervention. Without a measurable outcome, some interventions were unable to be included in the synthesis, although many organizations around the globe worked hard to promote WG intake. For example, in the US, Oldways Whole Grains Council holds WG challenges,

      Oldways Whole Grains Council. Whole Grains Council kicks off 6th annual Whole Grains Challenge. https://oldwayspt.org/news-media/press-releases/whole-grains-council-kicks-6th-annual-whole-grains-challenge. Accessed September 12, 2017.

      sampling days,

      Oldways Whole Grains Council. Whole Grain Sampling Day. https://wholegrainscouncil.org/get-involved/whole-grain-sampling-day. Accessed September 12, 2017.

      and conferences

      Oldways Whole Grains Council. 2018 Whole Grains Council Conference. https://oldwayspt.org/events/2018-whole-grains-council-conference. Accessed September 12, 2017.

      to promote WG intake (C. Harriman and K. Toups, written communication, 2017), and in the Philippines, partnerships to make brown rice more affordable

      PhilRice. Brown rice made affordable. http://www.philrice.gov.ph/brown-rice-made-affordable/. Accessed June 15, 2018.

      and campaigns

      Agricultural Credit Policy Council. #BROWN4good. http://www.acpc.gov.ph/1479-2/. Accessed June 15, 2018.

      , 

      PhilRice. Be Riceponsible.http://www.philrice.gov.ph/campaign/be-riceponsible/. Accessed June 15, 2018.

      have been undertaken to promote WG intake actively. Singapore has also undertaken various initiatives such as the Healthier Hawker Centre Program.

      Health Hub. Healthy Hawker Food Programme. https://www.healthhub.sg/live-healthy/24/healthyhawkerfood. Accessed September 9, 2017.

      However, the effectiveness and reach of these interventions were unclear; hence, it was difficult to ascertain their level of success and draw on the relevant characteristics to achieve positive outcomes.

      Implications for Research and Practice

      Interventions aimed at increasing WG consumption may benefit from incorporating all components of the food system: the food supply chain, surrounding environment and consumers, with partnerships including public and private, or with multiple stakeholders forming the basis for the collaboration between stakeholders and targeting multiple points in the socioecological food provision system.
      Interventions aimed at increasing WG consumption should incorporate all components of the food system.
      To ensure interventions can be measurable, scaled, and available to multiple groups for use, evaluated interventions might be captured in a standardized manner in a searchable online database. This would include a consistent measurement of WG intake (grams per day or a consistent definition of WG foods and their intake) performed at baseline and after the intervention. Such information sharing would enable health professionals globally to plan local interventions across different cultural settings, by drawing on best practice adopted elsewhere. The dissemination and technology transfer module of the HEALTHGRAIN project
      • Poutanen K
      • Shepherd R
      • Shewry PR
      • Delcour JA
      • Björck I
      • Van Der Kamp JW
      Beyond whole grain: the European HEALTHGRAIN project aims at healthier cereal foods.
      Cereal Foods World. 2008; 53: 32-35
      may provide such a platform.
      Evaluated interventions should be captured in a standardized manner in a searchable online database. This would include consistent measurement of WG intake.

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      Article info

      Publication history

      Published online: August 01, 2018
      Accepted: May 16, 2018
      Received in revised form: May 13, 2018
      Received: February 19, 2018

      Footnotes

      ☆Conflict of Interest Disclosure: The authors have not stated any conflicts of interest.

      Identification

      DOI: https://doi.org/10.1016/j.jneb.2018.05.013

      Copyright

      © 2018 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.

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