A prospective analysis of dietary policies in Iran: Applying the NOURISHING Framework to Identify Challenges and Policy Gaps

A prospective analysis of dietary policies in Iran: Applying the NOURISHING Framework to Identify Challenges and Policy Gaps | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A prospective analysis of dietary policies in Iran: Applying the NOURISHING Framework to Identify Challenges and Policy Gaps Elham Shareghfarid, Ahmadreza Dorosty Motlagh, Amirhossein Takian, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7062418/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Non-communicable diseases (NCDs) remain a major global challenge, imposing significant costs on health systems worldwide. In low and middle-income countries, where challenges like malnutrition and infectious diseases are prevalent, NCDs remain a severe problem requiring attention. The present study aimed to evaluate dietary policies and compare them with best practices in European countries to analyze Iran’s progress in NCD-related nutritional challenges. Methods We conducted a case study to identify dietary policies in Iran. We searched the National databases with relevant keywords. After that, for a deep understanding of nutritional policies, we identified a total of 31 individuals from different sectors of the food system. Finally, 27 of them accepted our request. We systematically transcribed and analyzed these semi-structured interviews using a mix of inductive-deductive approach within the NOURISHING framework and the Health Policy Triangle. Framework analysis was conducted for content analysis. Results Findings of analyzing documents and interviews revealed that dietary interventions in Iran, compared to the NOURISHING framework, are classified in 3 main policy processes, which are: · 30% of interventions in Iran have not been formulated. · 15% were formulated but not implemented. · 55% have been implemented. Challenges in policy implementation were analyzed across three main dimensions: policy process , policy content , and policy context , as well as four sub-dimensions: dietary behavior , food environment , and food system . Actions requiring improvement include: · Food Environment (12%) : Measures like unhealthy food taxation, unhealthy food advertisements, food quality in retail outlets, and school canteen standards need revision. · Dietary Behavior (2%) : Nutrition education in schools and community education requires modifications. · Food System (1%) : Cross-sectoral collaboration within the food system in Iran is weak. Conclusion In this research, we found that Iran has made considerable efforts to mitigate NCDs. However, due to low attention to socio-economic factors in policy making, weaknesses in food system governance, environmental and educational dietary policies have not reached their expected efficiency. We recommend that food environment policies be developed in Iran. NOURISHING framework Dietary policies Case study Figures Figure 1 Figure 2 Introduction The food system (FS) is the single biggest driver of global challenges, including malnutrition in all its forms that causes non-communicable diseases (1). Iran faces a significant public health challenge with non-communicable diseases (NCDs) due to dietary risk factors. NCDs were responsible for 73% of deaths (280,000 individuals) in 2019 (2). The healthcare system's primary concerns are cardiovascular diseases, hypertension, diabetes, cancers, and mental health disorders. As a Middle Eastern nation with an aging population and shifting disease risk factors, Iran is currently confronting NCDs as a major health issue. Addressing preventable risk factors is vital to reduce this substantial burden, enhancing life expectancy and quality of life (3). The complex interplay of diet, lifestyle, and social determinants requires multi-sectoral strategies for effective prevention and management (4). FS can transform and influence consumption of affordable, healthy, sustainable diets for all (5). Transformation of such a dynamic, interconnected system requires holistic consideration for effective solutions through a diverse combination of hard and soft policies, including taxes, legislation, labelling, and education (6). The World Health Organization (WHO) has recommended Best Buy's actions to meet the WHO’s targets on diet-related NCD and Sustainable Development Goal Target 2.2 on ending all forms of malnutrition by 2030 (7, 8). To combat these challenges, Iran has been implementing various policies aimed at promoting healthier diets and lifestyles. These actions include public education campaigns, improving food labeling, and regulating the marketing of unhealthy foods, especially to children (9, 10). Addressing non-communicable diseases in Iran requires a comprehensive approach that involves multiple sectors, including healthcare, education, and agriculture. Collaboration between government agencies, NGOs, and international partners is essential to create policies and programs that effectively tackle the root causes of NCDs (11, 12). We aimed to identify and evaluate the national food and nutrition interventions implemented in Iran compared to the best policy actions in the NOURISHING framework. We explored the policies executed, their impacts, and the gaps that persist within the nation's healthcare system. While some interventions have been successfully implemented and have yielded positive outcomes, these policies require regular evaluation and revision within the policymaking cycle. Therefore, the evaluation of previous policy reforms is especially critical for Iran, as a lower-middle-income country. These reforms take precedence over unformulated policies that need to be incorporated into the decision-making process. Furthermore, we seek to address a question: why have some interventions been temporarily implemented but later discontinued or remained at the drafting stage without progressing to execution? The exploration of this issue sheds light on systemic challenges and highlights the importance of fostering robust and sustainable dietary policies to reduce the burden of NCDs in Iran. Methods We chose a single case study design for investigating a complex multi-variant phenomenon. The investigation proceeded in two stages. First, content analysis, and second, semi-structured interview. Document collection We searched official databases of the Ministry of Agriculture (www.maj.ir), the Ministry of Industry, Mine, and Trade (www.mimt.gov.ir), the Ministry of Health and Medical Education (www.behdasht.gov.ir), and the Research Center of the Islamic Consultative Assembly (www.rc.majlis.ir) to find relevant documents by keywords. Then we included relevant documents based on the inclusion criteria. To ensure that all relevant documents were extracted, we searched databases manually (ES). Relevant keywords are nutrition, food, food labelling, food standards, tax, subside, advertisement, reformulation, rule, education, skill, information, food chain, food choice, food preference, food environment, financial incentive, access, price, income, fruit, vegetable, red meat, legumes, fish, dairy products, oil, fat, grain, nuts, sugar, salt, trans fatty acid, policy, strategy. Inclusion criteria The documents needed to be related to Iran and in Farsi. They had to include general policies or keywords relevant to our research goals. Full access to the documents was necessary. Authenticated documents came from verified sources like the Parliament, government, and the Supreme Council of Health and Food Security (13). Valid documents weren't misleading, biased, or conflicted by personal or organizational interests. Exclusion criteria If the text was published by non-governmental organizations, food industry groups, or campaigns. If documents include speeches, announcements, or summaries. If the content of the documents does not cover any policy interventions or actions. We designed a document checklist to extract the mentioned elements. This checklist contained the title, date, and location of publication, along with items related to the NOURISHING and health policy triangle. Document analysis We analyzed the contents by an inductive approach to identify policies influencing dietary patterns, analysis. We conducted the mixed-method (inductive/deductive) comparative analysis (14). Then we developed the themes based on the NOURISHING policy action framework (ES & AT). This framework provides a structured and coherent pathway for policy actions aimed at reducing non-communicable diseases. It is a comprehensive package from the World Health Organization's global action plan (15), offering policymakers the flexibility to shape appropriate and contextually relevant responses tailored to national, local, and regional settings and targeted populations. Finally, we classified the identified policies into three groups: policies not mentioned in Iranian policy documents, policies mentioned in Iranian policy documents but not implemented (policies formulated), and policies that are currently being implemented in Iran with an operational plan in place (16). Data collection We conducted a semi-structured interview to gain deeper insights into the research topic. The interview guidance included open-ended questions designed by researchers specialized in community nutrition (ADM) and health policy (AT) and developed (Appendix). Before the start of the interviews, we piloted the designed questions (ES). Subsequently, we invited participants and asked them to answer the questions in about an hour for deep reflection after a short explanation of research goals and methods. We designed the questions to encourage descriptive responses and foster the generation of ideas. Data analysis Interviews were analyzed by Framework analysis. The analysis process involved: a) text Familiarization and organization, b) themes Identification: grouping codes into broader categories or creating themes, c) reviewing and analyzing the themes to identify structures (17). We identified and developed the themes using the health policy triangle (18). For organizing and coding data, MAXQDA software version 12 facilitated the progress. We ensured the validity of the study using the triangulation method. Two researchers with different perspectives reviewed the study, multiple sources were used for data collection, and participants were asked to review the final themes and results to provide feedback. We ensure the reliability through a structured process for recording, documenting, and interpreting the data. Consensus on findings and evaluation of the research was conducted under the supervision of experts (AT). Explanation number Sample description Identified individuals who could be contacted through publicly available channels or relevant organizations/industry 31 Participants identified The individual accepted the appointment time to be interviewed and returned the consent form 27 Participants accepted Individuals did not respond to initial or follow-up emails 1 Non-respondents The individual was unable to participate within the project timeline 3 Unable to participate Results To evaluate Iran’s policies aimed at enhancing dietary practices, we conducted a comprehensive content analysis of a total of 142 documents. These documents included parliamentary bills and proposals (n=15), agricultural sector (n=16), monthly reports from the food industry and trade sector (n=64), nutrition and health (n=3), government general policies (n=5), cooperation agreements (n=6), and the Secretariat of the Supreme Council for Health and Food Security (n=33). Additionally, we conducted semi-structured interviews with 27 stakeholders from 19 diverse sectors, both within and outside the health system . As demonstrated in Figure 1, under the NOURISHING framework, 30% of interventions in Iran remain undeveloped, 15% have been developed but not implemented, and 55% have been successfully implemented. Table 2: Dietary policies content based on the NOURISHING framework Policy domain Phases of the policy cycle Policy option Food environment implemented Mandatory implementation of nutritional value labels on packaged food products, with nutritional labeling including trans fatty acids Mandatory standards for foods available in schools, including restrictions on unhealthy foods, standards for social support programs, and standards for specific locations (such as health centers and workplaces). Increasing import tariffs on specific unhealthy foods, and reducing import tariffs on specific healthy foods Mandatory regulations for food advertising across all media, mandatory regulations for the marketing of specific food and beverages, and mandatory regulations for food marketing in schools Voluntary reformulation of food products, mandatory restrictions on the amount of salt in food products, and mandatory removal of trans fats from food products Initiatives to increase the availability of healthy foods in stores and food service centers, as well as incentives and regulations to reduce trans fats and salt in food service centers documented Labeling should be interpretable and warning-based, regulations on nutrient and health claims, and voluntary guidelines for food accessibility in schools. Voluntary health-related food taxes, targeted subsidies for healthy foods, restrictions on the availability of high-sugar food and beverage products. Planning for unhealthy food product accessibility restrictions in food retail centers. Not mentioned Shelf labelling, energy and nutrient labeling on menus, and warning labels on menus. Fruit and vegetable initiatives in schools, mandatory standards for food accessibility in schools and nearby areas, and specific restrictions for vending machines in schools. Mandatory regulations for broadcasting food advertisements for children, mandatory regulations for food advertisements in non-broadcast communication channels, mandatory regulations for specific marketing techniques, and a mandatory requirement for advertisements to include health messages or warnings. Government engagement with industry to establish self-regulation aimed at restricting food marketing to children, with the government supporting voluntary commitments developed by the industry. Voluntary commitments to reduce food portion sizes and restrictions on the availability of high-fat meat products. Incentives and regulations for stores to establish themselves in underserved neighborhoods, and incentives and regulations to provide healthy food options as defaults in food service centers. Food system implemented Collaboration with food suppliers to provide healthier food options. Nutritional standards for the procurement of goods and services by the government. Government procurement of goods and services through "short" supply chains (e.g., local farmers). Incentives for the supply chain aimed at food production. Community-based food production. Governance structures for multi-sectoral/stakeholder participation. documented - Not mentioned Support for urban agriculture. Food behavior implemented Development and dissemination of food-based dietary guidelines. Formulation and dissemination of guidelines for specific food groups. Public awareness campaigns, mass media, and information and social marketing programs on healthy nutrition. Public awareness campaigns specifically for fruits and vegetables. Public awareness campaigns on salt consumption. Guidelines and programs to support preventing overweight and obesity in primary care. Nutritional counseling in primary health care. Training programs for healthcare professionals. Nutrition education in school curricula. Community nutrition education. Workplace or community health initiatives, cooking skills programs, and training for caterers and food service providers. documented Food production skills in education curricula Not mentioned Public awareness campaigns about specific unhealthy foods and beverages. Policy Content: As shown in Table 2, several initiatives in Iran still require development. These include shelf and menu labeling, school-based fruit and vegetable programs, restrictions on vending machines, advertising limitations on non-broadcast channels and prohibitions targeting children, collaboration between the government and the industry, voluntary industry commitments to the government, incentives for providing healthy food service, support for urban agriculture, and public awareness campaigns on unhealthy foods. Additionally, some programs, despite being developed and implemented at some point, require content modification or reimplementation. These include initiatives for food gardening for students, clear and interpretable warning front packages labelling, regulations on nutrient and health claims, voluntary guidelines for food accessibility in schools, voluntary health-related food taxes, targeted subsidies for healthy foods, restrictions on the availability of high-sugar food and beverage products, and unhealthy food restrictions in food retail. Policy process Food Environment Interventions Food Safety in Food Retail Services, the National Food Security Document, noted a public reporting system, which plays a vital role in inspections at the retail level. In 2011, public complaints totaled 1,200 cases, with an estimated value of 1.8 million dollars. Most inspections have been related to grains (26,278 cases). Despite these efforts, food fraud still exists. In addition to community-level reporting, inspections help ensure the quality of food products available in the market. However, a lack of portable equipment is the main problem, and only 40% of inspectors are equipped. Furthermore, penalties imposed are not proportionate to the nature of the offense, allowing violators to continue their activities after paying fines. “We procured several equipment items centrally, achieving approximately 40% of the required coverage. Universities are instructed to provide equipment corresponding to the number of inspectors they have. From their income—primarily derived from fines—they allocate around 100 million IRR, which roughly covers the cost of one unit of equipment. Given that an inspector serves both as a judicial officer and as an agent of the state, they must be adequately equipped. Lack of proper tools may increase the risk of deviation from protocol.” Informant 16, Ministry of Health. Prohibition of Unhealthy Food Product Advertisements. Although budgets are defined for public awareness via broadcast channels, allocation is inconsistent. This inconsistency has become an obstacle to implementing media-based public awareness campaigns. Another challenge in mass media is the lack of precise oversight on advertising content. One participant highlighted this issue: "Diet soda enriched with calcium was introduced—how is it possible for carbonated soda to be enriched with calcium? At the start of the school year, what’s the advertisement? Chocolate cake in your school backpack enriched with something. A chocolate cake with all those calories packed into a student’s school backpack." Informant 7, Academic section. School Food Standards One of the school food standards is the guideline for school cafeterias. However, in practice, the sale of food products is a source of income for cafeteria operators. Since the cafeteria operator is usually one of the school staff, the supervision of distributed products is not strictly enforced by school principals. Instead, it is treated as a secondary job for additional income. Another issue is the lack of a designated space within schools to set up cafeterias that can be equipped according to health standards. “T he cafeteria vendor argues that without selling items like unhealthy food products, it would be difficult to generate sufficient income to sustain their livelihood.” Informant 21, Ministry of Education. Food Taxation and Subsidies So far, taxes have only been applied to the sweetened beverage industry in Iran. The primary reason for not implementing a taxation system for other unhealthy products is the lack of necessary infrastructure within the tax organization to manage and allocate funds. Regarding this issue, one participant explained: "For example, if I pay 500 Rial for a pack of chips, 10% of that should go into a separate account. This requires all our stores to be connected to electronic systems so that 50 Rial is directly deducted from the store's account and deposited into national accounts, such as the Central Bank, as a tax on harmful products. The process of collecting and allocating taxes needs infrastructural support, which we currently lack." Informant 9, Supreme council of health and food security. Food System Policies Conflicts of interest between the policies of the Ministry of Health (MoH) and the Ministry of Industry, Mine, and Trade (MoIMT) have led to a lack of coordination in policy implementation. For example, regarding the prohibition of unhealthy food advertising, if MoIMT declares a ban on advertising such products, food industries may stop producing them. This, in turn, creates challenges related to unemployment and production in MoIMT. “ If he had been informed at the time that soft drink advertising would be restricted, he would not have invested billions in producing them. Instead, he would have focused on producing milk.” Informant 22, food industry. Purchasing system directly from local farmers and selling them in relevant markets is inefficient in Iran. Consequently, the production costs of healthy products are high, and demand remains low. Another issue at the supply level is the absence of a traceability system for agricultural goods. Although a program for traceable agricultural products has been approved in Iran, it lacks enforcement mechanisms. Additionally, even if implemented, the costs associated with labeling and using approved products. “You want farmers to reduce their use of fertilizers and pesticides? That can’t be achieved by mere orders. Let’s assume we’ve already educated the farmers — even then, if the quality of them isn’t available domestically, we’re forced to import them. Considering the current exchange rate, we end up importing low-quality pesticides. When those are used, pesticide residues increase. High-quality pesticides are expensive.” Informant 18, ministry of agriculture. A critical aspect of the food system is inter-sectoral collaboration at national and sub-national levels. The Supreme Council for Health and Food Security is responsible for facilitating this coordination. Each department assigns one senior manager and one expert to collaborate with the Council's Secretariat. However, challenges within the Secretariat include its shift from inter-sectoral coordination to parallel activities with other offices in the Ministry of Health. Another issue with Secretariat meetings is that representatives from non-health organizations are often low-ranking officials. Regarding this issue, one participant remarked: "How many of the approved policies get implemented? They’re invited to participate. We consult them when drafting documents and involve them in the process. We invite their representatives, but either they don’t attend, or they send their lowest-ranking officials. Sometimes they act defensively, or they show enthusiasm during meetings, but fail to implement anything afterward. Either they ignore the issue entirely." Informant 29, ministry of health. A further issue is the lack of a unified understanding of the concept of unhealthy foods. Within the food sector, sugar-sweetened beverages, cakes, pastries, and processed meats are not considered harmful or health-risk foods, whereas in the healthcare sector, these products are categorized as unhealthy. One ongoing solution is changing the terminology of "health-threatening" to "less healthy." Food Behavioral Programs. One of the major challenges in educational programs is the lack of alignment between training content and its intended audience due to social, cultural, or educational levels. Additionally, the frequency of training sessions for healthcare staff is excessive, while the quality of these programs remains low. Another skill gap among nutrition sector employees is their ability to highlight the importance of their work. As one participant stated: "Our experts haven’t received adequate training; they can’t properly introduce themselves to the community or deliver appropriate nutrition education. Meanwhile, people involved in economic activities come forward confidently." Informant 4, academic sector. Figure 2 illustrates the trends in contextual factors influencing the dietary patterns of Iranian households over the past three decades. It highlights the aging of the Iranian population and the impact of the Iran-Iraq war around 1991. Moreover, public nutritional awareness in Iran has been shaped by various developments, including the introduction of traditional medicine into university curricula, the Health Transformation Plan, and the rise of social media platforms. Additionally, the inflation rate in recent years has doubled compared to the previous decades, negatively affecting overall societal welfare. Discussion We aimed to examine the implementation of interventions within the NOURISHING framework. The findings underscore the critical need for policy measures aimed at promoting healthy dietary patterns in Iran's food environment. Food environment interventions are the most effective when targeted toward the adult population, which constitutes approximately half of Iran's population. Among the food environment interventions that require improvement are food safety at the point of sale and food fraud. The study identified incomplete risk assessment systems and disproportionate penalties as key drivers of food fraud. Despite increased oversight in recent years, these issues continue to hinder the effectiveness of regulatory measures. Policy recommendations should align penalties with the severity of violations to mitigate food fraud and enhance the integrity of food services. By addressing these challenges, Iran can move toward a more robust and healthy food environment conducive to the well-being of its population. As stated in the 1996 World Food Summit declaration, food safety has received increased attention as an important public health issue in developing countries (19). And some countries, such as Turkey, prioritize food safety programs over nutritional programs (20). The rationale for governmental intervention in food safety stems from market failures caused by insufficient consumer information. Such intervention may take the form of establishing minimum safety standards through oversight and penalties. Another critical issue is risk communication. This involves public education about known violations, their associated risks, uncertainties, and the rationale behind interventions aimed at mitigating risks. Unfortunately, this remains an ongoing challenge. Consequently, training market vendors, particularly regarding the economic costs of violations, could serve as an effective policy action. In Japan, to support the food industry, a digital platform has been established for obtaining licenses and permits remotely, and consumers can access detailed information about food products through this system (21). One of the most advanced approaches in the U.S. and Europe for effective risk assessment is product traceability from farm to table. Consumer awareness of food safety risks and the demand for safer products have also contributed to the proliferation of private standards in food markets (22, 23). One significant food environment action that influences public awareness is the prohibition of advertising unhealthy food products. In Iran, the issue lies in the lack of coordination and consensus within the food system for budget allocation and insufficient oversight on the content of food advertisements. Studies have revealed that advertisements for unhealthy foods are prevalent around schools and in socioeconomically disadvantaged areas. The emergence of new technologies, such as social media, poses additional challenges, such as no restrictions on food advertising that is popular among young people (24). For example, Instagram has been identified as the most popular social media platform (with 52% to 68% usage rates in Australia, Canada, the U.S., and the UK). In Iran, approximately 40% of participants active in the dairy sector on social media were laypersons without professional expertise in the production, distribution, or consumption of dairy products (25). Consistent with the findings of our study, policy implementation is often impeded by lobbying efforts from food industries and media organizations. In China, the effectiveness of the program is enhanced when legislation and regulations support voluntary initiatives and self-regulation within the industry (26). Research indicates that effective collaboration and active participation are essential to implementing advertising bans successfully (27). Another crucial aspect of a healthy food environment is ensuring standards for food accessible to school-age children. In Iran, the issue of non-standard school canteens stems from the fact that canteen vendors are often staff members at the school itself, and school management tends to support these employees regardless of the substandard practices. In Japan, standards and regulations for foods in schools and kindergartens, specifically for lunch meals, are established. Additionally, vending machines that sell food are prohibited in schools in Japan and Turkey (28). Additionally, programs such as Health-Promoting Schools and Nutrition-Friendly Initiatives are implemented in Turkish schools. Studies in the U.S. and the UK highlight that, in addition to the school environment, strong program leadership, the inclusion of healthy nutrition in the curriculum, children’s food preferences, and the home environment significantly influence effective program implementation by fostering changes in children’s eating behaviors (29) Finally, another impactful intervention targeting market demand through financial accessibility is the imposition of taxes on unhealthy food products. Traditional economic theory justifies that consumer concern about food consumption is determined by price and the consumer's level of income (30). Tasty but unhealthy food has become more affordable recently, especially in developing countries. The WHO recommends taxation as one of the most cost-effective tools for addressing population levels of obesity and other related non-communicable diseases (NCDs) (31). Studies highlight several barriers, including weaknesses in decision-making, planning, and execution; issues related to production; smuggling and weak monitoring systems; increased demand for unhealthy food products and conflicts of interest. Weak coordination and collaboration between legislative and executive bodies, an overabundance of government agencies handling the matter, outdated and incorrect tax codes, insufficient data on unhealthy goods, weak commitment to addressing the issue, and inadequate oversight cause decision-making problems. The food system engages multiple stakeholders across both health-related and non-health-related sectors; effective coordination among these entities is vital for sustainable policy implementation. In Iran, inter-sectoral coordination is assigned to councils, but the directives issued lack enforceability. Consistent with our research, evidence suggests that promoting healthy diets largely depends on fostering strong relationships within agri-food systems (29). Japan has developed guidelines for certain foods with specific health benefits—such as oral and digestive health, bone health, blood pressure, cholesterol, and subcutaneous fat—under a program called FoSHU (Foods for Specified Health Uses). Following the establishment of these guidelines, the government provides support to food industries and other sectors that adhere to FOSHU (32). Another initiative in Turkey is providing financial support for nutrition-related programs in non-health sectors, such as transportation, trade, urban planning, employment, sports, and agriculture (33). Educational interventions face significant shortcomings that must first be addressed. One major issue lies in the misalignment of educational programs with their target audiences. School nutrition education program is undervalued because health-related subjects do not influence university entrance exams and place little importance on the education process. Notably, research on food education often focuses on short-term or static interventions outside the formal curriculum, unlike subjects such as mathematics, where learning progresses continuously throughout early education. While integrating food education into the formal curriculum is essential, current recommendations emphasize a shift from temporary measures toward a more consistent, sequential, and developmentally appropriate approach. Such programs should be taught by specialized educators as part of a structured subject, such as home economics, to ensure continuity and effectiveness (30). “food education” definition varies widely from “Nutrition Education” that focuses on health knowledge, to “Food Literacy” that focuses on practical planning and techniques and sustainability and sociocultural topics, combining food and health knowledge. The first notable limitation of this study was the limited access to certain key stakeholders, especially in non-health sectors, due to their reluctance to participate in the research process. The second one is the inherently subjective nature of the methodology that may have introduced a degree of researcher interpretation into the findings, which should be considered when assessing the results. The third is due to this study was specifically designed to inform policy development within the context of Iran, to enhance the precision of policy analysis tailored to the country’s sociopolitical and health system characteristics, its findings may also offer insights for other low- and middle-income countries. However, the policy implications derived from this research may not be generalizable to all global settings. Policy recommendation Introduction of Reliable Government Platforms and revise educational content: our findings revealed that to prevent misinformation and societal confusion, establish credible government platforms by the Ministry of Health aimed at clarifying contradictions between traditional medicine and nutrition. Additionally, revise and tailor nutrition education content to suit the needs of the target audience effectively by programming the social marketing framework educational interventions based on cultural and local situations. Tailored Interventions Based on Evaluations: We recommend that the Ministry of Health that to solve the problems in dietary policies implementation, execute interventions aligned with evaluation findings and evidence-informed policy making, and give special attention to socio-economic factors associated with health outcomes. School Nutrition Program: The Ministry of Education, in collaboration with the Judiciary, should intensify supervision of school canteens to promote healthier food environments and address conflicts of interest. Furthermore, a sustained approach to nutrition education in schools should be maintained, whereby healthy dietary patterns are integrated and taught to students and their parents through various subjects. Food system engagement for healthy diet: We suggest s trengthening synergistic collaboration in the implementation phase of regulatory and educational policies related to healthy and unhealthy foods between the Food and Drug Administration and the Deputy for Health Affairs of the Ministry of Health. Conclusion Our study evaluated interventions aimed at improving diet-related non-communicable diseases. The findings highlight the necessity of further research within the food system. While socio-economic factors influencing health are addressed to some extent in Iran, the findings reveal the need to expand research in the domains of food and nutrition. Additionally, after evaluation, interventions targeting socio-economic factors must be prioritized. The study also underscores that food environment measures require national research initiatives. These interventions must be scrutinized and discussed at the policymaking level. As we mentioned, all interventions are significantly impacted by macroeconomic factors. Beyond economic influences, social and technological factors—such as the population age structure and advancements in computer sciences—also affect the country’s dietary trends. Declarations Acknowledgments We thank the Tehran University of Medical Sciences for administrative support and for editing the research project. We thank all Iranian participants in different sectors for their help in developing the NCD-dietary policies process. Ethics approval and consent to participate Our study method was designed according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving human subjects/patients were approved by the Tehran University of Medical Sciences Human Ethics Committee. Following a full explanation of the study objectives, all participants from various sectors were asked to provide verbal informed consent to participate in the interviews. We keep the personal information of participants. Throughout all phases of the research—from inviting participants to gathering feedback on the analysis results—respect for and protection of participants' rights were upheld. We asked participants about their expertise or general capacity, not personal information. Before starting the research, we briefed participants about the main topic, general objectives, and the type of study. We assured participants that their information would be kept confidential for three years. Consent for publication No identifiable personal data are included in this manuscript; therefore, consent for publication is not applicable. However, the findings were sent to the participants for review and confirmation before publication. Availability of data and materials The data supporting the findings of this study are not publicly available due to confidentiality agreements with participants, but may be available from the corresponding author upon reasonable request and with ethical approval. competing interests None. Funding No funding was received to support this study Authors' contributions Conceptualization: The core research idea was conceptualized and developed by Amirhossein Takian (AT). Methodology: The interview guide was developed by Elham Shareghfarid (ES) in collaboration with AT. AT was responsible for selecting the sampling method, choosing the analytical frameworks, and determining the content analysis approach. The overall study design was developed collaboratively by all authors. Validation: AT contributed to the identification and finalization of the key dimensions. Investigation: ES collected data (interviews and document extraction) and analyzed them. 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Reducing sugar, fat, and salt for prevention and control of noncommunicable diseases (NCDs) as an adopted health policy in Iran. Medical Journal of the Islamic Republic of Iran. 2020;34:136. Smith J, Firth J. Qualitative data analysis: the framework approach. Nurse researcher. 2011;18(2). Walt G, Shiffman J, Schneider H, Murray SF, Brugha R, Gilson L. ‘Doing’health policy analysis: methodological and conceptual reflections and challenges. Health policy and planning. 2008;23(5):308-17. Organization WH. Foodborne Diseases 2014. Available from: https://www.who.int/health-topics/foodborne-diseases#tab=tab_3. Yeğenoğlu S, Aslan D, Şahne BS, Büken NÖ. Innovative approaches to healthy nutrition and sustainable food matters by concerned parties: Insights from the INPROFOOD project (case study: Turkey). Turkey's outputs from INPROFOOD. Health Policy and Technology. 2021;10(2):100516. Putera PB, Gustina A, Hastanto WY, Wulandari PT, Kusuma W, Kurniawati W. Japanese recipe to build functional food policy and industry: a note to Indonesia. Nutrition. 2019;4:7. Henson S, Hooker NH. Private sector management of food safety: public regulation and the role of private controls. The International Food and Agribusiness Management Review. 2001;4(1):7-17. Hobbs RJ, Harris JA. Restoration ecology: repairing the earth's ecosystems in the new millennium. Restoration ecology. 2001;9(2):239-46. Demers-Potvin É, White M, Kent MP, Nieto C, White CM, Zheng X, et al. Adolescents’ media usage and self-reported exposure to advertising across six countries: implications for less healthy food and beverage marketing. BMJ Open. 2022;12(5):e058913. Esbati A, Rezazadeh A, Omidvar N, Eini Zeinab H, Haghighian-Roudsari A, Roustaee R. Explaining Perspectives of Iranian Instagram Social Media Users about Dairy Product Consumption. Iranian Journal of Nutrition Sciences and Food Technology. 2023;18(2):23-38. Hawkes C. Agro-food industry growth and obesity in China. 2008. Chung A, Zorbas C, Riesenberg D, Sartori A, Kennington K, Ananthapavan J, et al. Policies to restrict unhealthy food and beverage advertising in outdoor spaces and on publicly owned assets: a scoping review of the literature. Obesity Reviews. 2022;23(2):e13386. Global Nutrition Policy Review [Internet]. 2018. Devi A, Surender R, Rayner M. Improving the food environment in UK schools: policy opportunities and challenges. Journal of Public Health Policy. 2010;31:212-26. Samuelson PA. Economics of Forestry in an Evolving Society∗. Classic Papers in Natural Resource Economics Revisited: Routledge; 2018. p. 355-78. Organization WH. Taxes on Sugary Drinks: Why do it? 2017. Shimizu M. Functional food in Japan: current status and future of gut-modulating food. Journal of Food and Drug Analysis. 2012;20(1):27. Turkey. Healthy Nutrition and Active Life Program. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7062418","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":486833479,"identity":"1e3137e9-8210-4ebe-bc50-c35af7e29e41","order_by":0,"name":"Elham Shareghfarid","email":"","orcid":"","institution":"Tehran University of Medical Sciences (TUMS)","correspondingAuthor":false,"prefix":"","firstName":"Elham","middleName":"","lastName":"Shareghfarid","suffix":""},{"id":486833480,"identity":"66028e7c-eeb1-4486-a407-cfc8660428e0","order_by":1,"name":"Ahmadreza Dorosty Motlagh","email":"","orcid":"","institution":"Tehran University of Medical Sciences (TUMS)","correspondingAuthor":false,"prefix":"","firstName":"Ahmadreza","middleName":"Dorosty","lastName":"Motlagh","suffix":""},{"id":486833482,"identity":"001a7021-4ac9-4fb8-8956-de236e8a7f09","order_by":2,"name":"Amirhossein Takian","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAv0lEQVRIiWNgGAWjYFACNoYDDAw2cC4PQQ08EC1pEqRpAYLDEoQUIoA9+7HEAz93nK8zuHb8AcOPGgYZ8wZCtvCkHTjYe+a2hMHtHAPGnmMMPDIHCDosveEAbxtYCwMDbwMDD0En8vA/bzj4t+0cUEv6A8a/RGmRSDtwmLftAFBLggEzcbbceJZwWLYtWXIm0C+HZY5JENbC3p9m/PFtmx0/3+30hw/f1NjYkxDcQHCAgYE0DaNgFIyCUTAKcAAAl1o7LgXEOkMAAAAASUVORK5CYII=","orcid":"","institution":"Tehran University of Medical Sciences (TUMS)","correspondingAuthor":true,"prefix":"","firstName":"Amirhossein","middleName":"","lastName":"Takian","suffix":""},{"id":486833483,"identity":"37a47f7f-2ae1-48bc-8e7a-b868716c456e","order_by":3,"name":"Ahmad Esmaeilzadeh","email":"","orcid":"","institution":"Tehran University of Medical Sciences (TUMS)","correspondingAuthor":false,"prefix":"","firstName":"Ahmad","middleName":"","lastName":"Esmaeilzadeh","suffix":""}],"badges":[],"createdAt":"2025-07-07 07:23:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7062418/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7062418/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87344520,"identity":"825f2a19-ce2c-4696-a339-6586c7d35de4","added_by":"auto","created_at":"2025-07-23 02:04:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":24099,"visible":true,"origin":"","legend":"\u003cp\u003ePie chart related to the interventions of the NOURISHING framework in Iran\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7062418/v1/ae00153a964d8d34cf6606c2.png"},{"id":87344510,"identity":"c7d79f80-c8a9-4d44-8d66-4845c5ddd8e0","added_by":"auto","created_at":"2025-07-23 02:04:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":81483,"visible":true,"origin":"","legend":"\u003cp\u003eContextual event trends influencing the Iranian dietary patterns from 1991 to 2021.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7062418/v1/f09c8f44a4422e324449462a.png"},{"id":90798064,"identity":"8c32b257-8d99-4ded-92bb-9ff542b9ad8e","added_by":"auto","created_at":"2025-09-08 09:32:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1170277,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7062418/v1/b80aa6cb-c435-461b-82cf-2d41dcc8dd2e.pdf"},{"id":87344512,"identity":"a1f40472-3a5d-4928-bcb7-4ec0ef122ccc","added_by":"auto","created_at":"2025-07-23 02:04:01","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":21463,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-7062418/v1/188e2e4af61b5f5ebc7a15c6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A prospective analysis of dietary policies in Iran: Applying the NOURISHING Framework to Identify Challenges and Policy Gaps","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe food system (FS) is the single biggest driver of global challenges, including malnutrition in all its forms that causes non-communicable diseases (1). Iran faces a significant public health challenge with non-communicable diseases (NCDs) due to dietary risk factors. NCDs were responsible for 73% of deaths (280,000 individuals) in 2019 (2). The healthcare system\u0026apos;s primary concerns are cardiovascular diseases, hypertension, diabetes, cancers, and mental health disorders. As a Middle Eastern nation with an aging population and shifting disease risk factors, Iran is currently confronting NCDs as a major health issue. Addressing preventable risk factors is vital to reduce this substantial burden, enhancing life expectancy and quality of life (3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe complex interplay of diet, lifestyle, and social determinants requires multi-sectoral strategies for effective prevention and management (4). FS can transform and influence consumption of affordable, healthy, sustainable diets for all (5). Transformation of such a dynamic, interconnected system requires holistic consideration for effective solutions through a diverse combination of hard and soft policies, including taxes, legislation, labelling, and education (6). The World Health Organization (WHO) has recommended Best Buy\u0026apos;s actions to meet the WHO\u0026rsquo;s targets on diet-related NCD and Sustainable Development Goal Target 2.2 on ending all forms of malnutrition by 2030 (7, 8).\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eTo combat these challenges, Iran has been implementing various policies aimed at promoting healthier diets and lifestyles. These actions include public education campaigns, improving food labeling, and regulating the marketing of unhealthy foods, especially to children\u0026nbsp;(9, 10). Addressing non-communicable diseases in Iran requires a comprehensive approach that involves multiple sectors, including healthcare, education, and agriculture. Collaboration between government agencies, NGOs, and international partners is essential to create policies and programs that effectively tackle the root causes of NCDs\u0026nbsp;(11, 12).\u003c/p\u003e\n\u003cp\u003eWe aimed to identify and evaluate the national food and nutrition interventions implemented in Iran compared to the best policy actions in the NOURISHING framework. We explored the policies executed, their impacts, and the gaps that persist within the nation\u0026apos;s healthcare system. \u003cstrong\u003eWhile some interventions have been successfully implemented and have yielded positive outcomes, these policies require regular evaluation and revision within the policymaking cycle. Therefore, the evaluation of previous policy reforms is especially critical for Iran, as a lower-middle-income country.\u0026nbsp;\u003c/strong\u003eThese reforms take precedence over unformulated policies that need to be incorporated into the decision-making process. Furthermore, we seek to address a question: why have some interventions been temporarily implemented but later discontinued or remained at the drafting stage without progressing to execution? The exploration of this issue sheds light on systemic challenges and highlights the importance of fostering robust and sustainable dietary policies to reduce the burden of NCDs in Iran.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe chose a single case study design for investigating a complex multi-variant phenomenon. The investigation proceeded in two stages. First, content analysis, and second, semi-structured interview.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDocument collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe searched official databases of the Ministry of Agriculture (www.maj.ir), the Ministry of Industry, Mine, and Trade (www.mimt.gov.ir), the Ministry of Health and Medical Education (www.behdasht.gov.ir), and the Research Center of the Islamic Consultative Assembly (www.rc.majlis.ir) to find relevant documents by keywords. Then we included relevant documents based on the inclusion criteria. To ensure that all relevant documents were extracted, we searched databases manually (ES). Relevant keywords are nutrition, food, food labelling, food standards, tax, subside, advertisement, reformulation, rule, education, skill, information, food chain, food choice, food preference, food environment, financial incentive, access, price, income, fruit, vegetable, red meat, legumes, fish, dairy products, oil, fat, grain, nuts, sugar, salt, trans fatty acid, policy, strategy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eThe documents needed to be related to Iran and in Farsi. They had to include general policies or keywords relevant to our research goals.\u003c/li\u003e\n \u003cli\u003eFull access to the documents was necessary.\u003c/li\u003e\n \u003cli\u003eAuthenticated documents came from verified sources like the Parliament, government, and the Supreme Council of Health and Food Security (13).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eValid documents weren\u0026apos;t misleading, biased, or conflicted by personal or organizational interests.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eIf the text was published by non-governmental organizations, food industry groups, or campaigns.\u003c/li\u003e\n \u003cli\u003eIf documents include speeches, announcements, or summaries.\u003c/li\u003e\n \u003cli\u003eIf the content of the documents does not cover any policy interventions or actions.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eWe designed a document checklist to extract the mentioned elements. This checklist contained the title, date, and location of publication, along with items related to the NOURISHING and health policy triangle.\u003c/p\u003e\n\u003ch3\u003eDocument analysis\u003c/h3\u003e\n\u003cp\u003eWe analyzed the contents by an inductive approach to identify policies influencing dietary patterns, analysis. We conducted the mixed-method (inductive/deductive) comparative analysis (14). Then we developed the themes based on the NOURISHING policy action framework (ES \u0026amp; AT). This framework provides a structured and coherent pathway for policy actions aimed at reducing non-communicable diseases. It is a comprehensive package from the World Health Organization\u0026apos;s global action plan (15), offering policymakers the flexibility to shape appropriate and contextually relevant responses tailored to national, local, and regional settings and targeted populations. Finally, we classified the identified policies into three groups: policies not mentioned in Iranian policy documents, policies mentioned in Iranian policy documents but not implemented (policies formulated), and policies that are currently being implemented in Iran with an operational plan in place (16).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eWe conducted a semi-structured interview to gain deeper insights into the research topic. The interview guidance included open-ended questions designed by researchers specialized in community nutrition (ADM) and health policy (AT) and developed (Appendix).\u003c/p\u003e\n\u003cp\u003eBefore the start of the interviews, we piloted the designed questions (ES). Subsequently, we invited participants and asked them to answer the questions in about an hour for deep reflection after a short explanation of research goals and methods. We designed the questions to encourage descriptive responses and foster the generation of ideas.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eData analysis\u003c/h3\u003e\n\u003cp\u003eInterviews were analyzed by Framework analysis. The analysis process involved: a) text Familiarization and organization, b) themes Identification: grouping codes into broader categories or creating themes, c) reviewing and analyzing the themes to identify structures (17). We identified and developed the themes using the health policy triangle (18). For organizing and coding data, MAXQDA software version 12 facilitated the progress.\u003c/p\u003e\n\u003cp\u003eWe ensured the validity of the study using the triangulation method. Two researchers with different perspectives reviewed the study, multiple sources were used for data collection, and participants were asked to review the final themes and results to provide feedback. We ensure the reliability through a structured process for recording, documenting, and interpreting the data. Consensus on findings and evaluation of the research was conducted under the supervision of experts (AT).\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable dir=\"rtl\" border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 434px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eExplanation\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003enumber\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eSample description\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 434px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eIdentified individuals who could be contacted through publicly available channels or relevant organizations/industry\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e31\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eParticipants identified\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 434px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eThe individual accepted the appointment time to be interviewed and returned the consent form\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e27\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eParticipants accepted\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 434px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eIndividuals did not respond to initial or follow-up emails\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eNon-respondents\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 434px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eThe individual was unable to participate within the project timeline\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eUnable to participate\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTo evaluate Iran\u0026rsquo;s policies aimed at enhancing dietary practices, we conducted a comprehensive content analysis of a total of 142 documents.\u0026nbsp;These documents included parliamentary bills and proposals (n=15), agricultural sector (n=16), monthly reports from the food industry and trade sector (n=64), nutrition and health (n=3), government general policies (n=5), cooperation agreements (n=6), and the Secretariat of the Supreme Council for Health and Food Security (n=33). Additionally, we conducted semi-structured interviews with 27 stakeholders from 19 diverse sectors, both within and outside the health system\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eAs demonstrated in Figure 1, under the NOURISHING framework, 30% of interventions in Iran remain undeveloped, 15% have been developed but not implemented, and 55% have been successfully implemented.\u003c/p\u003e\n\u003cp\u003eTable 2: Dietary policies content based on the NOURISHING framework\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"765\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePolicy domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhases of the policy cycle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 539px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePolicy option\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eFood environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eimplemented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 539px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eMandatory implementation of nutritional value labels on packaged food products, with nutritional labeling including trans fatty acids\u003c/li\u003e\n \u003c/ul\u003e\n \u003cul\u003e\n \u003cli\u003eMandatory standards for foods available in schools, including restrictions on unhealthy foods, standards for social support programs, and standards for specific locations (such as health centers and workplaces).\u003c/li\u003e\n \u003cli\u003eIncreasing import tariffs on specific unhealthy foods, and reducing import tariffs on specific healthy foods\u003c/li\u003e\n \u003cli\u003eMandatory regulations for food advertising across all media, mandatory regulations for the marketing of specific food and beverages, and mandatory regulations for food marketing in schools\u003c/li\u003e\n \u003cli\u003eVoluntary reformulation of food products, mandatory restrictions on the amount of salt in food products, and mandatory removal of trans fats from food products\u003c/li\u003e\n \u003cli\u003eInitiatives to increase the availability of healthy foods in stores and food service centers, as well as incentives and regulations to reduce trans fats and salt in food service centers\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003edocumented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 539px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLabeling should be interpretable and warning-based, regulations on nutrient and health claims, and voluntary guidelines for food accessibility in schools.\u003c/li\u003e\n \u003cli\u003eVoluntary health-related food taxes, targeted subsidies for healthy foods, restrictions on the availability of high-sugar food and beverage products.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePlanning for unhealthy food product accessibility restrictions in food retail centers.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNot mentioned\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 539px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eShelf labelling, energy and nutrient labeling on menus, and warning labels on menus.\u003c/li\u003e\n \u003cli\u003eFruit and vegetable initiatives in schools, mandatory standards for food accessibility in schools and nearby areas, and specific restrictions for vending machines in schools.\u003c/li\u003e\n \u003cli\u003eMandatory regulations for broadcasting food advertisements for children, mandatory regulations for food advertisements in non-broadcast communication channels, mandatory regulations for specific marketing techniques, and a mandatory requirement for advertisements to include health messages or warnings.\u003c/li\u003e\n \u003cli\u003eGovernment engagement with industry to establish self-regulation aimed at restricting food marketing to children, with the government supporting voluntary commitments developed by the industry.\u003c/li\u003e\n \u003cli\u003eVoluntary commitments to reduce food portion sizes and restrictions on the availability of high-fat meat products.\u003c/li\u003e\n \u003cli\u003eIncentives and regulations for stores to establish themselves in underserved neighborhoods, and incentives and regulations to provide healthy food options as defaults in food service centers.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eFood system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eimplemented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 539px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCollaboration with food suppliers to provide healthier food options.\u003c/li\u003e\n \u003cli\u003eNutritional standards for the procurement of goods and services by the government.\u003c/li\u003e\n \u003cli\u003eGovernment procurement of goods and services through \u0026quot;short\u0026quot; supply chains (e.g., local farmers).\u003c/li\u003e\n \u003cli\u003eIncentives for the supply chain aimed at food production.\u003c/li\u003e\n \u003cli\u003eCommunity-based food production.\u003c/li\u003e\n \u003cli\u003eGovernance structures for multi-sectoral/stakeholder participation.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003edocumented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 539px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e-\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNot mentioned\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 539px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eSupport for urban agriculture.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eFood behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eimplemented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 539px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDevelopment and dissemination of food-based dietary guidelines.\u003c/li\u003e\n \u003cli\u003eFormulation and dissemination of guidelines for specific food groups.\u003c/li\u003e\n \u003cli\u003ePublic awareness campaigns, mass media, and information and social marketing programs on healthy nutrition.\u003c/li\u003e\n \u003cli\u003ePublic awareness campaigns specifically for fruits and vegetables.\u003c/li\u003e\n \u003cli\u003ePublic awareness campaigns on salt consumption.\u003c/li\u003e\n \u003cli\u003eGuidelines and programs to support preventing overweight and obesity in primary care.\u003c/li\u003e\n \u003cli\u003eNutritional counseling in primary health care.\u003c/li\u003e\n \u003cli\u003eTraining programs for healthcare professionals.\u003c/li\u003e\n \u003cli\u003eNutrition education in school curricula.\u003c/li\u003e\n \u003cli\u003eCommunity nutrition education.\u003c/li\u003e\n \u003cli\u003eWorkplace or community health initiatives, cooking skills programs, and training for caterers and food service providers.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003edocumented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 539px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFood production skills in education curricula\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNot mentioned\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 539px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePublic awareness campaigns about specific unhealthy foods and beverages.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ePolicy Content:\u003c/strong\u003e As shown in Table 2, several initiatives in Iran still require development. These include shelf and menu labeling, school-based fruit and vegetable programs, restrictions on vending machines, advertising limitations on non-broadcast channels and prohibitions targeting children, collaboration between the government and the industry, voluntary industry commitments to the government, incentives for providing healthy food service, support for urban agriculture, and public awareness campaigns on unhealthy foods.\u003c/p\u003e\n\u003cp\u003eAdditionally, some programs, despite being developed and implemented at some point, require content modification or reimplementation. These include initiatives for food gardening for students, clear and interpretable warning front packages labelling, regulations on nutrient and health claims, voluntary guidelines for food accessibility in schools, voluntary health-related food taxes, targeted subsidies for healthy foods, restrictions on the availability of high-sugar food and beverage products, and unhealthy food restrictions in food retail.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePolicy process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFood Environment Interventions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFood Safety in Food Retail Services,\u003c/strong\u003e the National Food Security Document, noted a public reporting system, which plays a vital role in inspections at the retail level. In 2011, public complaints totaled 1,200 cases, with an estimated value of 1.8 million dollars. Most inspections have been related to grains (26,278 cases). Despite these efforts, food fraud still exists. In addition to community-level reporting, inspections help ensure the quality of food products available in the market. However, a lack of portable equipment is the main problem, and only 40% of inspectors are equipped. Furthermore, penalties imposed are not proportionate to the nature of the offense, allowing violators to continue their activities after paying fines.\u003cem\u003e\u0026nbsp;\u0026ldquo;We procured several equipment items centrally, achieving approximately 40% of the required coverage. Universities are instructed to provide equipment corresponding to the number of inspectors they have. From their income\u0026mdash;primarily derived from fines\u0026mdash;they allocate around 100 million IRR, which roughly covers the cost of one unit of equipment. Given that an inspector serves both as a judicial officer and as an agent of the state, they must be adequately equipped. Lack of proper tools may increase the risk of deviation from protocol.\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u003cspan dir=\"RTL\"\u003e \u003c/span\u003e\u003c/em\u003eInformant 16, Ministry of Health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProhibition of Unhealthy Food Product\u003c/strong\u003e \u003cstrong\u003eAdvertisements.\u0026nbsp;\u003c/strong\u003eAlthough budgets are defined for public awareness via broadcast channels, allocation is inconsistent. This inconsistency has become an obstacle to implementing media-based public awareness campaigns. Another challenge in mass media is the lack of precise oversight on advertising content. One participant highlighted this issue: \u003cem\u003e\u0026quot;Diet soda enriched with calcium was introduced\u0026mdash;how is it possible for carbonated soda to be enriched with calcium? At the start of the school year, what\u0026rsquo;s the advertisement? Chocolate cake in your school backpack enriched with something. A chocolate cake with all those calories packed into a student\u0026rsquo;s school backpack.\u0026quot; Informant 7, Academic section.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSchool Food Standards\u003c/strong\u003e One of the school food standards is the guideline for school cafeterias. However, in practice, the sale of food products is a source of income for cafeteria operators. Since the cafeteria operator is usually one of the school staff, the supervision of distributed products is not strictly enforced by school principals. Instead, it is treated as a secondary job for additional income. Another issue is the lack of a designated space within schools to set up cafeterias that can be equipped according to health standards. \u003cem\u003e\u0026ldquo;T\u003c/em\u003e\u003cem\u003ehe cafeteria vendor argues that without selling items like unhealthy food products, it would be difficult to generate sufficient income to sustain their livelihood.\u0026rdquo;\u003c/em\u003e Informant 21, Ministry of Education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFood Taxation and Subsidies\u003c/strong\u003e So far, taxes have only been applied to the sweetened beverage industry in Iran. The primary reason for not implementing a taxation system for other unhealthy products is the lack of necessary infrastructure within the tax organization to manage and allocate funds. Regarding this issue, one participant explained: \u003cem\u003e\u0026quot;For example, if I pay 500 Rial for a pack of chips, 10% of that should go into a separate account. This requires all our stores to be connected to electronic systems so that 50 Rial is directly deducted from the store\u0026apos;s account and deposited into national accounts, such as the Central Bank, as a tax on harmful products. The process of collecting and allocating taxes needs infrastructural support, which we currently lack.\u0026quot; Informant 9, Supreme council of health and food security.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFood System Policies\u003c/strong\u003e Conflicts of interest between the policies of the Ministry of Health (MoH) and the Ministry of Industry, Mine, and Trade (MoIMT) have led to a lack of coordination in policy implementation. For example, regarding the prohibition of unhealthy food advertising, if MoIMT declares a ban on advertising such products, food industries may stop producing them. This, in turn, creates challenges related to unemployment and production in MoIMT. \u0026ldquo;\u003cem\u003eIf he had been informed at the time that soft drink advertising would be restricted, he would not have invested billions in producing them. Instead, he would have focused on producing milk.\u0026rdquo;\u0026nbsp;\u003c/em\u003eInformant 22, food industry.\u003c/p\u003e\n\u003cp\u003ePurchasing system directly from local farmers and selling them in relevant markets is inefficient in Iran. Consequently, the production costs of healthy products are high, and demand remains low. Another issue at the supply level is the absence of a traceability system for agricultural goods. Although a program for traceable agricultural products has been approved in Iran, it lacks enforcement mechanisms. Additionally, even if implemented, the costs associated with labeling and using approved products. \u003cem\u003e\u0026ldquo;You want farmers to reduce their use of fertilizers and pesticides? That can\u0026rsquo;t be achieved by mere orders. Let\u0026rsquo;s assume we\u0026rsquo;ve already educated the farmers \u0026mdash; even then, if the quality of them isn\u0026rsquo;t available domestically, we\u0026rsquo;re forced to import them. Considering the current exchange rate, we end up importing low-quality pesticides. When those are used, pesticide residues increase. High-quality pesticides are expensive.\u0026rdquo;\u003c/em\u003e Informant 18, ministry of agriculture.\u003c/p\u003e\n\u003cp\u003eA critical aspect of the food system is inter-sectoral collaboration at national and sub-national levels. The Supreme Council for Health and Food Security is responsible for facilitating this coordination. Each department assigns one senior manager and one expert to collaborate with the Council\u0026apos;s Secretariat. However, challenges within the Secretariat include its shift from inter-sectoral coordination to parallel activities with other offices in the Ministry of Health. Another issue with Secretariat meetings is that representatives from non-health organizations are often low-ranking officials. Regarding this issue, one participant remarked: \u003cem\u003e\u0026quot;How many of the approved policies get implemented? They\u0026rsquo;re invited to participate. We consult them when drafting documents and involve them in the process. We invite their representatives, but either they don\u0026rsquo;t attend, or they send their lowest-ranking officials. Sometimes they act defensively, or they show enthusiasm during meetings, but fail to implement anything afterward. Either they ignore the issue entirely.\u0026quot; Informant 29, ministry of health.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA further issue is the lack of a unified understanding of the concept of unhealthy foods. Within the food sector, sugar-sweetened beverages, cakes, pastries, and processed meats are not considered harmful or health-risk foods, whereas in the healthcare sector, these products are categorized as unhealthy. One ongoing solution is changing the terminology of \u0026quot;health-threatening\u0026quot; to \u0026quot;less healthy.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFood Behavioral Programs.\u003c/strong\u003e One of the major challenges in educational programs is the lack of alignment between training content and its intended audience due to social, cultural, or educational levels. Additionally, the frequency of training sessions for healthcare staff is excessive, while the quality of these programs remains low. Another skill gap among nutrition sector employees is their ability to highlight the importance of their work. As one participant stated: \u003cem\u003e\u0026quot;Our experts haven\u0026rsquo;t received adequate training; they can\u0026rsquo;t properly introduce themselves to the community or deliver appropriate nutrition education. Meanwhile, people involved in economic activities come forward confidently.\u0026quot; Informant 4, academic sector.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 2 illustrates the trends in contextual factors influencing the dietary patterns of Iranian households over the past three decades.\u003c/strong\u003e It highlights the aging of the Iranian population and the impact of the Iran-Iraq war around 1991. Moreover, public nutritional awareness in Iran has been shaped by various developments, including the introduction of traditional medicine into university curricula, the Health Transformation Plan, and the rise of social media platforms. Additionally, the inflation rate in recent years has doubled compared to the previous decades, negatively affecting overall societal welfare.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe aimed to examine the implementation of interventions within the NOURISHING framework. The findings underscore the critical need for policy measures aimed at promoting healthy dietary patterns in Iran\u0026apos;s food environment. Food environment interventions are the most effective when targeted toward the adult population, which constitutes approximately half of Iran\u0026apos;s population. Among the food environment interventions that require improvement are food safety at the point of sale and food fraud. The study identified incomplete risk assessment systems and disproportionate penalties as key drivers of food fraud. Despite increased oversight in recent years, these issues continue to hinder the effectiveness of regulatory measures. Policy recommendations should align penalties with the severity of violations to mitigate food fraud and enhance the integrity of food services. By addressing these challenges, Iran can move toward a more robust and healthy food environment conducive to the well-being of its population. As stated in the 1996 World Food Summit declaration, food safety has received increased attention as an important public health issue in developing countries (19). And some countries, such as Turkey, prioritize food safety programs over nutritional programs (20). The\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003erationale for governmental intervention in food safety stems from market failures caused by insufficient consumer information. Such intervention may take the form of establishing minimum safety standards through oversight and penalties. Another critical issue is risk communication. This involves public education about known violations, their associated risks, uncertainties, and the rationale behind interventions aimed at mitigating risks. Unfortunately, this remains an ongoing challenge. Consequently, training market vendors, particularly regarding the economic costs of violations, could serve as an effective policy action. In Japan,\u0026nbsp;to support the food industry, a digital platform has been established for obtaining licenses and permits remotely, and consumers can access detailed information about food products through this system\u0026nbsp;(21).\u0026nbsp;One of the most advanced approaches in the U.S. and Europe for effective risk assessment is product traceability from farm to table. Consumer awareness of food safety risks and the demand for safer products have also contributed to the proliferation of private standards in food markets\u0026nbsp;(22, 23).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne significant food environment action that influences public awareness is the prohibition of advertising unhealthy food products. In Iran, the issue lies in the lack of coordination and consensus within the food system for budget allocation and insufficient oversight on the content of food advertisements. Studies have revealed that advertisements for unhealthy foods are prevalent around schools and in socioeconomically disadvantaged areas. The emergence of new technologies, such as social media, poses additional challenges, such as no restrictions on food advertising that is popular among young people (24). For example, Instagram has been identified as the most popular social media platform (with 52% to 68% usage rates in Australia, Canada, the U.S., and the UK).\u0026nbsp;In Iran, approximately 40% of participants active in the dairy sector on social media were laypersons without professional expertise in the production, distribution, or consumption of dairy products\u0026nbsp;(25).\u0026nbsp;Consistent with the findings of our study, policy implementation is often impeded by lobbying efforts from food industries and media organizations.\u0026nbsp;In China, the effectiveness of the program is enhanced when legislation and regulations support voluntary initiatives and self-regulation within the industry\u0026nbsp;(26).\u0026nbsp;Research indicates that effective collaboration and active participation are essential to implementing advertising bans successfully\u0026nbsp;(27).\u003c/p\u003e\n\u003cp\u003eAnother crucial aspect of a healthy food environment is ensuring standards for food accessible to school-age children. In Iran, the issue of non-standard school canteens stems from the fact that canteen vendors are often staff members at the school itself, and school management tends to support these employees regardless of the substandard practices. In Japan, standards and regulations for foods in schools and kindergartens, specifically for lunch meals, are established. Additionally, vending machines that sell food are prohibited in schools in Japan and Turkey (28). Additionally, programs such as Health-Promoting Schools and Nutrition-Friendly Initiatives are implemented in Turkish schools. Studies in the U.S. and the UK highlight that, in addition to the school environment, strong program leadership, the inclusion of healthy nutrition in the curriculum, children\u0026rsquo;s food preferences, and the home environment significantly influence effective program implementation by fostering changes in children\u0026rsquo;s eating behaviors\u0026nbsp;(29)\u003c/p\u003e\n\u003cp\u003eFinally, another impactful intervention targeting market demand through financial accessibility is the imposition of taxes on unhealthy food products. Traditional economic theory justifies that consumer concern about food consumption is determined by price and the consumer\u0026apos;s level of income (30). Tasty but unhealthy food has become more affordable recently, especially in developing countries.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe WHO recommends taxation as one of the most cost-effective tools for addressing population levels of obesity and other related non-communicable diseases (NCDs) (31). Studies highlight several barriers, including weaknesses in decision-making, planning, and execution; issues related to production; smuggling and weak monitoring systems; increased demand for unhealthy food products and conflicts of interest. Weak coordination and collaboration between legislative and executive bodies, an overabundance of government agencies handling the matter, outdated and incorrect tax codes, insufficient data on unhealthy goods, weak commitment to addressing the issue, and inadequate oversight cause decision-making problems.\u003c/p\u003e\n\u003cp\u003eThe food system engages multiple stakeholders across both health-related and non-health-related sectors; effective coordination among these entities is vital for sustainable policy implementation. In Iran, inter-sectoral coordination is assigned to councils, but the directives issued lack enforceability. Consistent with our research, evidence suggests that promoting healthy diets largely depends on fostering strong relationships within agri-food systems (29).\u0026nbsp;Japan has developed guidelines for certain foods with specific health benefits\u0026mdash;such as oral and digestive health, bone health, blood pressure, cholesterol, and subcutaneous fat\u0026mdash;under a program called FoSHU (Foods for Specified Health Uses). Following the establishment of these guidelines, the government provides support to food industries and other sectors that adhere to FOSHU (32). Another initiative in Turkey is providing financial support for nutrition-related programs in non-health sectors, such as transportation, trade, urban planning, employment, sports, and agriculture (33).\u003c/p\u003e\n\u003cp\u003eEducational interventions face significant shortcomings that must first be addressed. One major issue lies in the misalignment of educational programs with their target audiences. School nutrition education program is undervalued because health-related subjects do not influence university entrance exams and place little importance on the education process. Notably, research on food education often focuses on short-term or static interventions outside the formal curriculum, unlike subjects such as mathematics, where learning progresses continuously throughout early education. While integrating food education into the formal curriculum is essential, current recommendations emphasize a shift from temporary measures toward a more consistent, sequential, and developmentally appropriate approach. Such programs should be taught by specialized educators as part of a structured subject, such as home economics, to ensure continuity and effectiveness (30).\u0026nbsp;\u0026ldquo;food education\u0026rdquo; definition varies widely from \u0026ldquo;Nutrition Education\u0026rdquo; that focuses on health knowledge, to \u0026ldquo;Food Literacy\u0026rdquo; that focuses on practical planning and techniques and sustainability and sociocultural topics, combining food and health knowledge.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe first notable limitation of this study was the limited access to certain key stakeholders, especially in non-health sectors, due to their reluctance to participate in the research process. The second one is the inherently subjective nature of the methodology that may have introduced a degree of researcher interpretation into the findings, which should be considered when assessing the results. The third is due to this study was specifically designed to inform policy development within the context of Iran, to enhance the precision of policy analysis tailored to the country\u0026rsquo;s sociopolitical and health system characteristics, its findings may also offer insights for other low- and middle-income countries. However, the policy implications derived from this research may not be generalizable to all global settings.\u003c/p\u003e\n\u003ch3\u003ePolicy recommendation\u003c/h3\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eIntroduction of Reliable Government Platforms and revise educational content:\u003c/strong\u003e our findings revealed that to prevent misinformation and societal confusion, establish credible government platforms by the Ministry of Health aimed at clarifying contradictions between traditional medicine and nutrition. Additionally, revise and tailor nutrition education content to suit the needs of the target audience effectively by programming the social marketing framework educational interventions based on cultural and local situations.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTailored Interventions Based on Evaluations:\u003c/strong\u003e We recommend that the Ministry of Health that to solve the problems in dietary policies implementation, execute interventions aligned with evaluation findings and evidence-informed policy making, and give special attention to socio-economic factors associated with health outcomes.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSchool Nutrition Program:\u003c/strong\u003e The Ministry of Education, in collaboration with the Judiciary, should intensify supervision of school canteens to promote healthier food environments and address conflicts of interest. Furthermore, a sustained approach to nutrition education in schools should be maintained, whereby healthy dietary patterns are integrated and taught to students and their parents through various subjects.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFood system engagement for healthy diet:\u0026nbsp;\u003c/strong\u003eWe suggest s\u003cstrong\u003etrengthening synergistic collaboration in the implementation phase of regulatory and educational policies related to healthy and unhealthy foods between the Food and Drug Administration and the Deputy for Health Affairs of the Ministry of Health.\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study evaluated interventions aimed at improving diet-related non-communicable diseases. The findings highlight the necessity of further research within the food system. While socio-economic factors influencing health are addressed to some extent in Iran, the findings reveal the need to expand research in the domains of food and nutrition. Additionally, after evaluation, interventions targeting socio-economic factors must be prioritized. The study also underscores that food environment measures require national research initiatives. These interventions must be scrutinized and discussed at the policymaking level. As we mentioned, all interventions are significantly impacted by macroeconomic factors. Beyond economic influences, social and technological factors\u0026mdash;such as the population age structure and advancements in computer sciences\u0026mdash;also affect the country\u0026rsquo;s dietary trends.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eWe thank the Tehran University of Medical Sciences for administrative support and for editing the research project. We thank all Iranian participants in different sectors for their help in developing the NCD-dietary policies process.\u003c/p\u003e\n\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eOur study method was designed according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving human subjects/patients were approved by the Tehran University of Medical Sciences Human Ethics Committee. Following a full explanation of the study objectives, all participants from various sectors were asked to provide verbal informed consent to participate in the interviews. We keep the personal information of participants. Throughout all phases of the research\u0026mdash;from inviting participants to gathering feedback on the analysis results\u0026mdash;respect for and protection of participants\u0026apos; rights were upheld. We asked participants about their expertise or general capacity, not personal information. Before starting the research, we briefed participants about the main topic, general objectives, and the type of study. We assured participants that their information would be kept confidential for three years.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNo identifiable personal data are included in this manuscript; therefore, consent for publication is not applicable. However, the findings were sent to the participants for review and confirmation before publication.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe data supporting the findings of this study are not publicly available due to confidentiality agreements with participants, but may be available from the corresponding author upon reasonable request and with ethical approval.\u003c/p\u003e\n\u003ch2\u003ecompeting interests\u003c/h2\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNo funding was received to support this study\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eConceptualization: The core research idea was conceptualized and developed by Amirhossein Takian (AT). Methodology: The interview guide was developed by Elham Shareghfarid (ES) in collaboration with AT. AT was responsible for selecting the sampling method, choosing the analytical frameworks, and determining the content analysis approach. The overall study design was developed collaboratively by all authors. Validation: AT contributed to the identification and finalization of the key dimensions. Investigation: ES collected data (interviews and document extraction) and analyzed them. Supervision: AT and Ahmadreza Dorosty Motlagh (ADM) supervised and conceived the study. Writing original draft: ES drafted the manuscript. Writing review and editing: AT critically reviewed the manuscript and suggested revisions and approved the final draft. The revisions were implemented by ES.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePanel G. Future food systems: for people, our planet, and prosperity. 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Adolescents\u0026rsquo; media usage and self-reported exposure to advertising across six countries: implications for less healthy food and beverage marketing. BMJ Open. 2022;12(5):e058913.\u003c/li\u003e\n\u003cli\u003eEsbati A, Rezazadeh A, Omidvar N, Eini Zeinab H, Haghighian-Roudsari A, Roustaee R. Explaining Perspectives of Iranian Instagram Social Media Users about Dairy Product Consumption. Iranian Journal of Nutrition Sciences and Food Technology. 2023;18(2):23-38.\u003c/li\u003e\n\u003cli\u003eHawkes C. Agro-food industry growth and obesity in China. 2008.\u003c/li\u003e\n\u003cli\u003eChung A, Zorbas C, Riesenberg D, Sartori A, Kennington K, Ananthapavan J, et al. Policies to restrict unhealthy food and beverage advertising in outdoor spaces and on publicly owned assets: a scoping review of the literature. Obesity Reviews. 2022;23(2):e13386.\u003c/li\u003e\n\u003cli\u003eGlobal Nutrition Policy Review [Internet]. 2018.\u003c/li\u003e\n\u003cli\u003eDevi A, Surender R, Rayner M. Improving the food environment in UK schools: policy opportunities and challenges. Journal of Public Health Policy. 2010;31:212-26.\u003c/li\u003e\n\u003cli\u003eSamuelson PA. Economics of Forestry in an Evolving Society\u0026lowast;. Classic Papers in Natural Resource Economics Revisited: Routledge; 2018. p. 355-78.\u003c/li\u003e\n\u003cli\u003eOrganization WH. Taxes on Sugary Drinks: Why do it? 2017.\u003c/li\u003e\n\u003cli\u003eShimizu M. Functional food in Japan: current status and future of gut-modulating food. Journal of Food and Drug Analysis. 2012;20(1):27.\u003c/li\u003e\n\u003cli\u003eTurkey. Healthy Nutrition and Active Life Program.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"NOURISHING framework, Dietary policies, Case study","lastPublishedDoi":"10.21203/rs.3.rs-7062418/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7062418/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNon-communicable diseases (NCDs) remain a major global challenge, imposing significant costs on health systems worldwide. In low and middle-income countries, where challenges like malnutrition and infectious diseases are prevalent, NCDs remain a severe problem requiring attention. The present study aimed to evaluate dietary policies and compare them with best practices in European countries to analyze Iran’s progress in NCD-related nutritional challenges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a case study to identify dietary policies in Iran. We searched the National databases with relevant keywords. After that, for a deep understanding of nutritional policies, we identified a total of 31 individuals from different sectors of the food system. Finally, 27 of them accepted our request. We systematically transcribed and analyzed these semi-structured interviews using a mix of inductive-deductive approach within the NOURISHING framework and the Health Policy Triangle. Framework analysis was conducted for content analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFindings of analyzing documents and interviews revealed that dietary interventions in Iran, compared to the NOURISHING framework, are classified in 3 main policy processes, which are:\u003c/p\u003e\n\u003cp\u003e· 30% of interventions in Iran have not been formulated.\u003c/p\u003e\n\u003cp\u003e· 15% were formulated but not implemented.\u003c/p\u003e\n\u003cp\u003e· 55% have been implemented.\u003c/p\u003e\n\u003cp\u003eChallenges in policy implementation were analyzed across three main dimensions: \u003cstrong\u003epolicy process\u003c/strong\u003e, \u003cstrong\u003epolicy\u003c/strong\u003e \u003cstrong\u003econtent\u003c/strong\u003e, and \u003cstrong\u003epolicy\u003c/strong\u003e \u003cstrong\u003econtext\u003c/strong\u003e, as well as four sub-dimensions: \u003cstrong\u003edietary behavior\u003c/strong\u003e, \u003cstrong\u003efood environment\u003c/strong\u003e, and \u003cstrong\u003efood system\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eActions requiring improvement include:\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eFood Environment (12%)\u003c/strong\u003e: Measures like unhealthy food taxation, unhealthy food advertisements, food quality in retail outlets, and school canteen standards need revision.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eDietary Behavior (2%)\u003c/strong\u003e: Nutrition education in schools and community education requires modifications.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eFood System (1%)\u003c/strong\u003e: Cross-sectoral collaboration within the food system in Iran is weak.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this research, we found that Iran has made considerable efforts to mitigate NCDs. However, due to low attention to socio-economic factors in policy making, weaknesses in food system governance, environmental and educational dietary policies have not reached their expected efficiency. We recommend that food environment policies be developed in Iran.\u003c/p\u003e","manuscriptTitle":"A prospective analysis of dietary policies in Iran: Applying the NOURISHING Framework to Identify Challenges and Policy Gaps","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 02:03:56","doi":"10.21203/rs.3.rs-7062418/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1354e852-32e3-4af8-ae80-2d37d4cb4f18","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-08T09:24:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-23 02:03:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7062418","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7062418","identity":"rs-7062418","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}