9. The Danish Whole Grain Partnership

A Global Burden of Disease Study released in 2018 estimated that between 2007 and 2017 the number of deaths attributed to insufficient whole grain consumption increased by about 17%, from 2.63 million to 3.07 million deaths (Stanaway et al., 2018[1]). Consequently, insufficient whole grain consumption became the second leading dietary risk factor for population health behind high sodium consumption (Stanaway et al., 2018[1]).

Persistently low rates of whole grain consumption have prompted policy makers across the world to act, including Denmark (Lourenço et al., 2019[2]). In Denmark, findings showing increased levels of fat in the population’s diet and a decline in bread consumption (caused by growing popularity in a diet promoting low levels of carbohydrates) led to discussions between the Danish Veterinary and Food Administration, the food industry and non-governmental health organisations (NGOs) on how to boost whole grain consumption (Fuldkorn, 2020[3]). Following these discussion, in 2008, the National Food Institute within the Technical University of Denmark released a report defining what is considered a whole grain product1 and a scientifically based whole grain consumption recommendation of 75g / 10 megajoules (mJ) per day (DTU Fødevareinstituttet, 2008[4]).

The adoption of the recommended consumption of whole grains into national dietary guidelines led to the establishment of the Danish Whole Grain Partnership (DWGP) in 2008. DWGP is a public-private partnership (PPP) between the Danish Veterinary and Food Administration (government), the Danish Cancers, the Danish Heart Foundation and the Danish Diabetes Association as well as a number of commercial partners such as food manufacturers and retailers (Figure 9.1).

The main objective DWGP is to increase the average daily intake of whole grain in the population. The Partnership achieves this by employing a multi-pronged strategy (Lourenço et al., 2019[2]):

  • Increasing the availability of “tasty” whole grain products, for example by adding small amounts (5-20%) of whole grain to relevant products.

  • Promoting the development of whole grain products and incorporating whole grains in all cereal-based products

  • Promoting the whole grain logo (see below for further details), informing people about the health benefits of whole grains as well as dispelling myths regarding whole grains

  • Helping shape new norms for whole grains via campaigns, events and structural changes.

The whole grain logo – pictured in Figure 9.1 – (“choose whole grains first”) – represents a key pillar of the Partnership. The logo is printed on products developed by DWGP members given they meet minimum whole grain requirements (Table 9.2) as well as wider dietary requirements outlined within the Nordic Keyhole labelling scheme. That products must meet both the DWGP and Keyhole requirements is a key strength of the intervention as it limits unintended consequences arising from the “halo effect” (see Box 9.1).

In order to become a partner, organisations pay a fee, which is dependent on their size.2 At present, DWGP includes 30 partners ranging from manufacturers in the food industry, retailers, Danish Veterinary and Food Administration, craft bakers, millers, associations and non-government health organisations (health NGOs) (Fuldkorn, 2020[6]).

This section analyses DWGP against the five criteria within OECD’s Best Practice Identification Framework – Effectiveness, Efficiency, Equity, Evidence-base and Extent of coverage (see Box 9.2 for a high-level assessment). Further details on the OECD Framework can be found in Annex A.

DWGP is considered one of the most successful interventions for boosting whole grain consumption, which can be classified in one of two ways (see Box 9.3).

Since the introduction of DWGP, consumption of whole grain has increased for children and adults. The evolution of whole grain consumption has been studied using data from a nationally representative survey on diet and physical activity in Denmark and a cohort study.

Results from the data show consumption of whole grain increased between the period 2000-04 and 2011-12 for both men and women – specifically, from 39 to 64 grammes/day for men and from 28 to 48 grammes/day for women (Figure 9.2) (Mejborn et al., 2013[12]).

Mejborn et al. (2013[12]), using 2011-12 data, also measured whole grain consumption in grammes per 10 MJ. The study found that the total population on average consumed 60g/10 MJ of whole grains per day and that 27% of the population met the recommended 75g threshold. Since then, whole grain consumption has increased markedly with 54% of the population now meeting the recommended whole grain consumption threshold (Andersen et al., 2020[13]).

Results from these studies have led external researchers to conclude that DWGP is one of the “most successful intervention[s] to increase WG [whole grain] consumption” (Suthers, Broom and Beck, 2018[14]). Further, whole grain consumption in Denmark is now one of the highest in the OECD (Table 9.3).

The efficiency of DWGP has not been estimated, however, studies indicate there are high costs associated with insufficient whole grain consumption. A study by the University of Copenhagen (2020[16]) estimated the annual economic impact if Danes met the recommended 75g/10 MJ per day of whole grains. The results found meeting this threshold would lead to:

  • 129 million Danish Krone (DKK) (EUR 17.35 million) saved in health care costs

  • DKK 1 239 million (EUR 167 million) reduction in lost labour productivity

  • DKK 1 185 million (EUR 159 million) reduction in the loss of life quality.

Studies on the cost of failing to meet whole grain consumption are also available, however, they are not specific to Denmark. For example, Lieffers et al. (2018[17]) estimated the cost of failing to meet recommended whole grain consumption in Canada at CAD 3.27 billion (EUR 2.21 billion) per year, which covers both direct and indirect costs of associated chronic conditions such as ischemic heart disease, stroke and diabetes (Lieffers et al., 2018[17]).

Whole grain intake is lower among people with lower education levels and worse risk factors. In 2020, Andersen et al. (2020[13]) compared whole grain intake among different population groups in a Danish cohort. Results from the analysis indicate less advantaged groups in society consume lower levels of whole grain, specifically:

  • Those with a “long education” (e.g. MSc or higher university degree) were 20% more likely to meet recommended whole grain intake levels compared to those with a “short education” (e.g. primary school, high school or a short course)

  • Those who are obese are 39% less likely to meet recommended whole grain intake levels compared to those with a normal weight.

Findings from the literature indicate less advantaged groups have lower levels of access to nutritious foods. The DWGP logo is displayed on products that meet pre-defined dietary requirements. The logo has a simple design and message (“Choose whole grains first”) (Figure 9.1) and is therefore easily interpretable by the wider population. The costs of applying the logo to products high in whole grain are not explicitly passed onto consumers. Nevertheless, international studies into the difference in price between products with and without health logos indicate the former can be more expensive, which exacerbates existing health inequities. For example:

  • Research undertaken in Canada found bread products with a front-of-package whole grain label were 74% less likely to be found in the lower price range (i.e. bread below CAD 3.00 per loaf) (Sumanac, Mendelson and Tarasuk, 2013[18]).

  • In Romania, a country in the process of adopting the Whole Grain Partnership, research has shown that whole grain products are more expensive the refined grain products. It is important to note that in Denmark, there is no evidence to suggest that products with the whole grain logo are systematically more expensive than substitute products without the logo.

Higher prices of foods with health labels may reflect a higher willingness-to-pay amongst consumers for “healthier” products and/or greater production costs (e.g. breads high in whole grain take longer to bake and have a shorter shelf life) (Sumanac, Mendelson and Tarasuk, 2013[18]; Van Loo et al., 2011[19]). Access to high whole grain products by lower income groups may be further curtailed if food stores sell a lower number of high whole grain products. For example, research has found lower-income neighbourhoods have less access to nutritious foods (Larson, Story and Nelson, 2009[20]). A report analysing availability of products with the Whole Grain logo is not available in Denmark, however, feedback from DWGP indicate such products are sold in a variety of stores across the country, including discount stores and retail chains.

It is important to note that DWGP also aims to increase whole grain content in foods that do not have the logo. Therefore, all groups in society, regardless of their attitude towards healthy eating, stand to benefit from DWGP.

Two different surveys were used to collect data on whole grain consumption. Data to measure the level of whole grain intake within the Danish population has been measured for periods 2000-04, 2011-12 and 2015-19 (see “Effectiveness”). Data for the first two observations (i.e. period 2000-04 and 2011-12) were based on data from the nationally representative Danish diet and physical activity survey. Conversely, measures of whole grain intake in the period 2015-19 were measured by the Danish Cancer Society using data from the Diet, Cancer and Health – Next Generation (DCH-NG) cohort study (Andersen et al., 2020[13]). The focus of the evidence-based assessment is on the latest study from the Danish Cancer Society.

The DCH-NG cohort study includes data from men and women above the age of 18 who are descendants of participants of the preceding DCH cohort. In total 183 764 people were eligible for the study and 38 553 agreed to participate.

Consumption of whole grain was measured using the food-frequency questionnaire. To measure whole grain intake, survey participants completed a 376-item food-frequency questionnaire (FFQ), which is considered a reliable and valid measurement tool. The questionnaire asked participants to state average daily intake of each food and beverage item over the past year ranging from never to eight or more times per day. The intake of whole grain was estimated by multiplying consumption frequency of whole grain foods by a standardised portion size, which has a pre-defined whole grain intake (obtained from the Danish National Food Institute, Technical University of Denmark).

Limitations associated with DCH-NG data to measure whole grain consumption are summarised below:

  • Cohort studies, such as DCH, are overrepresented by individuals with a high socio-economic status (SES). Therefore, it is possible that high DCH-NG cohort also includes a disproportionate number of people with a high SES, who have the knowledge and resources to lead healthy lifestyles (Andersen et al., 2020[13]).

  • DCH data is cross-sectional therefore there is no information on whole grain consumption for the same population group prior to the establishment of the Partnership.

The evidence-base supporting the relationship between whole grain intake cardiovascular diseases (CVDs), cancer, type 2 diabetes, overweight and overall mortality is well established and summarised in a document developed as part of the WholEUGrain project (see Box 9.4 for further details) (WholEUGrain, 2021[21]).

Key indicators reflecting the reach of DWGP are summarised below:3

  • The number of products with the whole grain logo increased from 150 to 987 between 2009-20

  • Consumer awareness of the logo increased from around 20% to 64% between 2009 and 2019

  • The proportion of people who buy products with the logo increased from 40% to 80% between 2011 and 2019

  • The number of DWGP members increased from 18 to 30 between 2009 and 2020.

DWGP is a world-renowned intervention for boosting whole grain consumption. A 2018 systematic review into public health interventions aimed at increasing whole grain intake concluded DWGP was the “most successful” (Suthers, Broom and Beck, 2018[14]). Further, Curtain et al. in (2020[22]) noted Denmark was one of few nations to markedly increase whole grain consumption as a result of DWGP.

The success of DWGP is not attributable to a single characteristic, rather a suite of characteristics considered essential for boosting whole grain consumption. For example, there are a range of activities involved in the Partnership including marketing campaigns; there are a comprehensive group of stakeholders involved, which increases the availability of whole grain products; the logo is placed on the front of the package and is colourful and easy to interpret; in addition, DWGP also aims to increase whole grain content in foods without the logo.

To further enhance DWGP’s performance, several policy options have been listed. Policy options may target DWGP administrators or other policy makers (e.g. at the national level) where proposed changes fall outside the scope of day-to-day administrators.

Each of the policy options align with high-level recommendations outlined by the European Commission (Box 9.5).

Improve health literacy levels. Research has shown that low rates of health literacy reduce understanding of nutrition-related information (Campos, Doxey and Hammond, 2011[24]). A nation-wide study of health literacy in Denmark revealed approximately 40% of the population have either inadequate or problematic health literacy. When adjusting for confounders, those in the following groups have higher odds of inadequate health literacy: men, young people, immigrants, and individuals with a basic education and below average income (Svendsen et al., 2020[25]). To enhance the effectiveness of the DWGP logo, efforts to enhance health literacy (with a focus on nutritional knowledge), particularly among vulnerable groups, are encouraged (OECD, 2019[26]). Example policies to boost health literacy are outlined in Box 9.6.

Increasing the number of producers signed up to DWGP will also enhance the intervention’s effectiveness, as explored under “Enhancing extent of coverage”.

Efficiency is calculated by obtaining information on effectiveness and expressing it in relation to inputs used. Therefore policies to boost effectiveness without significant increases in costs will have a positive impact on efficiency.

Implement strategies to increase affordability. The rise of cheap foods low in nutritional value has contributed to higher rates of overweight and obesity in poorer populations (e.g. in Denmark, 14.3% of the population are obese in the lowest income quintile compared to 11.4% in the highest income quintile) (Eurostat, 2014[28]). To improve access to high whole grain foods, policies that reduce the price of products with the whole grain logo could be considered, as has been done in other countries. For example:

  • Singapore: In Singapore, the Health Promotion Board (a government organisation promoting healthy living) partnered with supermarkets to provide discounts on brown rice and to encourage price competition. Over a period of three years, brown rice sales increased by 15% (Toups, 2020[29]).

  • South Africa: In 2009, the private health insurance company, Discovery, implemented the Healthy Food Program, which provides members with a 10-25% discount on “healthy food purchases” at supermarkets. An evaluation in 2013 revealed that those enrolled in the Program were between 2-3 times more likely to consume at least three servings of whole grain foods per day compared to those not enrolled (An et al., 2013[30]). By offering this discount to holders of private health insurance only, this policy risks increasing inequalities. It is nonetheless used here as an example to demonstrate the positive impact of making healthy foods more affordable.

It is important to note, however, that the market economy, not policy instruments, are the main driver of prices.

Review how access to high whole grain products differs across population groups. A review into the price difference between products with and without the Whole Grain Partnership logo would provide important information on whether lower socio-economic groups face barriers to purchasing high whole grain foods. Similarly, a review into where Whole Grain Partnership products are sold is important for understanding if certain geographical regions have limited access to these products (e.g. by urban/regional/remote areas and by type of store such as a supermarkets and health food stores). Findings from the study will guide follow-up action to improve equal access to high whole grain products.

Explore the possibility of natural experiments and/or experimental studies. The increase in whole grain intake cannot be directly attributed to the Whole Grain Partnership as studies do not control for whether a person was exposed to the logo or not. To address this limitation, researchers could explore the possibility of undertaking natural experiments – i.e. an empirical study where participants are “naturally” exposed to the logo or not. This may not be possible in Denmark given the Whole Grain Partnership logo is widely known, however, it may be possible in countries transferring the intervention as part of WholEUGrain initiative (described further under “Transferability assessment”) – namely Romania, Slovenia, and Bosnia and Herzegovina. Alternatively, or in addition, researchers could run experimental studies in a controlled environment, as has been done to evaluate the impact of the food labelling scheme, Nutri-Score (see Box 9.7 for an example study). However, caution must be taken when interpreting results from these studies given they can markedly overestimate the impact of food labelling schemes (Dubois et al., 2020[31]).

Collect food consumption data using population surveys. Food purchases from retail stores are a reliable data source however they are not directly linked to consumption. Further, this type of data cannot be used to analyse the impact of nutrition labelling schemes across population groups (for instance, by age, gender and education), except for data linked to loyalty card registration. Future studies using survey-based data on consumption would enhance the evidence-base supporting DWGP.

Increase access to small producers. Small producers of whole grain products may face barriers to becoming a Whole Grain member given the cost of reformulating products to meet specific guidelines as well as annual membership costs (see Box 9.8). To increase the number of members and therefore products with the whole grain logo, policy makers could offer membership subsidies and/or tax benefits that incentivise manufactures to reformulate their products.

Policy makers can also enhance the extent of coverage through non-financial incentives. For example, in Chile, the Ministry of Agriculture has put in place a platform that brings together public institutions and private industry, working together to promote reformulation toward healthier products (OECD, 2019[36]). In addition, policy makers can put in place actions to encourage consumption of products with the DWGP logo for example by promoting such foods in workplaces, schools and hospitals.

This section explores the transferability of DWGP and is broken into three components: 1) an examination of previous transfers; 2) a transferability assessment using publically available data; and 3) additional considerations for policy makers interested in transferring DWGP.

The success of DWGP led to the European project – “A European Action on Whole Grain Partnerships” (WholEUGrain). The project, which will run from 2019-22, is designed to assist countries transfer and adapt the Whole Grain Partnership to their local setting. Four countries, including Denmark, are involved in WholEUGrain – Romania, Slovenia, and Bosnia and Herzegovina (European Commission, 2019[37]).

As part of WholEUGrain, a “Toolbox” to guide countries through the implementation process was developed (see Box 9.9 for further details). In addition, there is a three-day summer or spring school, which will be hosted every year of the project (typically in person, however, due to COVID-19 pandemic, in 2021 and partly in 2022, were run virtually). The summer and spring schools consists of several webinars providing answers to questions such as “what are the pre-requisites for a well-functioning Partnership”?

The following section outlines the methodological framework to assess transferability and results from the assessment.

A few indicators to assess the transferability of the Whole Grain Partnership were identified (see Table 9.4). Indicators were drawn from international databases and surveys to maximise coverage across OECD and non-OECD European countries. Please note, the assessment is intentionally high level given the availability of public data covering OECD and non-OECD European countries.

The transferability assessment of DWGP is in particular limited given indicators related to the food retail market and consumer behaviour are collected by private research companies and therefore not available for public use.

Over half (64%) of OECD and non-OECD European countries have a FOB nutrition labelling scheme, however, they do not relate to whole grain consumption, rather they focus on the overall nutrition quality of a product based on salt, sugar and fat intake (see Table 9.5). These results indicate there is support for food labelling schemes to help people make better choices.

The majority of countries have in place a national action plan to reduce levels of unhealthy eating (91%) and spend proportionally more on preventative care than Denmark (2.4% versus 2.5% of current health expenditure) – similarly, these results reflect political support for interventions that encourage people to eat better.

To help consolidate findings from the transferability assessment above, countries have been clustered into one of three groups, based on indicators reported in Table 9.4. Countries in clusters with more positive values have the greatest transfer potential. For further details on the methodological approach used, please refer to Annex A.

Key findings from each of the clusters are below with further details in Figure 9.3 and Table 9.6:

  • Countries in cluster one, which includes Denmark, have sector specific, political and economic arrangements in place to transfer DWGP. Countries in this cluster are therefore less likely to experience issues in implementing and operating DWGP in their local context.

  • Countries in cluster two, prior to transferring DWGP, would benefit from assessing whether the sector is ready to implement such an intervention (e.g. determining whether front-of-pack labelling is allowed).

  • Countries in cluster three would similarly benefit from assessing the sector’s readiness to implement DWGP, as well as ensuring that the intervention aligns with overarching political priorities and is affordable in the longer term given relatively low levels of spending on prevention.

Data from publically available datasets is not ideal to assess the transferability of public health interventions, in particular for DWGP given indicators on the food retail market and consumer behaviour are collected by private research companies (e.g. Euromonitor International). Hence, Box 9.10 outlines several new indicators policy makers could consider before transferring DWGP.

DWGP uses a multi-pronged strategy to boost whole grain consumption in Denmark. Activities to boost consumption include increasing the availability of whole grain products, promoting the development of whole grain products and the whole grain logo, delivering educational campaigns and events and promoted whole grain s as a climate-positive food.

DWGP is associated with an increase in whole grain consumption. The introduction of DWGP is associated with an increase in whole grain consumption. Given there is strong evidence to support the link between high whole grain consumption and lower risk of developing certain cancers (e.g. colorectal cancer), type 2 diabetes and CVDs, DWGP plays an important role in improving population health (WholEUGrain, 2021[21]).

An assessment of DWGP’s performance against the best practice criteria highlighted potential areas for improvement. These include, but are not limited to, partnerships between policy makers and retail outlets offering discounts/promotions on DWGP products as well as making it easier for small producers to sign up to the Partnership.

There are a number of factors countries need to consider before transferring DWGP. Indicators measuring the transferability potential of DWGP to OECD and non-OECD European countries is limited given data on the food retail market and consumer behaviour are not for public use. Instead, this case study outlines a range of indicators policy makers should consider before transferring the Partnership such as existing dietary habits and attitudes towards whole grains in society.

Box 9.11 outlines next steps for policy makers and funding agencies regarding DWGP.


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[21] WholEUGrain (2021), WholEUGrain project: a European Action on Whole Grain Partnerships - Deliverable number 4.1 (evidence base for the health benefits of whole grains including sustainability aspects), https://www.gzs.si/Portals/288/210427_WholEUGrain_Deliverable%204.1_FINAL%20report.pdf.


← 1. The Danish Food Institute define a whole grain as “the intact and processed (dehulled, ground, cracked, flaked or the like) grain, where the fractions endosperm, bran, and germ are present in the same proportions as in the intact grain” (DTU Fødevareinstituttet, 2008[4]).

← 2. Annual turnover < DKK 5 million (EUR 0.67 million) = fee is DKK 10 000 (EUR 1 344) per year; annual turnover < DKK 15 million (EUR 2 million) = fee is DKK 25 000 (EUR 3 361) per year; and if annual turnover is > DKK 15 million (EUR 2 million) = annual fee is DKK 50 000 (EUR 6 721) per year.

← 3. Data provided by the Whole Grain Partnership, Denmark.

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