WHO – Lausanne University Seminar on Non Communicable Diseases Geneva, 12 August 2010 Multisectoral action to improve nutrition throughout the life course for the prevention of NCD Early nutrition can determine the risk to develop chronic diseases later in life. Protection of optimal health and promotion of optimal function has therefore to be initiated since conception. F.Branca Director, Department of Nutrition for Health and Development WHO

Nutritional influences throughout the life course  Nutritional influences throughout the life course

A LBW baby is also likely to be exposed to further environmental stressors after birth, trapping him in a cycle of malnutrition that spills over into the next generation. United Nations Subcommittee on Nutrition Fourth Report on the World Nutrition Situation, 2000

Mental development and function Early nutritional exposure Stature and mass Body composition CHO metabolism Fat metabolism Blood pressure Work capacity Obesity Diabetes Hypertension Heart disease Cancer We are aware that a poor nutritional environment can affect mental development and function, body size and body composition, substrate metabolism and blood pressure, with long term irreversible effects on mental and physical function as well as increased risk of chronic diseases.

Life course influences on nutrition Fetal Life Infancy and Childhood Adolescence Adult Life Elderly Established adult risky behaviours Diet/Physical activity, Tobacco, Alcohol Biological risks Socioeconomic status Environmental conditions Breast Feeding SES Infection PEM Micronutrients Growth rate Tallness Physical Activity Food behaviour TV viewing Soft drinks WHO/NMH/NPH/ALC, 2001 Obesity Smoking Physical Activity Food behaviour TV viewing Soft drinks Development of Malnutrion SES Mother’s Nutrition Growth birth weight Accumulated risk Genetic susceptibility to Malnutrition Age 5

The multifaceted challenge of malnutrition  The multifaceted challenge of malnutrition Malnutrition should be dealt in all its forms (underweight, wasting, stunting and overweight, as well as micronutrient deficiencies and nutrition-related chronic diseases)

Percent low birth weight UNICEF/WHO estimates circa 2000 (187 countries) LBW is a public health problem in most developing countries but is also a concern in developed countries. The greatest proportion is observed in Asia, where almost a child in 5 is born with LBW.

Exclusive breastfeeding rates in children <6 months are stalling Global Trend

Children 6-23 months receiving the minimum number of food groups in sub-Saharan Africa (percent)

186 million children under 5 are stunted Prevalence of Stunting 10 10

293 million children under 5 are anemic Category of public health significance (anaemia prevalence) Normal (<5.0%) Mild (5.0-19.9%) Moderate (20.0-39.9%) Severe (≥40.0%) No Data Source: WHO Global database on Anaemia, 2006

Over 400 million adults are obese These maps tell us that the prevalence of overweight in adult women will significantly increase over the next 10 years. If current overweight trends continue, average levels of body mass index are projected to increase in almost all countries. By 2015, it is estimated that over 1.5 billion people will be overweight. Similarly, deaths from chronic diseases are projected to increase over the same period. Statistical projections show that 64 million people will die in 2015; 41 million (64%) of them will die from chronic diseases. This is a 17% increase in chronic disease deaths from 2005 to 2015.

The double burden of malnutrition Source: WHO Global Database on Child Growth and Malnutrition

Households with double burden (Caballero B. NEJM 352:1514 2005) 14

Early stunting and adolescent obesity in South Africa Source : Kimani-Murage et al. BMC Public Health 2010, 10:158

 Changing food systems

Changes in food systems Source : FAO, 2004

Growth of transnational food companies Greater availability, greater accessibility, lower prices and greater desirability for energy-dense processed and fast foods Transformation of the food supply chain and food systems as a whole by stimulating new forms of competition, introducing new ways to sell and promote foods, and creating new cultural identities for different foods Source : Hawkes, 2007

Growth of supermarkets Shifting demand for home-produced foods or foods purchased in open markets to increased dependence on store-bought foods supplied by transnational food companies Expanding available food choices, especially of processed foods (e.g., soft drinks, snacks, baked goods and dairy products) Source : Hawkes, 2007

Foreign Direct Investment the allocation of investment has shifted away from products for export to the home market and products produced by primary processing, towards highly processed foods for sale in the host market FDI has played a role in the nutrition transition by increasing the amount of highly processed foods in the global diet

The food crisis Dramatic rise of food prices coupled with shortages of food stocks, seeds, fertilizers, finance and high fuel prices threat global food and nutrition security Creates various humanitarian, human rights, socio-economic, health and political-related challenges Rise of food prices not due to any specific climate shock or other emergency Results from cumulative effects of long-term trends e.g. lack of agricultural sector investment, rising demand for food due to economic growth, trade distorting subsidies, bio-fuels

Food systems affected by financial volatility and recession Source: Joachim von Braun, IFPRI, October 2009. Data from IMF 2009; Ratha, Mohapatra, and Silwal. 2009; UNCTAD 2009, and World Bank 2009

Interventions and strategies  Interventions and strategies

Integrated food and nutrition action Inadequate foetal development Lack of breastfeeding Inappropriate complementary feeding Child under nutrition Low fruit and vegetable intake High salt (NaCl) intake Saturated fat and trans fatty acid intake High blood pressure High cholesterol Overweight and obesity Physical inactivity

Evidence based maternal nutrition interventions All Countries Iron folate supplementation Maternal supplements of multiple micronutrients Maternal iodine through iodization of salt Maternal calcium supplementation Interventions to reduce tobacco consumption or indoor air pollution Specific Situational Contexts Maternal supplements of balanced energy and protein Maternal iodine supplements Maternal deworming in pregnancy Intermittent preventative treatment for malaria Insecticide-treated bednets

Effective actions to improve fetal development ? Strength of evidence Strong Some Limited ↓ Adolescent pregnancies ↓ Occupational hazards Social support Improved nutrition in girls and women Safe water and sanitation Self-esteem ↓ Infectious and other diseases Pregnancy complications Sleep duration ↓ Life style risk factors (smoking, alcohol, workload)   Number of partners/duration of cohabitation ↓ Environmental toxins Other nutritional factors Protection including food supplementation of pregnant women in humanitarian crisis Strong evidence of improvement of fetal development (LBW ?) with improved nutrition in girls and women, as well as a reduction of adolescent pregnancies, a reduction of infectious diseases, a reduction of the exposure to smoking, alcohol and heavy physical work, a reduction of the exposure to environmental toxins Evidence is less compelling for occupational hazards, safe water and sanitation and pregnancy complications And only limited for the improvement of social support, and self esteem, crowding of the household, sleep duration

Infant and Young Child Feeding Protection, promotion and support of appropriate IYCF Exclusive breast feeding for 6 months Complementary feeding (need strengthening and support for use of local foods, food fortification, micronutrient supplementation) Feeding of IYC in difficult circumstances (HIV, malnutrition, emergencies, LBW) Health services Baby Friendly Hospital Initiative Pre-service education and in-service training Maternity protection Code of marketing of breastmilk substitutes Monitoring and evaluation

The European Food And Nutrition Action Plan ACTION AREAS Supporting a healthy start Ensuring safe, healthy and sustainable food supply Providing comprehensive information and education to consumers Implementing integrated actions Strengthening nutrition and food safety in the health sector Monitoring and evaluation HEALTH CHALLENGES Diet related noncommunicable diseases Obesity in children and adolescents Micronutrient deficiencies Foodborne diseases The Action Plan aims to tackle four main health challenges : Diet related noncommunicable diseases Obesity in children and adolescents Micronutrient deficiencies Foodborne diseases And recommends to do it through a series of priority actions 6 action areas are envisaged 1) Supporting a healthy start – dealing with infant and young child nutrition 2) Ensuring safe, healthy and sustainable food supply 3) Providing comprehensive information and education to consumers 4) Implementing integrated actions – promotion of physical activity, control alcohol, ensure safe water supply 5) Strengthening nutrition and food safety in the health sector 6) Monitoring and evaluation

PAHO regional strategy on nutrition in health and development (2006-2015) Food and Nutrition in Health and Development Objective: To promote integration of nutrition into social and economic policies and plans in order to meet nutritional needs throughout the life course and to tackle nutrition transition problems at regional, subregional, national, and local levels Suboptimal Nutrition and Nutritional Deficiencies Objective: To reduce nutritional deficiencies and suboptimal nutrition through prevention and treatment strategies targeted towards vulnerable groups throughout the life course and in the event of disasters Nutrition and Physical Activity in Obesity and Nutrition-related Chronic Diseases Objective: To promote the adoption of healthy dietary habits, active lifestyles, the control of obesity- and nutrition-related chronic diseases.

Eastern Mediterranean draft nutrition strategy and plan of action 2010-2019 Increasing political commitment for nutrition Supporting a healthy start by promoting and protecting the nutritional well-being of women and children and ensure good nutrition throughout the life-cycle for all age groups Ensuring a safe, healthy and sustainable food supply Promoting food with adequate micronutrient content Providing comprehensive information and education to the public Carrying out integrated actions to address noncommunicable disease related determinants Strengthening nutrition and food safety Improving nutrition services and capacity building in the health sector Monitoring, evaluating and conducting research into nutrition Building capacity for nutritional care and support in emergency situations

Country strategies and plans  Country strategies and plans

Global Review of food and nutrition policies Questionnaire circulated to 193 WHO Member States 117 respondents (Ministry of Health) Additional sources for data validation and integration

Components of food and nutrition policies EMR SEAR 50 52 5 62 46 35 79 55 66 51 57 18 65 67 47 43 3 31 22 24 1 32 28 75 10 20 30 40 60 70 80 90 AFR AMR EUR WPR % Underweight Overweight IYCN Vitamins and Minerals All four areas

Components of overweight policies 100 100 95 88 88 89 86 86 80 80 80 77 77 73 73 75 75 69 71 71 68 70 70 70 62 60 57 % 60 50 50 50 50 43 43 43 38 39 39 40 28 25 25 25 23 20 6 7 AFR AMR EMR EUR SEAR WPR Reporting policies FBDG Labelling Marketing Food and beverages Promotioin of fruits and vegetables Media Counselling in Primary Care

Nutrition governance 7 17 4 15 66 45 73 92 55 63 14 9 8 25 2 10 20 30 40 50 60 70 80 90 100 AFR AMR EMR EUR SEAR WPR % President or Prime Ministers Office Ministry of Health Ministry of Agriculture

Country "readiness to act" Ready Good opportunity to accelerate action Need to help build capacity Better Health System Capacity Poor Health System Capacity Strong Nutrition Governance Poor Health System Capacity, (High PH Expenditure) Weaker Nutrition Governance Improving both child stunting and maternal anemia Vietnam Indonesia Kenya Pakistan South Africa Bangladesh India Cambodia Mozambique Improving child stunting, Not improving maternal anemia Egypt Peru Philippines Ethiopia Not improving child stunting Improving maternal anemia Ghana Yemen Cameroon Myanmar Nigeria Burkina Faso Guatemala Mali Niger Zambia Not improving: both child stunting and maternal anemia Burundi Cote D’Ivoire Madagascar Nepal Uganda Malawi U R Tanzania Readiness Factor MCU groups (from stunting and anemia level and trend) 37

Slovenia : health in all policies (FNAP 2005-10) CAP Fruit School Scheme (2009/10) : 75 % participating primary schools, involving agriculture, education and health sector. Education sector : School nutrition programs. In 2008 - all children 1-18 eat up to four cooked meals per day in the public education institutions. Up to one third of meals are distributed for free and the rest of them are subsidized by the state budget. Finance : differentiation in taxation of different types of foods Culture : reducing marketing pressure to children Social affairs : nutrition for undeprivileged population groups. Activities with private sector (with public health leadership) : reformulation of food products,

France : Plan National Nutrition et Santé information, communication and education action in the health system intervention over the economic stakeholders and consumers Multistakeholder representation (Ministries of agriculture, education, consumption, research young and sports, health agencies, research institutes, local and regional governments, food industry, mass caterers, retailers, producers and consumers)

Municipalities and districts France A federative logo For local governments Municipalities and districts

Norway : Diet Action Plan (2007 – 2011) Improved availability of healthy food and hinder access to unhealthy food/drinks 2. Increased knowledge in all parts of the population 3. Building competence and awareness among stakeholders and key groups 4. Stronger local basis for action through partnership and integrated public health approaches 5. Strengthening nutrition in prevention and treatment within the health and care system The Action Plan on Nutrition is worked out and signed by 12 Ministries

Western Pacific – legislative action Taxation on beverages (American Samoa, Fiji) Taxation on foods (Fiji. PNG, Samoa, Solomon Islands) Taxation on foods and drinks for the establishment of a prevention fund (French Polinesia) Import laws (Cook Islands, Micronesia, Fiji) Restrictions on the use of ingredients with little nutritonal value (Fiji) Controls on advertising (Fiji) Source : Clarke & Mc Kenzie, WHO, 2007

Western Pacific - non-regulatory School programs (American Samoa , Cook Islands, Micronesia, Fiji, French Polynesia, Marshall Islands, Niue, Palau, Samoa) Community awareness programs (Micronesia, Samoa, Solomon Islands, Tonga, Tuvalu) Workplace programmes (Samoa, Solomon Islands, Tonga) Healthy stores programs (Marshall Islands) Media awareness campaigns (Cook Islands, Fiji, French Polynesia, Marshall Islands, Solomon Islands, Tonga) Promotion of healthy diet (French Polynesia, Guam) Training of health professionals (French Polynesia, Tonga) Counselling in primary care (Tuvalu, Vanuatu) Hospital based promotion (Samoa) Source : Clarke & Mc Kenzie, WHO, 2007

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