How to work multisectorally at country level : nutrition WHO – Lausanne University Seminar on Non Communicable Diseases Geneve, 7 September 2011 How to work multisectorally at country level : nutrition 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 WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

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) WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

13 million children born with restricted intrauterine growth or prematurely 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. UNICEF/WHO, 2000 WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

171 million children under 5 are stunted (in 2010) Prevalence of Stunting WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011 4 4

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 WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

Over 500 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.

Stunting prevalence and number affected in developing countries 50 48.6 50 100 150 200 190 40.3 39.3 40 38.2 37.7 138 30 Number of stunted (millions) 27.6 Stunting (%) 23.7 100 20 18.1 60 13.5 45 51 10 In developing countries, stunting remains the biggest problem (29%) with relative decrease of 20% per ten-year period, followed by wasting which shows a persistent rate around 10% for the last 20 years In Africa, stunting stagnated at ~ 40% which translates into increasing numbers of stunted children (from 45 million in 1990 to 60 million in 2010) Asia, in contrast, with a prevalence of 28%, nearly halved the number of stunted children over the last 20 years from 190 million (1990) to 100 million (2010) 13 10 7 1990 2000 2010 1990 2000 2010 AFRICA ASIA LATIN AMERICA Source: Department of Nutrition, World Health Organization WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

Wasting prevalence and number affected in developing countries 1990 2000 2010 2 4 6 8 10 12 Wasting (%) 8.3 11.6 2.3 9.1 11.3 1.9 10.6 1.6 20 30 40 50 Number of wasted (millions) 9 45 1 41 16 38 For wasting, Africa shows an increased rate from 8% to 10%, while Asia – where highest rates are found – wasting decreased slightly (from 12% to 11%) between 1990 and 2010 AFRICA ASIA LATIN AMERICA Source: Department of Nutrition, World Health Organization WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

Overweight prevalence and number affected in developing countries 2 4 6 8 10 5 10 15 20 8.5 18 6.8 6.9 6.8 14 13 13 5.7 Number of overweight (millions) Overweight (%) 4.9 4 3.7 7 3.2 4 4 4 4 43 million children worldwide Globally, overweight increased from 4% to 7%, with highest rates in developed countries (12%) followed by Africa (9%) and Latin America (7%) 1990 2000 2010 1990 2000 2010 AFRICA ASIA LATIN AMERICA Source: Department of Nutrition, World Health Organization WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

Children's overweight increasing more rapidly in LMI countries We are aware of the global epidemic of obesity, but we are now witnessing a much more rapid increase in countries of Low and Middle Income. This slide shows the change in the prevalence of overweight in children under 5. Countries have been grouped by income, according to the World Bank classification. IN LMIC countries the prevalence has doubled between 1990 and 2010 and is further increasing at the level of UMIC, that include many countries in the Middle East The prevalence is now higher in LMI countries than in High Income countries Source : WHO WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

The double burden of malnutrition Source: WHO Global Database on Child Growth and Malnutrition WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011 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 WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

Exclusive breastfeeding rates in children <6 months are stalling WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

Changes in food systems Source : FAO, 2004 WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

Global dietary trends Starches have decreased and refined sugars increased - up to 15% of energy intake from refined sugar fat content increased from 20% to 40% Dietary salt intake currently at 9 - 12 g/d Meat consumption in developing countries : from 10 kg/person/yr in the '60s to 26 kg '90s (projected rise to 37 kg/person/ year in 2030 Milk and dairy products : from 28 kg/person/ year in the '60s to 45 kg (66 kg in 2030) fruit and vegetable production has not been growing sufficiently, particularly in Africa WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

Interventions and strategies  Interventions and strategies WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

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 WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

Global Strategy on Diet, Physical Activity and Health (2004) Reducing trans fatty acids and salt Restricting availability of energy dense foods and high calorie non-alcoholic beverages Increasing availability of healthier foods including fruits and vegetables Practice of responsible marketing to reduce impact of unhealthy foods to children Making healthy options available and affordable Providing simple, clear and consistent food labels that are consumer friendly Reshaping industry to introduce new products with better nutritional value Making physical activity accessible in all settings WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

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Outline of comprehensive implementation plan ACTION 1 : To create a supportive environment for the implementation of comprehensive food and nutrition policies ACTION 2 : To adopt efficient strategies and include all required effective health interventions with an impact on nutrition in plans for scaling up ACTION 3: To stimulate the implementation of non health interventions with an impact on nutrition ACTION 4 : To provide adequate human and financial resources for the implementation of health interventions with an impact on nutrition ACTION 5 : To monitor and evaluate the implementation of policies and programmes WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

Health interventions with an impact on nutrition (1) Behavioural change interventions in communities and health facilities Early initiation of breastfeeding Exclusive breastfeeding for the first six months of life Continued breastfeeding up to two years of age and beyond Timely introduction of complementary foods Provision of advice on safe and nutritionally-adequate home-made complementary foods Nutrition counselling through food-based dietary guidelines Nutrition counselling for the adequate care of sick children Nutrition counselling for the adequate care of malnourished children Implementation of the Baby Friendly Hospital Initiative Implementation of the International Code of Marketing of Breast-milk Substitutes and related resolutions of the World Health Assembly subsequent to resolution WHA34.22 adopting the Code Provision of micronutrient supplements in children, adolescents and women Vitamin A supplementation for children under five years of age Iron supplementation for children under five years of age Iron and folic acid supplementation for adolescent girls and women of reproductive age Multiple micronutrient supplementation for women during pregnancy Calcium supplementation for women during pregnancy Zinc supplementation for diarrhoea management Home fortification of foods intended for young children WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

Health interventions with an impact on nutrition (2) Targeted nutritional support Integrated management of severe acute malnutrition through facility- and community-based interventions Treatment of moderate acute malnutrition Nutritional care of people living with HIV Nutrition support of patients infected with tuberculosis Energy and protein supplementation in women with low body mass index Nutritional support in emergencies Provision of adequate support according to the Operational Guidance for Emergency Relief Staff and Programme Managers on infant and young child feeding in emergencies, which includes the protection, promotion and support for optimal breastfeeding, and the need to minimize the risks of artificial feeding Other health interventions Prevention of adolescent pregnancy Pregnancy spacing Intermittent preventive treatment of malaria in pregnancy Prevention and cessation of tobacco, alcohol and drug consumption in pregnancy Reduction of indoor air pollution Prevention and control of occupational risk in pregnancy Prevention and control of genitourinary infections in pregnancy Provision of insecticide-treated bednets Properly-timed cord clamping Prevention of mother-to-child transmission of HIV Deworming of children and adolescents Deworming of pregnant women Hand washing and other hygienic interventions WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

Non-health interventions with an impact on nutrition Agriculture and food production Micronutrient fortification of staple foods Micronutrient fortification of complementary foods Salt iodization Water fluoridation Interventions to improve food security at household level Interventions to improve the nutritional quality of foods (reduction of salt, fat and sugar content,elimination of trans-fatty acids) Trade Taxation and application of  price policies Enacting legislation on marketing of foods and non-alcoholic beverages to children Provision of food in public institutions Nutritional labelling of food Social protection Conditional and unconditional cash transfers Food aid Education Women's primary and secondary education Improvement of diet and physical activity in schools Labour Support to lactating working women (through adopting and enforcing the ILO Maternity Protection Convention, 2000 (No. 183) and Recommendation (No. 191) Information Conducting social marketing campaigns Labelling of food products WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

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 WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

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. WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

Eastern Mediterranean 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 WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

Country strategies and plans  Country strategies and plans WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

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 WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

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 WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

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 WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

What is limiting progress? Choice of interventions Comprehensiveness Coverage and quality Policy coherence Population awareness Targeting Level of investments Coordination for delivering interventions WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

Developing country plans Context mapping and assessment of implementation challenges in countries Holding of a country stakeholders' workshop to discuss and identify existing challenges for implementation of scale up plans Analysis of programme delivery options and preparation of policy briefs Convening deliberative dialogue Preparation of scale up plan WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

What is there for each actor ? (1) Government Agricultural sector : primary production, food processing, distribution and retail is mindful of health objectives Consumer protection : adequate information is provided to consumers. Education : schools orient food preferences and consumption towards healthy goals Urban planning : enhance access to healthy and safe food Labour : adequate parental leave, breastfeeding breaks and flexibility to support working women during lactation Social policy : social benefits to improve the food security of vulnerable population groups WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

What is there for each actor ? (2) non government Advocacy NGOs and consumers’ organizations : monitor the implementation of commitments from the public sector and the private sector Food operators : improve the availability of healthy foods including fruits and vegetables, products with lower levels of saturated fats, added sugars and salt Media : support awareness raising campaigns about nutrition and food safety Advertisers and marketers : comply with recommendations about the marketing of food and non-alcoholic beverages to children. WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

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, WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

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) WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

For local governments, municipalities and districts France A federative logo For local governments, municipalities and districts WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

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 WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

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 WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

http://www.who.int/nutrition/en/index.html WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011