1. 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

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

3. 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

4. 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.

5. 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

6. 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)

7. 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.

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

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

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

11. 293 million children under 5
are anemic
Category of public health significance
(anaemia prevalence)
Normal (<5.0%)
Mild ( %)
Moderate ( %)
Severe (≥40.0%)
No Data
Source: WHO Global database on Anaemia, 2006

12. 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.

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

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

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

16. 
Changing food systems

17. Changes in food systems
Source : FAO, 2004

18. 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

19. 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

20. 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

21. 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

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

23. Interventions and strategies

Interventions and strategies

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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.

31. 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

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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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 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,

39. 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)

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

41. 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

42. 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

43. 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