1. 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
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2. 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)
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3. 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
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4. 171 million children under 5
are stunted (in 2010)
Prevalence of Stunting
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5. 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
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6. 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.

7. Stunting prevalence and number affected in developing countries50
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
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8. 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
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9. Overweight prevalence and number affected in developing countries2 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
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10. 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
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11. The double burden of malnutrition
Source: WHO Global Database on Child Growth and Malnutrition
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12. 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
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13. Exclusive breastfeeding rates in children <6 months are stalling
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14. Changes in food systems
Source : FAO, 2004
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15. 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 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
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16. Interventions and strategies

Interventions and strategies
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17. 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
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18. 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
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19. … …
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20. 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
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21. 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
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22. 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
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23. 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
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24. 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
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25. 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.
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26. WHO – Lausanne University Seminar on NCD Lausanne, 7.9.2011

27. 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
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28. Country strategies and plans

Country strategies and plans
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29. 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
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30. 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
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31. 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
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32. What is limiting progress?
Choice of interventions
Comprehensiveness
Coverage and quality
Policy coherence
Population awareness
Targeting
Level of investments
Coordination for delivering interventions
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33. 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
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34. 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
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35. 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.
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36. 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,
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37. 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)
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38. For local governments, municipalities and districts
France
A federative logo
For local governments, municipalities and districts
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39. 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
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40. 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
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41. http://www.who.int/nutrition/en/index.html WHO – Lausanne University
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