How to work multisectorally at country level : nutrition WHO – Lausanne University Seminar on Non Communicable Diseases Geneve, 9 May 2012 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 Geneva, 9.5.2012

The multifaceted challenge of malnutrition  WHO – Lausanne University Seminar on NCD Geneva, 9.5.2012

171 million children under 5 are stunted (in 2010) Prevalence of Stunting WHO – Lausanne University Seminar on NCD Geneva, 9.5.2012 3 3

500 million obese individuals aged 20+ years (2008) Source: Global status report on noncommunicable diseases 2010. World Health Organization 2011 WHO – Lausanne University Seminar on NCD Geneva, 9.5.2012

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 Geneva, 9.5.2012

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 Geneva, 9.5.2012

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 Geneva, 9.5.2012

The double burden of malnutrition Source: WHO Global Database on Child Growth and Malnutrition WHO – Lausanne University Seminar on NCD Geneva, 9.5.2012

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 Geneva, 9.5.2012

WHO – Lausanne University 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 Geneva, 9.5.2012

Changes in food systems Source : FAO, 2004 WHO – Lausanne University Seminar on NCD Geneva, 9.5.2012

Interventions and strategies  WHO – Lausanne University Seminar on NCD Geneva, 9.5.2012

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 Geneva, 9.5.2012

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 Geneva, 9.5.2012

WHO – Lausanne University Seminar on NCD Geneva, 9.5.2012

Global nutrition targets 40% reduction of childhood stunting by 2025 50% reduction of anemia in women of reproductive age by 2025 30% reduction of Low Birth Weight by 2025 0% increase in childhood overweight by 2025 Increase exclusive breastfeeding rates in the first 6 months up to 50% by 2025 Reducing and maintaining childhood wasting to less than 5% by 2025 World Nutrition Rio2012

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 Geneva, 9.5.2012

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 Geneva, 9.5.2012

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 Geneva, 9.5.2012

Country strategies and plans  WHO – Lausanne University Seminar on NCD Geneva, 9.5.2012

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 Geneva, 9.5.2012

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 Geneva, 9.5.2012

WHO – Lausanne University 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 Geneva, 9.5.2012

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 Geneva, 9.5.2012

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 Geneva, 9.5.2012

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 Geneva, 9.5.2012

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 Geneva, 9.5.2012 1

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 Geneva, 9.5.2012

WHO – Lausanne University http://www.who.int/nutrition/en/index.html WHO – Lausanne University Seminar on NCD Geneva, 9.5.2012