How to work multisectorally at country level : nutrition

1. WHO – Lausanne University Seminar on Non Communicable Diseases Lausanne, 9 March 2011 How to work multisectorally at country level : nutrition F.Branca Director, Department of Nutrition for Health and Development WHO

2.  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)

3. 13 million children born with restricted intrauterine growth or prematurely UNICEF/WHO, 2000

4. 186 million children under 5 are stunted Prevalence of Stunting

5. 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 293 million children under 5 are anemic Source: WHO Global database on Anaemia, 2006

6. Over 500 million adultsare obese

7. 200 150 100 50 0 AFRICA ASIA LATIN AMERICA Stunting prevalence and number affected in developing countries 50 48.6 190 40.3 39.3 40 38.2 37.7 138 Number of stunted (millions) 30 27.6 Stunting (%) 23.7 100 18.1 20 60 13.5 45 51 10 13 10 7 0 1990 2000 2010 1990 2000 2010 Source: Department of Nutrition, World Health Organization

8. 12 11.6 50 11.3 10.6 45 10 10 41 9.1 40 38 8.3 8 Number of wasted (millions) 30 Wasting (%) 6 20 16 4 12 2.3 9 10 1.9 1.6 2 1 1 1 0 0 1990 2000 2010 1990 2000 2010 AFRICA ASIA LATIN AMERICA Wasting prevalence and number affected in developing countries Source: Department of Nutrition, World Health Organization

9. 20 10 8 15 6 10 4 5 2 0 0 AFRICA ASIA LATIN AMERICA Overweight prevalence and number affected in developing countries 8.5 18 6.8 6.9 6.8 14 13 13 5.7 Number of overweight (millions) 4.9 Overweight (%) 4 3.7 7 3.2 4 4 4 4 1990 2000 2010 1990 2000 2010 Source: Department of Nutrition, World Health Organization

10. Children's overweight increasing more rapidly in LMI countries Source : WHO

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

12. United Nations Subcommittee on Nutrition Fourth Report on the World Nutrition Situation, 2000

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

14. Exclusive breastfeeding rates in children <6 months are stalling

15. Changes in food systems Source : FAO, 2004

16. 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

17.  Interventions and strategies

18. 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

19. 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

20. … …

21. 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

22. 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 Health interventionswith an impact on nutrition (1)

23. 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 Health interventionswith an impact on nutrition (2)

24. 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 Non-health interventions with an impact on nutrition

25. 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 European Food And Nutrition Action Plan

26. PAHO regional strategy on nutritionin 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.

28. 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

29.  Country strategies and plans

30. 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

31. 90 79 80 75 70 67 66 65 62 62 60 57 57 55 52 52 51 50 50 50 50 47 46 46 % 43 40 35 32 31 28 30 24 22 18 20 10 5 3 1 0 EMR AFR EUR SEAR WPR AMR Components of food and nutrition policies Underweight Overweight IYCN Vitamins and Minerals All four areas

32. Labelling Components of overweight policies 100 100 95 89 88 88 86 86 80 80 77 77 80 75 75 73 73 71 71 70 70 70 69 68 62 60 57 60 % 50 50 50 50 43 43 43 39 39 38 40 28 25 25 25 23 20 7 6 0 AFR EUR WPR AMR EMR SEAR FBDG Marketing Food and beverages Reporting policies Promotioin of fruits and vegetables Media Counselling in Primary Care

33. 100 92 90 80 73 70 66 63 60 55 50 45 % 40 30 25 17 20 15 14 9 8 7 10 4 2 0 0 0 0 AFR EUR WPR AMR EMR SEAR Nutrition governance President or Prime Ministers Office Ministry of Health Ministry of Agriculture

34. Choice of interventions Comprehensiveness Coverage and quality Policy coherence Population awareness Targeting Level of investments Coordination for delivering interventions What is limiting progress?

35. 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

36. 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

37. 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.

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 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,

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. 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

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. http://www.who.int/nutrition/en/index.html