The Double Burden of Malnutrition GCHB 6780 Roger Shrimpton John Mason Lisa Saldanha

1. The Double Burden of MalnutritionGCHB 6780Roger ShrimptonJohn MasonLisa Saldanha 13 February 2013 Class 8:Policy and Programmes for Prevention of DBM I

2. Readings: • 11. World Health Organization.2003. Diet, Nutrition and the Prevention of Chronic Diseases. Technical Report Series N0 916. Geneva: pp 54-71 (Steve) • 12. Zimmermann MB, et al 2008. Adiposity in women and children from transition countries predicts decreased iron absorption,etc. Int J Obesity 32(7): 1098-1104 (Kristine) Content • Mid term exams • Causes: Food deserts • What are Solutions? • Intergovernmental Political Agreements • Intergovernmental Policy Agreements • International Policy Recommendations and Technical Guidance • Regional policies related to the DBM • Country policies and plans for tackling DBM • Readings DBM Draft: 6.1 Policy recommendations for DBM (pp29-34)

3. Mid term exams

4. Food Desserts • The term food desert was coined in the late 1990s in the UK to describe low income neighbourhoods with poor access to fresh and affordable food* • Major changes in food retail systems in the UK in the sixties led to the rapid growth of supermarkets in out-of-town locations, • which in turn led to the decline of local shops and traditional markets. • Those without a car or access to public transport couldn’t get to supermarkets and hence get access to fresh fruit and vegetables. • Source: • * Wrigley N. 2002. Food Deserts in British Cities: Policy context and research priorities. Urban Studies 39 (11): 2029-2040

5. What is a Food Desert? • A food desert is an “area in the United States with limited access to affordable and nutritious food, particularly such an area composed of predominantly lower income neighborhoods and communities” Food Environment Food Access Dietary Intake Health/ Disease outcomes Source: 2008 Farm Bill

6. Access to Affordable and Nutritious Food: Measuring and Understanding Food Deserts and Their Consequences: Report to Congress • Overall Findings: • a small percentage of consumers are constrained in their ability to access affordable nutritious food because they live far from a supermarket or large grocery store and do not have easy access to transportation. • Urban core areas with limited food access are characterized by higher levels of racial segregation and greater income inequality. In small-town and rural areas with limited food access, the lack of transportation infrastructure is the most defining characteristic. • Existing data and research are insufficient to conclusively determine whether areas with limited access have inadequate access. United States Department of Agriculture, Economic Research ServiceJune 2009

7. A recent review of the literature confirms that those in the USA with better access to healthy foods, be it in supermarkets or neighborhood food stores, consume more fresh produce and healthy food items and have lower risks of obesity and other diet-related chronic diseases. Source: Treuhaft S, Karpyn A. 2010. The grocery gap: who has access to healthy food and why it matters. New York: Policy Link and The Food Trust

8. What are Solutions for DBM? Seems very likely that DBM and consequent NCD problem in LMICS will be of much greater magnitude than that see in HICS todate Although there are examples of countries reversing CHD risks, few (if any) countries have reversed obesity once established. Therefore best to prevent it. Desite lack of evidence of programme effectiveness for obesity prevention, there is a lot of policy and programme guidance related to food and obesity. BUT these are not “joined-up”

9. Global commitments for better nutrition • Global mechanisms/instruments that regulate and/or provide guidance for national nutrition efforts to improve nutrition are mostly intergovernmental, and principally through the United Nations, with commitments ranging from broad political ones to those that are more policy related. • Political commitments are for a nation as a whole • Policy commitments relate to a national government commitment for a programmatic area or sector such a Health or Agriculture. Source: Shrimpton 2003

10. Global political commitments to nutrition • Political commitments are formed when states agree to work together to achieve development outcomes, that usually include certain minimum standards or goals, some of which may be nutrition related. • The strength of commitment of these political agreements varies from international covenants and treaties such as those on Human Rights and World Trade, with potential legal implications, to far less binding ones to work together in favour of certain improved development outcomes such as the Millennium Development Goals (MDGs).

11. Global political commitments to nutrition • Most nations are politically committed to freeing their citizens from the scourge of hunger and malnutrition, be it through the Universal Declaration of Human Rights (UDHR) of 1948, or the International Covenant Economic, Social and Cultural Rights (ICESCR) of 1966. • The ICESCRs includes the right to work, to form trade unions, the right to social security, the rights to food, to education and to health. • There is no specific “right to nutrition”, but this is considered to be covered by the three essential but alone insufficient rights of “Food” “Health” and “Care” (Education). • Today most countries (>140) have ratified all but one of the six core covenants and conventions on the ESCRs.

12. Global political commitments to nutrition • The Convention on the Rights of the Child (CRC) and the Convention on the Elimination of all forms of Discrimination against Women (CEDAW) are complementary and mutually reinforcing human rights instruments. • The CEDAW applies to females of all age groups, and requires states to eliminate discrimination against women in the enjoyment of civil, political economic and cultural rights. Article 12 says that all states shall ensure to women appropriate services in connection with pregnancy, confinement and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation. • The CRC applies to boys and girls to age 18, and requires states to ensure the civil, political, social, economic and cultural rights of children. Article 27 states that State Parties shall in case of need provide material assistance and support programmes, particularly with regard to nutrition, clothing and housing. • 163 Countries have ratified CEDAW and 191 (all but 2) have ratified the CRC

13. Intergovernmental political agreements • Human Rights Principles: • Recognises human person as subject and claim holder and translates “needs” into “rights” • Strives to secure freedom and well being and dignity of people in framework of essential standards and principles • Reinforces capacities of governments as duty bearers to “respect”, “protect” and “fulfil” (facilitate/provide) • Enforceable and linked to “justiceability”

14. Intergovernmental political agreements • Millennium Development Declaration • Agreement to respect all internationally recognized human rights • Agreement to reach the 8 Development Goals (derived from earlier summits including the World Summit for Children and the World Food Summit) • MDG 1 is on Poverty Reduction and includes target to halve hunger by 2015 (underweight and undernourished) • Although Needs Based (achieved) and Rights Based (realized) approaches are different, they are complementary---progressive realization

15. Global political commitments to nutrition CONCLUSION: • Nearly all States are politically committed to progressively ensuring the rights to food health and care (nutrition) for all subjects. • Nearly all States are committed to achieving various development goals, including many related to trying to reduce undernutrition to half the levels of 1990 by 2015 • Global political commitments to nutrition prior to 2011 were almost solely focussed on maternal and child undernutrition and didn't contemplate the DBM across the life course • (BUT!: The NCD Summit in September 2011 recognized that NCDs , including obesity, will erode any progress on MDGs and requires urgent new efforts in LMICs to tackle these).

16. Global nutrition policy provision mechanisms • Principle international body for nutrition policy guidance is WHO through its Governing body the World Health Assembly (WHA) • Policy commitments are those that WHA endorses • The Department of Nutrition in Health and Development (NHD) is principal unit responsible for supporting the development of normative policy guidance in WHO • The life course and disease specific aspects of the DBM mean that many other departments of WHO also provide nutrition related policy guidance, including: • Dept of Child and Adolescent Health (CAH) • Department for Making Pregnancy Safer (MPS), • Department of Reproductive Health Research (RH), • Department of Chronic Diseases and Health Promotion (CHP)

17. Global nutrition policy provision mechanisms • Global Policy with regard to food security related issues are also produced by the Committee on World Food Security (CFS) of the Food and Agriculture Organization (FAO) • CFS monitors the progress in the implementation of the World Food Summit Plan of Action, which is focussed on “% of population that is “undernourished” based on reports from national governments and international organizations. • FAO provides technical support to the development of the realization of the right to food, and has excellent materials available on its website to support country led efforts in this area including a “Tool-box” on different aspects of the right to food.

18. Global nutrition policy provision mechanisms • Normative policy guidance on Food Safety is provided jointly by WHO and FAO through the Codex Alimentarius Commission (Codex). • The main purposes of Codex is to protect the health of the consumers and ensure fair trade practices in the international food trade, and promote coordination of all food standards work (e.g. food additives, food labelling) undertaken by international governmental and non-governmental organizations. • Codex recommendations are not “endorsed” by either WHO and/or FAO, as they are best practice guidelines and whether they are followed is on a voluntary basis. • Codex is recognized by the World Trade Organization however as an international reference point for the resolution of disputes concerning food safety and consumer protection

19. Intergovernmental Policy Agreements • Nutrition • The most common policy area with WHA resolutions is for Infant and Young Child Nutrition • Since the International Code of Marketing of Breastmilk Substitutes was adopted by the World Health Assembly in 1981 as a “minimum requirement” to be enacted “in its entirety” in “all countries”, there have been many further WHA resolutions on Infant and Young Child Nutrition (every 2 years).

20. Intergovernmental Policy Agreements • Nutrition • 2002 WHA resolution 55.25 on Infant and young child nutrition endorsed the Global Strategy for Infant and Young-Child Feeding (IYCF) and urged member States to adopt and implement the Strategy in order to ensure optimal feeding for all infants and young children, and to reduce the risks associated with obesity and other forms of malnutrition. • 2006 WHA resolution 59/7 adopting the report on Nutrition and HIV/AIDS urged Member States, as a matter of priority, to pursue policies and practices that promote, inter alia, the integration of nutrition into a comprehensive response to HIV/AIDS.

21. Global nutrition policies related to DBM • WHA 2010 endorsed WHA 63.23 on IYCF, which urged member states to scale up interventions to improve IYCF in an integrated manner, with BF and ACF as core interventions, plus severe malnutrition, and targeted control of micronutrient deficiencies. • WHA63.23 further requested the Director General to develop a comprehensive implementation plan on IYCN as a critical component of a global multi-sectoral nutrition framework for preliminary discussion at the Sixty-fourth World Health Assembly (2011) and for final delivery at the Sixty-fifth World Health Assembly (2012). • The WHA 2011 recommended changing the name of the WHA 63.23 IYCF global plan to cover maternal nutrition, i.e. to become Maternal Infant and Young Child Nutrition (MIYCN), as well as to deal more clearly with the double burden of undernutrition and overweight.

22. Global nutrition policies related to DBM • The WHA 2012 endorsed the MIYCF global plan with five Global Targets for 2022: 1: 40% reduction of childhood stunting. 2: 50% reduction of anaemia in women of reproductive age. 3: 50% reduction of low birth weight. 4: No increase in childhood overweight. 5:Increase rates of exclusive breastfeeding for 6 months to >50%

23. Intergovernmental Policy Agreements • Healthy Life styles • WHO provides global policy guidance for the policy area of healthy lifestyles, which embraces both communicable and non-communicable diseases • 2004 WHA resolution 57.16 on “Health promotion and healthy lifestyles”, urged Member States: (1) to strengthen existing capability for the planning and implementation of gender-sensitive and culturally appropriate, comprehensive and multisectoral health-promotion policies and programmes, especially among young people , use of alcohol, tobacco, and exercise

24. Global nutrition policies related to DBM • WHA 2000 endorsed the Global Strategy on the Control of Non-Communicable Diseases, and WHA 2004 endorsed The Global Strategy on Diet, Physical Activity and Health (DPAS), both of which included recommendations on how populations should eat and take exercise in order to reduce the risk of obesity, diabetes and other non-communicable diseases. These included: • 1) To achieve energy balance and a healthy weight; • 2) To limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of trans-fatty acids; • 3) To increase consumption of fruits and vegetables, and legumes, whole grains and nuts; • 4) To limit the intake of free sugars; • 5) To limit salt (sodium) consumption from all sources and ensure that all salt is iodized. • WHA 2008 endorsed the 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases to promote interventions to reduce main risk factors (tobacco, unhealthy diets, physical activity, and alcohol) principally in adults.

25. Global nutrition policies related to DBM RECOMMENDED POPULATION NUTRIENT INTAKE GOALS (WHO Report 916) Many of these goals are turned into dietary recommendations, including the Food Guide Pyramids

26. Intergovernmental Policy Agreements • Healthy Life styles • 2010 WHA resolution 63.14 on the marketing of food and non-alcoholic beverages to children, urges member states to take necessary measures to reduce the impact on children of marketing of foods high in saturated fats, trans-fatty acids, free sugars, or salt

27. Intergovernmental Policy Agreements • Food Security • Principal authority is Committee on World Food Security (CFS) of FAO, • 2008 High Level Conference on World Food Security and High Level Task Force on Global Food Security produces “Comprehensive Framework for Action” • 2009 World Food Summit agreed to Global Partnership for Agriculture, Food Security and Nutrition (GPAFSN) linked to the CFS, and G20 committed $20bn over 3 years. • But most recommendations have yet to be acted upon. 

28. International Policy Recommendations and Technical Guidance • Policy Recommendations • The Department of Nutrition for Health and Development (NHD) is strengthening its role in providing evidence-based policy and programme guidance to Member States, in partnership with the Department of Research, Policy and Cooperation (RPC) and guided by the new WHO Guidelines Development process • To implement this, NHD has established the WHO Nutrition Guidance Expert Advisory Group (NUGAG)  • These processes are discussed in greater detail in the Annex on Nutrition Guidelines

29. International Policy Recommendations and Technical Guidance • Expert Reports • A list of the technical reports prepared in the last decade can be found on the NHD website under the following four topics: • Growth Assessment and Surveillance (GRS); • Reduction of Micronutrient Malnutrition (MNM); • Nutrition in the Lifecourse and Undernutrition (NLU); • Nutrition Policy and Scientific Advice (NPU). • The full list of the publications available is shown in the Annex on Guidelines.

30. Global nutrition policies related to DBM • The Lancet Nutrition Series Paper 5 on International nutrition system: • Considered Policy setting to be a function of STEWARDSHIP. • Found the system, to be fragmented and • dysfunctional. • Considered that current processes for producing normative guidance are • laborious and duplicative, • Source: Morris et al 2008. BUT ONLY LOOKED AT MATERNAL AND CHILD UNDERNUTRITION!!!

31. Global nutrition policy provision mechanisms • In 2010 NHD embarked on strengthening its role in providing evidence-informed policy and programme guidance to Member States, • To implement this, NHD established the WHO Nutrition Guidance Expert Advisory Group (NUGAG) including representatives from all Departments in WHO with an interest in the provision of recommendations in nutrition. • The membership of NUGAG includes experts from various WHO Expert Advisory Panels as well as from a larger roster of ad hoc experts • There are NUGAG expert groups for the interventions related to Micronutrients, Diet and Health, and Nutrition in Life Course and Undernutrition

32. Global nutrition policies related to DBM • Conclusion: • Many global policy recommendations coming from the WHA related to both maternal and child undernutrition, as well as overnutrition and diet related non-communicable diseases later in the life course. • Little recognition of the linkages of undernutrition and overnutrition across the life course (except breastfeeding). • No overarching umbrella policy framework or guidance, which brings together (even conceptually) the interventions for preventing the DBM across the life course • A new NUGAG process for providing WHA policy and programme guidance to member states, promises to try to increase the cohesion in nutrition interventions for the DBM across the life course

33. Regional policies related to the DBM There have been many political commitments and regional policies adopted for the DBM and NCDs, • September 2007 Declaration of the Heads of State and Government of the Caribbean Community entitled “Uniting to stop the epidemic of chronic non-communicable diseases • August 2008; the Libreville Declaration on Health and Environment in Africa, • November 2009 the statement of the Commonwealth Heads of Government on action to combat non-communicable diseases • March 2010 the Parma Declaration on Environment and Health, adopted by the Member States in the European Region of WHO; • December 2010 the Dubai Declaration on Diabetes and Chronic Non-communicable Diseases in the Middle East and Northern Africa Region, • November 2006, the European Charter on Counteracting Obesity, • June 2011 the Aruban Call for Action on Obesity, • July 2011 the Honiara Communiqué on addressing non-communicable disease challenges in the Pacific region.

34. Country policies and plans for tackling the DBM HOWEVER THERE IS LITTLE REAL ACTION ON THE GROUND AT COUNTRY LEVEL • The Lancet Nutrition Series Paper 4 found that although most countries with high levels of undernutrition have national nutrition policies and plans, most are not implementing the interventions and strategies shown to be effective in addressing the problem “at scale”. • Some interventions are the result of recent advances in research and technology, so implementation is only beginning. Others, however, have been promoted for years or even decades and are still being implemented in only a few areas or not at all, even in countries where the interventions are included in national policies and plans. • Few Poverty Reduction Strategy Papers (PRSPs) include substantive financial provision needed to support robust and sustainable action to address undernutrition. Source: Bryce et al 2008

35. Country policies and plans for tackling the DBM • HOWEVER THERE IS LITTLE REAL ACTION ON THE GROUND AT COUNTRY LEVEL • Despite increasing recognition of the pressing need to address the growing magnitude of noncommunicable diseases and their risk factors and the negative impact on socioeconomic development, official development assistance specifically to support low- and middle-income countries in building sustainable institutional capacity to tackled noncommunicable diseases remains insignificant (WHO 2009 NCD Action Plan Review).

36. Country policies and plans for tackling the DBM Most countries have Plans for nutrition related NCDs, but few are adequately funded Source: WHO 2011

37. Country policies and plans for tackling the DBM HOWEVER THERE IS LITTLE REAL ACTION ON THE GROUND AT COUNTRY LEVEL • The first action plan for food and nutrition policy in the WHO European Region 2000-2005 made the case for developing integrated and comprehensive national food and nutrition policies that address three areas: nutrition; food safety; and sustainable food security. • A survey of food and nutrition policies in Europe in 2003 revealed that less than a third of countries reported having an administrative structure to ensure that such policies are implemented.

38. Country policies and plans for tackling the DBM • CONCLUSIONS • Many countries have policies for both over and undernutrition, but few of these are operational, and/or not being implemented “at scale” mostly for lack of funding. • DBM policies through the Ministry of Health are often split between departments of nutrition and departments of noncommunicable diseases. • How to bring all of this together into comprehensive DBM policy umbrella that spans the life course is a challenge that few countries have mastered, be it in LMICs or the richer ones.

39. Conclusions • Nearly all States are politically committed to progressively ensuring the rights to food health and care (nutrition) for all subjects, as well as to achieving various development goals, including many related to trying to reduce undernutrition to half the levels of 1990 by 2015. However, global political commitments to nutrition are almost solely focussed on maternal and child undernutrition and don't contemplate the DBM across the life course • There are many global policy recommendations coming from the WHA related to both maternal and child undernutrition, as well as overnutrition and diet related non-communicable diseases later in the life course. There is little recognition of the linkages of undernutrition and overnutrition across the life course (except breastfeeding). Furthermore there is no overarching umbrella policy framework or guidance, which brings together (even conceptually) the interventions for preventing the DBM across the life course. The new NUGAG process for providing WHA policy and programme guidance to member states, promises to try to increase the cohesion in nutrition interventions for the DBM across the life course .