Presentation Transcript

1. The Double Burden of MalnutritionGCHB 6780Roger ShrimptonJohn MasonLisa Saldanha

   18 February 2013 Class 9:Policy and Programmes for Prevention of DBM II
2. Content Program recommendations for DBM (pp34-42) Programme interventions needed for tackling the DBM across the life course Direct interventions Health system “continuum of care” School system Workplace Indirect Interventions Limiting promotion of “unhealthy food” to children Food labeling public educational campaigns Fiscal policies Transport policy and environmental design Conclusions Case Studies Readings: Swinburn BA, Caterson I, Seidell JC, James WPT 2004. Diet, nutrition and the prevention of excess weight gain and obesity. (Anne) Gillespie S, Haddad L. 2001. Attacking the Double Burden of Malnutrition in Asia and the Pacific. Pp131-146 (Rory)
3. Programme interventions for tackling the DBM across the life course Program interventions needed for each stage of the life course The risks associated with malnutrition grows across the life course Source: Uauy and Solomons 2006)
4. Programme interventions for tackling the DBM across the life course Attacking the Double Burden of Malnutrition in Asia and the Pacific Gillespie S, Haddad L J 2001 Recognizes that little exists on the ground but proposes how to build and create such programmes
5. Programme interventions for tackling the DBM across the life course Building on the Table proposed by Gillespie S, Haddad L J 2001 Interventions to be UPDATED BASED ON LANCET NUTRITION SERIES Direct Interventions are at individual level Indirect actions are at the household/community levels Also known as Nutrition specific and Nutrition sensitive in the SUN framework
6. Package of Essential Nutrition Interventions for MCUEvidence-based “Direct” and “Indirect” interventions, Lancet Nutrition Series (Bhutta et al 2008) Maternal and birth outcomes Iron folate supplementation Maternal supplements of multiple micronutrients Maternal iodine through iodized salt Interventions to reduce tobacco consumption and indoor air pollution Maternal supplements of balanced energy and protein** Maternal deworming in pregnancy Maternal calcium supplementation Intermittent preventative treatment of malaria* Insecticide treated bednets* Newborn babies Promotion of breastfeeding (individual and group counseling) Delayed cord clamping Infants and children Promotion of breastfeeding (individual and group counseling) Behaviour change communications for improved complementary feeding Zinc in management of diarrhoea Vitamin A supplementation Universal salt iodization Handwashing or hygiene interventions Treatment of severe acute malnutrition Conditional cash transfer programmes (with nutritional education) Deworming Iron fortification and supplementation programmes Insecticide-treated bednets* *In areas with malaria **For women from poor families
7. Page 36 of DBM paper Lancet Nutrition Series Package for MCU (Bhutta et al 2008) * depending on local circumstances
8. “Continuum of Care” for Maternal Newborn and Child Health Direct interventions for MCU are largely provided through the continuum of HEALTH CARE SERVICES. The LNS package if taken to scale in LMICs would prevent about ¼ of deaths in young children and reduce the prevalence of stunting by 1/3. Source: Kerber et al 2003
9. Page 36 of DBM paper Reviews of evidence on diet and nutrition causes of obesity. -Swinburn et al 2004. - Gortmaker et al 2011 Lancet Obesity Series 4
10. Recommentations on Physical Activity WHO 2010 Adults aged 18-64y should do at least 150 minutes of moderate physical activity , or 75 minutes of vigorous physical activity throughout the week Children aged 5-17 y should accumulate at least 60 minutes of moderate physical activity daily
11. School based direct Interventions Schools have been found to be a critical setting for preventing child obesity*, as well as reducing other chronic disease risk factors and improving fitness**. School based programmes should cover the role of nutrition and physical activity, with school food services providing healthy meals, in addition to the promotion and provision of daily physical exercise as part of the curriculum. An example is provided by the Nutrition Friendly Schools Initiative (NFSI) which aims to increase access and availability of healthy foods as well as opportunities to be physically active, and to support healthy lifestyles***. *Waters E, de Silva-Sanigorsky A, Hall BJ, Brown T, Campbell KL, Gao Y, Armstrong, R, Prosser L, Summerbell CD. 2011. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 12:CD001871 **Flynn MA, McNeil DA, Maloff B, Mutaswinga D, Wu M, Ford C, Tough SC. 2006. Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with “best practice” recommendations. Obes Rev. Suppl 1:7-66 ***WHO 2006. Nutrition Friendly Schools Initiative (NFSI) available at http://www.who.int/nutrition/topics/nut_school_aged/en/index.htmli as well as at http://www.dur.ac.uk/school.health/orb/research/whonfsi/and http://www.ph.ucla.edu/chs/nfsc/index.htm
12. School based direct Interventions The NFSI encourages schools to make active efforts to improve the nutritional status of children and adolescents and increase their physical activity levels by meeting the following minimum criteria: develop a written nutrition-friendly school policy identifying objectives and setting timelines and milestones develop an action plan identifying roles and responsibilities and methods for monitoring and reporting against the objectives ensure awareness and capacity building of the school community (teachers, school staff, parents, schoolchildren, local community) ensure curriculum development and modification regarding nutrition and physical activity education provide a supportive school environment  (healthy foods and opportunities for physical activity) provide school nutrition and health services.
13. School based direct Interventions in LMICs NFSI should also include micronutrient and life-skill interventions aimed at adolescents especially in order to control anemia as achieved so successfully in Uttar Pradesh India * UCLA have also developed a NFSI pilot study on Los Angeles and the findings are very encouraging as reported in this report *Vir SC, Singh N, Nigam AK, Jain R. 2008 Weekly iron and folic acid supplementation with counseling reduces anemia in adolescent girls: a large-scale effectiveness study in Uttar Pradesh, India. Food Nutr Bull. 29(3):186-94.
14. Adulthood:Direct interventions by health care provider Interventions by health care providers aimed at controlling overweight/obesity in adults can also be very effective, especially if they are trained to measure BMI and/or waist circumference, so that they can detect patients who are either overweight and/or gaining weight*. Even brief messages about nutrition through diet counseling can influence behavior and the magnitude of the effect is related to the intensity of the intervention. A more recent meta analysis confirmed these findings**. * Pignone MPA, et al 2003. Counselling to promote a healthy diet in adults: A summary of the evidence for the US Preventive Services Task Force. Am J Prev Med. 24: 75-92. **Alice Ammerman A, Pignone M, Fernandez L, Lohr K, Jacobs AD, Nester C, Orleans T, Pender N, Woolf S, Sutton SF,Lux LJ,Whitener L, 2008. Systematic Evidence Review Number 18: Counseling to Promote a Healthy Diet. Rockville: Agency for Healthcare Research and Quality
15. Adulthood:Worksite direct interventions Offering staff education, screening for risk factors, incentives to walk or ride a bike to work and facilities for exercise during breaks, as well as healthy foods in cafeterias, can reduce staff sick days and health costs to the benefit of both employers and employees. An example is provided by Johnson & Johnson which introduced Live for Life in 1979 and by the end of the third year savings to the company were more than US$400 per year per employee*. A recent systematic review of worksite nutrition interventions provides further support to these findings **. *Bly JL, et al 1986. Impact of worksite health promotion on health care costs and utilization. Evaluation of Johnson & Johnson´s Live for Life program. JAMA 256: 3235-3240. **Anderson LM, Quinn TA, Glanz K, Ramirez G, Kahwati LC, Johnson DB, Buchanan LR, Archer WR, Chattopadhyay S, Geetika P, Kalra GP, Katz DL,Task Force on Community Preventive Services 2009. The Effectiveness of Worksite Nutrition and Physical Activity Interventions for Controlling Employee Overweight and Obesity: A Systematic Review. Am J Prev Med 37(4): 340–357
16. Page 29 of DBM paper
17. Indirect interventions: Limiting promotion of “unhealthy food” to children Ban on vending machines in school Many countries (e.g. UK, France) and states in the USA have introduced bans on vending machines in schools Control of advertising of food to children Recent WHA Resolution (WHA 63.14) proposed by Norway called for Member States to implement a set of recommendations which aim to reduce the impact on children of the marketing of 'junk' foods.  They call on Governments to restrict marketing,  including in 'settings where children gather' such as schools and to avoid conflicts of interest. Many developed countries have adopted bans on advertising (of food) to children , but little regulation in LMICS Code of marketing of breastmilk substitutes Passed by WHA in 1982 as a “minimum requirement” for all states. As of April 2011, only 37 states (22%) have the code as law, and 50% have few if any of the provisions as law (UNICEF 2011) *
18. Indirect interventions: Food labeling Nutrition profiling Nutrient profiling is the science of classifying or ranking foods according to their nutritional composition (WHO 2012). Such classifications can be used for various applications, including marketing of foods to children, health and nutrition claims, product labeling logos or symbols, information and education, provision of food to public institutions, WHO is working to provide guidance in developing or adapting nutrient profile models. The aim of the work is to harmonize nutrient profile model development to produce consistent and coherent public health nutrition messages for the consumer and ultimately improve nutrition and public health Food claims Based on such nutrient profiles claims on food labels and in marketing for being “low fat” or “healthy choice” can be regulated The food industry has also pledged to self regulate, but very stringent standards are needed if self regulation is to be effective. Evidence for the effectiveness of “front of pack” labeling is weak. Labels are most used by educated and richer segments of population.
19. Indirect Interventions: General public educational campaigns promoting a “healthy diet” Promotion of “Healthy diets” based on the food group and food pyramid approach has been much criticized, not least because during the thirty years they were employed obesity rates in the US have soared. The original food pyramid aimed at limiting fat intake, and in general seems to have had an effect, with low fat diets and special “light” foods becoming very popular. But with no differentiation between types of fats, the benefits of the “good” unsaturated fats were forgone Guidelines also recommended consumption of a more starchy foods, and in particular grains (cereals) and cereal products, with little or no consideration given to the benefits of eating reduced carbohydrate diets, and no differentiation between the types of processing that the cereal and/or starches have been subject to. Lobbying has also distorted the intention and defeated objectives of the pyramids
20. Indirect interventions: Fiscal policies Fiscal policies such as subsidies and taxes can either stimulate or reduce consumption of products including foods. Poland provides an example where reduced subsidies on lard and butter soon after the transition to a democratic government, resulted in a rapid increase in the consumption of cheaper non-hydrogenated vegetable fat. In consequence the ratio of dietary polyunsaturated to saturated fat increased from 0.33 in 1990 to 0.56 in 1999 and mortality from CAD dropped 28%*. Most US states have laws that regulate the availability of sugar sweetened beverages in school settings, although it is difficult to find evaluations of the effectiveness of such measures. A tax on sugar sweetened beverages has many proponents**, and if sufficiently large (20%) has great potential to reduce obesity as well as to raise revenues. *Zatonski et al 1998. Ecological study of reasons for the sharp decline in mortality from ischaemic heart disease in Poland since 1991. BMJ 316: 1047-1051. **Andreyeva T, Chaloupka FJ, Brownell KD. 2011. Estimating the potential of taxes on sugar-sweetened beverages to reduce consumption and generate revenue. Prev Med 52(6): 413-6 ***Sharma LL, Teret SP, Brownell KD. 2010. The food industry and self regulation: standards to promote success and to avoid public health failures. Am J Public Health 100(2):240-246
21. Indirect interventions: Transport policy and environmental design Transport policy and environmental design have fundamental effects on the determinants of physical activity and therefore influence the risk of obesity and other chronic diseases. Limiting the role of automobiles is one important area for interventions and this can be achieved by a variety of channels including making private car ownership and use more expensive by raising taxes on cars as well as on fuel, introducing road tolls and congestion charges, as well as parking fees. The fees collected can be used to improve the provision of public transportation. Walking and biking can also be encouraged by including creating special bike lanes, as well as making town centers pedestrian precincts. Increasing the space available for leisure activities such as playing fields for sport and parks and public gardens will also encourage more walking and running around.
22. Cost-effective interventions aimed at tackling obesity by improving diets and increasing physical activity can produce large gains in health outcomes Calculations used this model to simulate chronic disease prevention in the seven countries (China, India, Brazil, Russa, England, Mexico, South Africa). NB It doesnt include sugar Source:Cecchini M, et al. 2010. Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness. Lancet 376: 1775-1783.
23. Cost-effective interventions aimed at tackling obesity by improving diests and increasing physical activity can produce large gains in health outcomes: Especially through regulation of food advertising Source:Cecchini M, et al. 2010. Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness. Lancet 376: 1775-1783.
24. These interventions have a different impact over time, with physician counselling producing the quickest impact and advertising regulation taking longer but eventually becoming a bigger contributor to health improvement Source:Cecchini M, et al. 2010. Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness. Lancet 376: 1775-1783.
25. Conclusions Programmes are needed for tackling the DBM across the life course, and because risk accumulates prevention in early life is critically important. A framework is proposed which groups interventions as “direct” and “indirect” by stage of the life course The Health services are the principal service delivery channel for a package of direct nutrition interventions for protecting against maternal and child undernutrition , that are equally relevant in LMIC and richer country settings. Health care providers can also be effective in helping control overweight/obesity later in the life course with counseling. Direct interventions through schools are critical for preventing child obesity, as well as reducing other chronic disease risk factors and improving fitness Direct interventions also exist for employees in the work place, including provision of healthy foods and exercise during work hours, that benefit both employers and employees. Among the indirect interventions the limiting of sales and promotion of unhealthy foods to children is proven and increasingly being adopted by national authorities General public education through the use of “food pyramids” has not been shown to be effective, and requires a more comprehensive and coherent approach, including links to food labelling and fiscal policies. There is considerable evidence that modifying the price of “unhealthy” foods through removing subsidies and/or imposing taxes can be effective.