Diet and physical activity: how to develop a national program

1. Diet and physical activity: how to develop a national program Dr Godfrey Xuereb Team Leader Population-based Prevention Department of Chronic Diseases and Health Promotion xuerebg@who.int

2. Outline • Diet and physical activity as risk factors for NCDs • Global Response to NCDs • WHO tools for the implementation of diet and physical activity programmes • Prevention of NCDs: What works? • Multistakeholder involvement - key to success • Examples of national programmes • Conclusions

3. Leading risk factors for global mortality Source: WHO's report on "Global health risks" 60% of global deaths due to NCDs

4. Global response to the NCD epidemic 2000 Global Strategy for the Prevention and Control of Noncommunicable Diseases Member States are encouraged to implement the recommendations of the Global Strategy on Diet, Physical Activity and Health. Adopted by 192 Member States 2003 2004 2008 Ministerial Meetings (Doha) Doha Declaration ECOSOC Ministerial Declaration 2009 Global Strategy to Reduce the Harmful Use of Alcohol Set of Recommendations on the Marketing of Foods to Children UN General Assembly resolution A/RES/64/265 2010 Ministerial meeting, April High-level Meeting, Sept UNSG Report on NCDs 2011

5. Recommendations to Member States • School policies and programmes should support the adoption of healthy diets and PA • Govs should provide accurate and balanced information: • Education, communication, public awareness • Marketing, advertising, labelling, health claims sponsorships • National food and agriculture policies should be consistent with the protection and promotion of public health • Public policies can influence prices through taxation, subsidies or direct pricing in ways that encourage healthy eating and lifelong PA • Support the healthier composition of food by: • reducing salt levels • eliminating industrially produced trans-fatty acids • decreasing saturated fats • limiting free sugars

6. NCD Action Plan 2008 Objective 3 Physical Activity: actions for Member States "Ensure that physical environments support safe active commuting, and create space for recreational activity"

7. WHO tools for the implementation of diet and physical activity programmes http://www.who.int/dietphysicalactivity

8. Guidance, tools and technical support: childhood obesity • Population-based Prevention Strategies for Childhood Obesity: WHO Forum and Technical Meeting, Dec 2009 • Global representation, focus on LMIC, all relevant departments in WHO • Outcomes: • Meeting report (2010); • Development of a guide for population-based approaches to prevent childhood obesity (2011) • "Tool" for Member States to determine and identify priority areas for action in the prevention of childhood obesity(2011)

9. Childhood obesity: Examples of actions for governments identified by meeting participants • Ensure that policies include children with disability and vulnerable groups • Mix of "top-down" and community based actions in plans and programmes. • Encourage the use of legislative and financial tools. • Ensure that prevention of CO is integrated into a comprehensive nutrition policy. • Implement recommendations on marketing of foods and non-alcoholic beverages to children • Work in a healthy setting approach including: homes, pre-schools and schools, playgrounds, sports facilities, health care and community organizations. • Work with all relevant stakeholders to support policy development, adherence and implementation while minimizing conflicts of interest. • Develop comprehensive surveillance systems.

10. Recommendations on marketing of foods to children • 12 recommendations covering: • Policy development • Policy implementation • Monitoring and evaluation • Research • Main purpose: "to guide efforts by Member States in designing new and/or strengthening existing policies on food marketing communications to children in order to reduce the impact on children of marketing of foods high in saturated fats, trans-fatty acids, free sugars, or salt." • Implementation Framework developed (2011) • Platform for sharing of experiences, resources and best-practice models http://www.who.int/dietphysicalactivity/marketing-food-to-children/en/index.html

11. Some Data from the Private Sector • Food companies spent USD 38.1 billion on advertising in 2011 • Up by 11% since 2010 • 5 dollars per person in the World • USD1.5 billion per year on marketing to youth • USD3 billion annually marketing spend by fast food companies

12. Some more data from the Private Sector • In 2009 companies spent USD 55.2 billion on online advertising • Spain increased its spending on online marketing by 20% in 2010 • France online marketing spending reached 16% of all ads • By 2014 projected to be 21% of all ads

13. Some Internet Data • 169488 new fans join the Coca Cola website daily • Rated second most popular page on Facebook in 2009 • Second only to Barack Obama • Coca-Cola Happiness Machine (YouTube) had 3,545,029 hits in May 25, 2011 • It collected 50,000 views in 24 hours to reach 3,550,919 by May 26, 2011 • Pepsi mobile "Battle of Bands" in China attracted over 15 million users with a cost of USD 0.01 per user

14. Some Data from the Quick Service Industry • In 2009 out of USD 1,182 billion that America spent on food 48.6% was spent on food away from home • In 2008 the quick service industry in the USA spent USD 360 million on giveaway toys and USD 67 million on other prizes for children and teenagers

15. Marketing influences

16. Strong evidence for the link between salt and health Primarily linked with CVD • Sodium consumption increases BP • BP increases CVD risk • Age, sex and baseline BP specific effects . Source: He et al. J Human Hypertension, 2008

17. Reducing sodium intake at the population level Findings from the USA (Bibbins-Domingo et al. (2010) N Engl J Med;362:590-9): The reduction in salt intake of 3g per day would save $10 to $24 billion in health care costs annually. The intervention would be cost saving with even a modest reduction of 1g per day, and more cost-effective than using medications to lower blood pressure. Findings from the USA (Palar, Sturm (2009) AJHP: 24(1)49-57.): Reducing average population sodium intake to 2300 mg/day, the recommended maximum for adults, may save $18 billion health care costs. Large benefits to society may result from efforts to lower sodium consumption on a population level by modest amounts over time. Argentina: reduction in salt intake is the most cost-effective strategy (only $151 per DALY) in reducing CVD compared with other strategies such as mass media campaign ($547), drug therapy ($3,599), and tobacco cessation programs ($33,563).

18. Population Salt Reduction Strategies: WHO Action Creating enabling environment Evaluation and monitoring Salt: vehicle for fortification WHAT 1 2 3 Consumer education Sodium consumption Iodine fortification HOW Product Reformulation Food Composition Data Reduction of salt intake Policy makers Private sector NGOs Academia Policy makers Private sector NGOs Academia Policy makers NGOs Academia UN Agencies WHO London, England 30 June – 1, 2 July 2010 Calgary, Canada 18-20 October 2010 Date and location to be determined

19. Within Brand differences • Tesco Tomato Ketchup • Top Down 1.2gNa/100g • Standard 0.7gNa/100g • Value 0.4gNa/100g • Organic 0.4gNa/100g • Low Salt 0.2gNa/100g

20. Within Type differences • Low Salt Tomato Ketchup • Heinz 0.7gNa/100g • Tesco 0.2gNa/100g • Sainsbury 0.18gNa/100g

21. Country differences • Uncle Bens Long grain & Wild Mushroom Rice • USA 1.0gNa/100g • Canada 0.5gNa/100g • Australia 0.32gNa/100g • UK 0.32gNa/100g • Dr Oatker Quattro Formaggi Pizza • Finland 1.2gNa/100g • USA 0.49gNa/100g • UK 0.48gNa/100g

22. Country differences • Pringles Sour Cream and Onion • Australia 0.67gNa/100g • Ireland 0.64gNa/100g • USA 0.54gNa/100g • Campbell Tomato Soup • Finland 0.8gNa/100g • Canada 0.51gNa/100g • USA 0.48gNa/100g • Australia 0.39gNa/100g

23. Country differences • McCain Classic Cut Fries • USA 0.42gNa/100g • UK 0.30gNa/100g • Canada 0.19gNa/100g • Kellogg Special K • UK 0.85gNa/100g • Canada 0.79gNa/100g • USA 0.70gNa/100g • Australia 0.54gNa/100g • Ireland 0.45gNa/100g • Kellogg Cornflakes • UK 0.7gNa/100g • Canada ….gNa/100g • USA 0.7gNa/100g • Australia 0.7gNa/100g • Ireland 0.5gNa/100g

24. Has it been done with success?Reducing dietary sodium intake – UK example • Areas of work: • Working with food industry (retailers, manufacturers catering sector and small businesses) to reduce levels of salt in foods • Consumer awareness work • Clear food labelling • Monitoring and promoting success • Reductions in salt consumption in adults: • Decrease of 9%: daily salt intake has fallen from 9.5 grams in 2000/2001 to 8.6 grams in 2008 – • Reductions in salt content: • 16% in bread (2004 to 2008); over 33% overall (since 1980s) • 49% in breakfast cereals (1998 to 2008) • 25 to 55% in cakes and biscuits, crisps and snacks (2006/07) • Around 30% in soups and sauces, some processed cheeses spreads (2003-05) Source: Food Standards Agency, United Kingdom

25. Global recommendations on PA for Health • Why? • Limited existence of national guidelines in LMIC; different guidelines • Evidence based starting point to promoting PA + advocacy • Target audience: national policy makers Recommendations: • 5-17 yrs old: at least 60 minutes of moderate to vigorous intensity PA daily. • +18 yrs old: at least 150 minutes of moderate-intensity aerobic PA spread throughout the week or do at least 75 minutes of vigorous-intensity aerobic PA spread throughout the week or an equivalent combination. • 65yrs old & above: with poor mobility, should perform PA to enhance balance and prevent falls on 3 or more days/ week. • When 65yrs old & above adults cannot do the recommended amounts of PA due to health conditions, they should be as physically active as their abilities and conditions allow.

26. Example of success: Ciclovias, Bogotá, Colombia A cross between a street party and a marathon, Bogota's Ciclovía manages to combine sport, recreation, health, commerce and culture in one package. • Improvements in public transport at the city level. • % persons travelling by car has dropped from 17% to 12% during peak times. • 55% of programmes provide economic opportunities through temporary businesses. • 63% of programs surveyed reported engaging the community through volunteerism,. • Ciclovia has now extended to more than 38 cities in at least 11 countries in the Americas.

27. National strategies on diet and physical activity • Conduct a situation analysis (e.g.: STEPS survey) • Establish a coordinating team to develop the policy/ strategy/ programme • Multisectoral collaboration: • Coordinating mechanism headed or chaired by ministry of health. • Multisectoral collaboration containing representation from all key sectors including competent scientific bodies, NGOs, academia, civil society, communities, the private sector, and media. • Identification of necessary resources and national focal points for implementation (as well as key national institutes) • Include specific, measurable and goals, objectives and actions • Ensure that surveillance, monitoring and evaluation is part of the policy/ strategy/ programme

28. Prevention of NCD: What works? • Multi-component interventions • Adapted to the local context • Culturally and environmentally appropriate interventions • Using existing social structures of a community (e.g. schools, weekly meetings of older adults) • Multistakeholder involvement throughout the process • Listening, learning and targeting populations needs. • Interventions targeting the built environment. • Government regulatory policies to support a healthier composition of staple foods. • Government interaction with food producers aiming at product reformulation to reduce content of sodium in foods, in countries where the main sources of dietary sodium consumption are processed foods and foods eaten outside the house. http://www.who.int/dietphysicalactivity/whatworks/

29. Framework for implementation at the national level • Reduction in the prevalence of: • Raised BP • Raised Cholesterol • Physical Inactivity • Obesity • Diabetes Reduction in the prevalence of: • Raised BP • Raised cholesterol • Physical inactivity • Obesity • Diabetes

30. Multisectoral Approach to Prevention

31. Urban Planning

32. What works for national policies? Example of a regulatory approach In Denmark, as of 1 January 2004: • the level of industrially produced TFA in oil and fats intended for the consumer, either alone or as an ingredient in foods, must not exceed 2%. The rules do not apply to TFA naturally occurring in animal fats. • Surveys on target products 2002-03 and 2004-05 showed: • Significant decrease in products >2 % TFA • Low level of transgression (2-6 %) • Replacement of removed TFA: Both monounsaturated and saturated fats • IP-TFA reduced to negligible level in all product groups • No signs of increase in intake of saturated fats • New methods of production developed • No increase in prices • No reduction of product variability Source: Paolo M. DrostbyDept. Head of Division for Nutrition Danish Ministry of Food, Agriculture and Fisheries

33. Conclusions • Up to 80% of type 2 diabetes and premature heart disease cases & 40% of cancers could be prevented • Interventions to improve the dietary habits and PA levels of populations exist and have been successfully implemented. • Many NCD prevention interventions are simple, cheap and cost effective; example of "best buy": salt reduction programmes • Engaging all relevant stakeholders from sectors outside health is critical factor for effective and successful prevention; attention should be paid to: • Roles and responsibilities of each stakeholder • Management of conflict of interests

34. The Floor is Yours ! http://www.who.int/dietphysicalactivity/en/