Diet and physical activity strategies for NCD

1. Diet and physical activity strategies for NCD Implementation of the WHO Global Strategy on Diet, Physical Activity and Health Dr Timothy Armstrong Coordinator, Surveillance and Population-based Prevention Department of Chronic Diseases and Health Promotion World Health Organization

2. Outline • Diet and physical activity as risk factors for NCDs • Global Response to NCDs • WHO's activities to implement DPAS • Prevention of NCDs through diet and physical activity: What Works? • What works for national policies? • Recommended action at national level • Multistakeholder involvement - key to success • Conclusions

3. Leading causes of attributable global mortality and burden of disease, 2004 % High blood pressure 12.8 Tobacco use 8.7 High blood glucose 5.8 Physical inactivity 5.5 Overweight and obesity 4.8 High cholesterol 4.5 Unsafe sex 4.0 Alcohol use 3.8 Childhood underweight 3.8 Indoor smoke from solid fuels 3.3 59 million total global deaths in 2004 % Childhood underweight 7.8 High blood pressure 7.5 Unsafe sex 6.6 Unsafe water, sanitation, hygiene 6.1 High blood glucose 4.9 Indoor smoke from solid fuels 4.8 Tobacco use 3.9 Physical inactivity 3.8 Suboptimal breastfeeding 3.7 High cholesterol 3.3 1.5 billion total global DALYs in 2004 Attributable DALYs Attributable Mortality

4. Deaths attributed to 19 leading factors,by country income level, 2004

5. Obesity: 5th leading risk factor for death Fact: Being overweight or suffering from obesity is the 5th leading risk for death. It is responsible for: 8% of deaths in high income countries and 7 % of deaths in middle income countries. Source: WHO, 2009

6. Global prevalence and trends of overweight and obesity among preschool children • 43 million children are estimated to be overweight (2010) • In Africa, estimates for childhood overweight and obesity prevalence: • 8.5% in 2010 • expected to increase to 12.7% in 2020 • In developed countries, estimated prevalence of overweight in 2010 was double that in developing countries, but in absolute numbers the prevalence is higher in developing countries (35 vs 8 million) Source: WHO data presented at the WHO Forum and Technical Meeting on Population-based Prevention Strategies for Childhood Obesity; Dec. 2009

7. From risk factors to diseases Risk factors responsible for more than half of the deaths due to heart disease (the leading cause of death in the world): Low fruit and vegetable intake, Physical inactivity, alcohol and tobacco use, high BMI, high cholesterol, high blood glucose, and high blood pressure.

8. A six-year Global Action Plan to address cardiovascular disease, cancer, respiratory disease and diabetes was endorsed by the WHO World Health Assembly on 24 May 2008. What has WHO been doing to mobilize a global response? Global Strategy for the Prevention and Control of Non-communicable Diseases 2000 2002 2003 2004 2008

9.   What has WHO been doing to mobilize a global response? Endorsed by the World Health Assembly in May 2008 by 193 Member States Six objectives: 1. Raising the priority accorded to NCD in development work at global and national levels 2. Establishing and strengthening national policies and programmes 3. Reducing and preventing risk factors 4. Prioritizing research on prevention and health care 5. Strengthening partnerships 6. Monitoring NCD trends and assessing progress made at country level Under each of the six objectives, there are sets of actions for member states, WHO Secretariat and international partners

10. NCD Action Plan Objective 3 Member States are encouraged to implement the recommendations of the Global Strategy on Diet, Physical Activity and Health. Adopted by 192 Member States in 2004 www.who.int/dietphysicalactivity

11. NCD Action Plan Objective 3: WHO's activities to implement DPAS • Normative functions • Guidance, tools and technical support • Global Recommendations on Physical Activity for Health (2009/2010) • Recommendations on marketing of foods and non-alcoholic beverages to children (2007/2010) • Population-based Prevention Strategies for Childhood Obesity (2009/2010) • Multistakeholder platforms for reduction of salt intake at the population level (2010) • Capacity building • Interactions with global private sector • Interactions with UN Agencies

12. WHO's activities: Guidance, tools and technical support DPAS Implementation Tool Box - DPAS - Interventions on diet and physical activity: What Works - A Framework to Monitor and Evaluate Implementation - Guide for Population-based Approaches to Increasing PA - Global recommendations on physical activity for health (2010) - WHO/FAO Framework to Promote Fruits and Vegetables - Reducing Salt Intake in Populations - Prevention of NCDs at the Workplace - Marketing of Food and Non-alcoholic Beverages to Children (2010) - School Policy Framework - DPAS policy database (Member State experiences) http://www.who.int/dietphysicalactivity/implementation/toolbox

13. 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

14. 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.

15. What works for national policies? • Multi-targeted approaches to encourage walking and cycling to school, healthier commuting and leisure activities • Interventions targeting the built environment • Government regulatory policies to support a healthier composition of staple foods • Fiscal policies and point-of-purchase prompts to support healthier choices.

16. NCD Action Plan Objective 3 Example of government regulatory policies: 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

17. NCD Action Plan Objective 3 Example of government regulatory policies: • In 1987, the MoH of Mauritius introduced a regulatory policy to change the composition of general cooking oil: • limiting the content of palm oil and replacing it with soya bean oil. • 5 years after the intervention: • total cholesterol concentrations had fallen significantly in men and women. • Consumption of saturated fatty acids had decreased by an estimated 3.5% of energy intake. • This activity was part of the national NCD intervention programme and a demonstration project within WHO's “Interhealth” initiative Source: WHO, what works, 2009

18. NCD Action Plan Objective 3 Recommended action at national level Brazil Uganda Liberia Chile Laos • develop and implement national guidelines on physical activity for health;

19. NCD Action Plan Objective 3 Recommended action at national level • Introducing transport policies that promote active and safe methods of travelling to and from schools and workplaces, such as walking or cycling; Ciclovia, Bogota, Colombia http://www.streetfilms.org/archives/ciclovia/

20. NCD Action Plan Objective 3 Recommended action at national level Spotlight: The cook Islands health and physical well-being curriculum Spotlight: Inexpensive playground facilities in the UK Spotlight: Physical examination of all students in Iran • Implement school-based programmes in line with WHO’s health-promoting schools initiative; http://www.who.int/dietphysicalactivity/schools

21. Example of effective intervention in schools: Know Your Body – Crete, Greece Intervention: • Know Your Body: 6-year programme (grades 1 to 6) Characteristics: • Comprehensive, multi-component, focus on diet and PA. • Constructs from social learning theory • Curricula offered by trained teachers • Strong parental focus. Outcomes: • 4- to 5-fold increases in self-reported leisure-time activity. • improvements in knowledge and food choices. • reductions in intake of dietary fat. Source: WHO, What Works, 2009

22. Policies & interventions must be multisectoral Involve all relevant sectors and stakeholders Income & Social Status Social Support Networks Education Physical environments Employment & working conditions Health services Healthy child development Personal health practices & coping skills Agriculture, food production and distribution

23. Multistakeholder involvement is key to success WHO's activities NGOs: • International Olympic Committee: • Beijing (2008); London (2012); Brazil (2016) • International Society for Physical Activity and Health • Consumers International • IFAVA • World Heart Federation • International Diabetes Federation • International Association for the Study of Obesity • International Union Against Cancer

24. Multistakeholder involvement is key to success WHO's activities International partners: • FAO, e.g.: fruit and vegetable initiative • UNICEF, World Bank, ILO, UNESCO, WTO, SCN, UN University, IMF, ECOSOC Private Sector: • Informal dialogues with globally represented food and non-alcoholic beverage producers • Interaction with World Economic Forum: Workplace wellness

25. Multistakeholder involvement is key to success WHO & WEF Joint Events WHO: participants from academia, Government agencies, ministries of health, NGOs Joint decision on: goals, objectives, programme, agenda, background papers WEF: Participants from business/ private sector 2 Joint events (China 2007 & India 2008), 2 Joint reports Joint stakeholder mobilization http://www.who.int/dietphysicalactivity/workplace

26. Conclusions • Interventions to improve the dietary habits and PA levels of populations exist and have been successfully implement. • Up to 80% of type 2 diabetes and premature heart disease cases & 40% of cancers could be prevented • Many NCD prevention interventions are simple, cheap and cost effective.