Revisao WHO-Global Nutrition Policy Review

7/28/2019 Revisao WHO-Global Nutrition Policy Review

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Global nutritionpolicy review:What does it take

to scale up nutrition action?


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WHO Library Cataloguing-in-Publication Data

Global nutrition policy review: what does it take to scale up nutrition action?

1.Nutrition policy. 2.Malnutrition prevention and control. 3.Child nutrition disorders prevention and control. 4.Chronic disease. 5.Obesity.6.Overnutrition prevention and control. 7.Wasting Syndrome prevention and control. 8.Inant, Low birth weight. I.World Health Organization

ISBN 978 92 4 150552 9 (NLM classifcation: QU 145.7)

World Health Organization 2013

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Acknowledgements

Preface

Acronyms

Glossary

Executive summary

1. Background

2. Current global nutrition challenges

2.1Malnutrition and causes o death and disability2.2Child malnutrition2.3Adult overweight and obesity2.4Vitamin and mineral malnutrition

2.4.1 Iron deciency and anaemia2.4.2 Vitamin A deciency

2.4.3 Iodine deciency

2.5Inant and young child eeding2.6Undernourishment

3. Methods and findings of the Global Nutrition Policy Review

3.1Methods3.2Respondents3.3Analysis o policy environment and governance 3.3.1 National policy and institutional environment

3.3.2 Policy content3.3.3 Policy coordination3.3.4 Nutrition in national development plans3.3.5 Nutrition surveillance

3.4Analysis o policy implementation in specic areas 3.4.1 Maternal, inant and young child nutrition

3.4.2 International Code o Marketing o Breast-milk Substitutes3.4.3 School programmes

3.4.4 Vitamin and mineral nutrition3.4.5 Obesity and diet-related noncommunicable diseases3.4.6 Food security and agriculture

3.5Analysis o policy coherence 3.5.1 Stunting

3.5.2 Maternal undernutrition and low birth weight3.5.3 Womens overweight and obesity3.5.4 Double burden o malnutrition

3.5.5 Policy environment or scaling up interventions

4. Conclusions

5. The way forwardReferences

Contents

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List of boxes Box 1. Regional strategies and plans o action on nutrition

Box 2. We are what we eat: communication or political consensus and improvedood security in the PacicBox 3. Pan American Alliance or Nutrition and DevelopmentBox 4. Developments in ood and nutrition policy in Slovenia

Box 5. Reductions in stunting and in inequalities in stunting in BrazilBox 6. Kuwaiti nutrition surveillance systemBox 7. Adoption o WHO Child Growth StandardsBox 8. Implementation o actions o high priority in the WHO Global Strategyor Inant and Young Child FeedingBox 9. Promotion o breasteeding and the Baby-riendly Hospital Initiativein MalaysiaBox 10. The Baby Friendly Initiative in New ZealandBox 11. The inant and young child eeding programme in the PhilippinesBox 12. The Yen Bai story: a public health approach to reducing anaemia andimproving womens health in Viet NamBox 13. Combating iodine deciency disorders: a success story rom NigeriaBox 14. Wheat four ortication in JordanBox 15. Eect o French nutrition policy on the prevalence o obesityBox 16. Summary o policy gaps

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The review and preparation o the report were coordinated by Ms Kaia Engesveen

under the supervision o Dr Chizuru Nishida o the World Health Organization (WHO)Nutrition Policy and Scientic Advice Unit, Department o Nutrition or Health andDevelopment. Dr Francesco Branca, Director o the Department, provided valuableinput and guidance. Proessor Barrie Margetts o the University o Southamptonhelped in preparation o early drats o the report as a consultant.

Thanks are due to the nutrition ocal points in WHO Country Oces and their nationalcounterparts and colleagues in ministries o health, agriculture and other sectors; andto partner agencies in the 123 countries and territories that supported the Reviewand completed the questionnaire. We express our deep appreciation to the RegionalNutrition Advisers in the WHO regional oces and the intercountry support teams,including Dr Ayoub Al-Jawaldeh, Dr Kunal Bagchi, Ms Caroline Bollars, Dr JooBreda, Dr Frima Coulibaly-Zerbo, Dr Tomasso Cavalli-Sorza, Dr Abel Dushimimana,Dr Aichatou Diawara Gbaguidi, Dr Chessa Lutter, Dr Charles Sagoe-Moses, Ms UrsulaTrbswasser and Ms Trudy Wijnhoven or coordinating the country consultations ineach region and subregion, providing country case studies and reviewing the report.

Acknowledgement is also made to the colleagues in other WHO departments andthe United Nations Standing Committee on Nutrition (UNSCN) or their contributionsand comments. These include Dr Rdiger Krecht and Ms Nicole Britt Valentine o theDepartment o Ethics, Equity, Trade and Human Rights; Dr Marcus Stahlhoer andDr Cynthia Boschi Pinto o the Department o Maternal, Newborn, Child andAdolescent Health; Dr Regina Guthold and Dr Godrey Xuereb o the Department o

Prevention o Noncommunicable Diseases; Ms Tanja Kuchenmller o the Departmento Food Saety, Zoonoses and Foodborne Diseases; Ms Wahyu Retno Mahanani andMs Florence Rusciano o the Department o Health Statistics and Inormatics; Dr NickBanatvala o the Oce o the Assistant Director-General, Noncommunicable Diseasesand Mental Health; and Ms Lina Mahy and Dr Marzella Wsteeld o UNSCN.

Numerous experts also provided valuable inputs and contributions to the document,including Ms Laura Addati, Proessor Sharon Friel, Dr Stuart Gillespie, Dr CorinnaHawkes, Proessor Tim Lang, Dr Tim Lobstein, Proessor Carlos Monteiro, Dr VictoriaQuinn, Dr Roger Shrimpton and Dr Patrick Webb. Helpul comments were alsoreceived rom 11 stakeholders in academia, nongovernmental organizations and the

private sector through a global web-based consultation in early 2011.

Technical input and data rom nutrition surveys were provided by a number o colleagues inthe Department o Nutrition or Health and Development, including Dr Nancy Aburto,Dr Carmen Casanovas, Ms Monika Blssner, Dr Elaine Borghi, Ms Chantal Gegout,Ms Emma Kennedy, Ms Ann-Beth Moller, Dr Hannah Neueld, Dr Luz de Regil, Dr Mercedesde Onis, Dr Adelheid Onyango, Dr Juan Pablo Pena-Rosas, Ms Grace Rob, Ms PatriciaRobertson, Dr Lisa Rogers, Ms Randa Saadeh, Dr Amani Siyam and Ms Zita Weise-Prinzo.

Special appreciation is also expressed to the interns who compiled data and prepared tables:

Ms Eunice Abiemo, Ms Laurel Barosh, Ms Katherine Bishop, Ms Giselle Casillas, Dr Crystal

Cheng, Ms Hareyom Ghang, Ms Nathalie Kizirian, Ms Veronika Polozkova and Mr Jerey Yu.

Acknowledgement is also made to Mrs Elisabeth Heseltine in France and Dr HilaryCadman rom Cadman Editing Services in Australia or technical editing o thisdocument and Ms Valentina Frigerio and Mr Giacomo Frigerio rom Blossom in Italyor the cover design and layout.

Acknowledgements


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The double burden o undernutrition and obesity is one o the leading causes

o death and disability globally. In 2011, 165 million children under the age o 5years were stunted and 52 million had acute malnutrition, while 43 million wereoverweight or obese. Among adults, 500 million women were anaemic, and500 million people were obese. Childhood malnutrition is the underlying causeo more than one in three deaths among children under the age o 5 years, andnegatively aects cognitive development, school perormance and productivity.Approximately 200 million children are unable to attain their ull developmentpotential because o stunting and micronutrient deciency.

Improving nutrition is central to achieving the Millennium Development Goals(MDGs) and to the agenda or sustainable development. World leaders at the G8and G20 summits acknowledged the importance o addressing nutrition in orderto achieve development goals, and recognized that ood security and nutritionare key or sustainable development. A healthy diet is an important means orpreventing and controlling noncommunicable diseases (NCDs), as stated in theHigh-level Political Declaration on the prevention and control o NCDs.

WHO conducted a review o the presence and implementation o nutritionpolicies in countries in order to identiy gaps. This report summarizes theoutcome o the analysis, conducted in 123 countries and territories. The reviewwas undertaken as part o the preparation o the Comprehensive ImplementationPlan on Maternal, Inant and Young Child Nutrition, which was endorsed by the65th session o the World Health Assembly in May, 2012.

More than 90% o the responding countries in each region have policies andprogrammes that cover issues such as undernutrition, obesity and diet-relatedNCDs, inant and young child nutrition, and vitamins and minerals. Nevertheless,major gaps were identied in the design and content o some policies andprogrammes, in nutrition governance, in policy implementation, and in monitoringand evaluation. Furthermore, maternal undernutrition has received inadequateattention.

The Comprehensive Implementation Plan on Maternal, Inant and Young ChildNutrition includes a set o recommended actions which, when implemented

collectively by the health, agriculture, education, social support and tradesectors, will address the growing public health burden o malnutrition. The planalso includes global targets to be achieved by 2025:

1. 40% reduction in childhood stunting;

2. 50% reduction in anaemia in women o reproductive age;

3. 30% decrease in low birth weight;

4. 0% increase in childhood overweight;

5. an increase in the rate o exclusive breasteeding in the rst 6 months to atleast 50%;

6. a reduction in childhood wasting to less than 5%.

Preface

Dr Oleg Chestnov

AssistantDirector-GeneralNoncommunicableDiseases and MentalHealthWorld HealthOrganization


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These targets will guide global action in nutrition in the next decade, to

accompany those that Member States are discussing or reducing NCDs.

The commitment o the World Health Assembly to global nutrition issuesenhances the political impact o the Scaling-up Nutrition (SUN) Movement, whichbrings together high-level political leaders in governments, the United Nations(UN) system, civil society and the private sector. Nutrition is a priority o WHOs12th General Programme o Work. Within WHO, the Department o Nutritionor Health and Development, in the cluster o Noncommunicable Diseasesand Mental Health, will lead eorts in various parts o the organization. It willprepare guidance or reducing undernutrition, obesity and diet-related NCDs,monitor nutritional conditions and policy response, advocate or implementationo eective nutrition programmes, and assist Member States in adopting andadapting eective actions.

I would like to end with a statement made by Dr Margaret Chan, the Director-General o WHO, in a speech that she delivered at a high-level meeting onnutrition on the occasion o the UN High-level Meeting o the General Assemblyon the Prevention and Control o Non-communicable Diseases (New York,20 September 2011): We know what to do. We can reduce maternal anaemia,low birth weight and child stunting and bring down the risk o noncommunicablediseases within a generation. We can achieve this by giving nutrition the attentionit deserves.


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BFCI Baby Friendly Community Initiative

BFHI Baby-riendly Hospital Initiative

BFI Baby Friendly Initiative

BMI body mass index

CAADP Comprehensive Arica Agriculture Development Programme

CAP Common Agricultural Policy

CDC Centres or Disease Control and Prevention

CESCR Covenant on Economic, Social and Cultural Rights

CI confdence intervalCIP Comprehensive Implementation Plan

CSDH Commission on Social Determinants o Health

CSOs civil society organizations

FAO Food and Agriculture Organization o the United Nations

GINA Global database on the Implementation o Nutrition Action

HIV/AIDS human immunodefciency virus/acquired immunodefciency syndrome

IBRD International Bank or Reconstruction and Development

ICN International Conerence o Nutrition

ILO International Labour Organization

MDGs Millennium Development Goals

NCD noncommunicable disease

NEPAD New Partnership or Aricas Development

NGOs nongovernmental organizations

OR odds ratio

PAHO Pan American Health Organization

REACH Renewed Eorts Against Child Hunger and Undernutrition

SPSS Statistical Package or Social Science

SUN Scaling-up Nutrition

UN United Nations

UNICEF United Nations Childrens Fund

UNSCN United Nations Standing Committee on Nutrition

WHA World Health Assembly

WHO World Health Organization

Acronyms


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GlossaryAdult underweight and overweight: dened by the body mass index (BMI): a

simple index o weight-to-height. BMI is age-independent or adult populations andis the same or both genders. It is dened as the weight in kilograms divided by thesquare o the height in metres (kg/m2). A BMI o < 17.0 indicates moderate andsevere thinness, < 18.5 indicates underweight, 18.524.9 indicates normal weight, 25.0 indicates overweight and 30.0 indicates obesity.

Anaemia: a condition in which the number o red blood cells or their oxygen-carrying capacity is insucient to meet physiological needs, which vary by age,altitude, gender, pregnancy status and smoking status. The most common causeo anaemia globally is iron deciency, but other causes include deciencies inolic acid, vitamin B

12and vitamin A; chronic infammation; parasitic inections;

and inherited disorders. Severe anaemia is associated with atigue, weakness,dizziness and drowsiness. Pregnant women and children are particularly vulnerableto anaemia. In children aged 659 months and in pregnant women, anaemia isdened by a haemoglobin concentration o < 110 g/l at sea level.

Breasteeding indicators

Early initiation o breasteeding: proportion o children born in the past24 months who were put to the breast within 1 hour o birth.

Eclusive breasteeding under 6 months: proportion o inants aged05 months who are ed exclusively with breast milk.

Continued breasteeding at 1 year: proportion o children aged 1215 monthswho are ed breast milk.

Child obesity: weight-or-height > 3 standard deviations above the WHO childgrowth standard median or children aged under 5 years. In some countries,overweight and obesity in children are measured as BMI centiles or age.

Child overweight: weight-or-height > 2 standard deviations above the WHO childgrowth standard median or children aged under 5 years.

Child stunting: height-or-age < 2 standard deviations below the WHO childgrowth standard median or children aged under 5 years. Stunting becomes apublic health problem when 20% o the population is aected.

Child underweight: weight-or-age < 2 standard deviations below the WHO childgrowth standard median or children aged under 5 years. Underweight becomes apublic health problem when 10% o the population is aected.

Child wasting: weight-or-height < 2 standard deviations below the WHO childgrowth standard median or children aged under 5 years. Wasting becomes apublic health problem when 5% o the population is aected.


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Food and nutrition security: the situation in which all people at all times havephysical, social and economic access to ood that is sae, consumed in sucientquantity and quality to meet their dietary needs and ood preerences, andsupported by an environment o adequate sanitation, health services and care,allowing or a healthy and active lie.

Food security: the situation in which all people at all times have physical, socialand economic access to sucient sae, nutritious ood to meet their dietary needsand ood preerences or an active and healthy lie. The our pillars o ood securityare availability, access, utilization and stability.

Iodine deciency: the most requent cause o preventable brain damage inchildhood (this situation being the primary motivation behind the current worldwidedrive to eliminate iodine deciency). Caused mainly by a low dietary supply oiodine, the deciency is considered to be a public health problem in populations oschool-age children when the median urinary iodine concentration is < 100 g/l, orthe prevalence o goitre is > 5%. The median urinary iodine concentration used to

categorize insucient iodine intake by pregnant women is < 150 g/l.

Low birth weight: weight at birth < 2500 g.

Malnutrition: nutritional disorders in all their orms (including imbalances in energy,specic macronutrients and micronutrients, and dietary patterns). Conventionally,the emphasis has been on inadequacy, but malnutrition also applies to excessand imbalanced intakes. It occurs when the intake o essential macronutrientsand micronutrients does not meet or exceeds the metabolic demands or thosenutrients. Metabolic demands vary with age and other physiological conditions,they are also aected by environmental conditions, including poor hygiene andsanitation, which lead to diarrhoea, both oodborne and waterborne.

Nutrition security: a situation in which ood security is combined with a cleanenvironment, adequate health services, and appropriate care and eedingpractices, to ensure a healthy lie or all household members.

Nutrition surveillance: continual monitoring in a community, region or country o actors or conditions that indicate, relate to or impinge on the nutritionalstatus o individuals or groups o people. Direct or indirect indicators o nutritionthat are systematically collected, analysed, interpreted and disseminated may beused to assess changes in nutritional status; they can also be used in planning,implementing and evaluating nutrition policies and programmes.

Policy, strategy, action plan, programme and project

A policy is a written statement o commitment (generally in broad terms) by anation state. A strategy may be similar to a policy.

An action plan (e.g. a national plan o action on nutrition) arises rom policy; itcontains detailed operational plans, including budgets, and goals and targetsthat are specic, measurable, attainable, relevant and time-bound.

A programme provides details or implementation o the action plan; specic

projects are dened within a programme.


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Severe acute malnutrition: severe wasting (weight-or-height < -3 standarddeviations) or the presence o bilateral pitting oedema. In children aged 659months, an arm circumerence o < 115 mm is indicative o severe acutemalnutrition.

Undernutrition: a situation in which the bodys requirements are not met, due to

under-consumption, or to impaired absorption and use o nutrients. Undernutritioncommonly reers to a decit in energy intake, but can also reer to deciencies ospecic nutrients, and can be either acute or chronic.

Vitamin A deciency: can be clinical or subclinical. The prevalence o serumretinol < 0.70 mol/l in a population can be used to assess the severity ovitamin A deciency in most age groups. This deciency is a public health problemthat requires intervention when at least one o two specications is met: (1) theprevalence o low serum retinol is within the range specied andwidespreaddeciency is indicated by another biological indicator o vitamin A status (includingnight blindness, breast milk retinol, relative doseresponse, modied dose

response or conjunctival impression cytology); (2) the prevalence o low serumretinol indicates widespread deciency, and the presence o certain demographicand ecological risk actors.


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Much progress has been made since the 1992 International Conerence onNutrition in the design and implementation o national nutrition policies andplans o action. Most countries that responded to the survey had policies andprogrammes that are addressing key nutrition issues, such as undernutrition,obesity and diet-related NCDs, inant and young child eeding, and vitamin andmineral malnutrition. The Review nevertheless identied a number o gaps in the

design, content and implementation o these policies and programmes.

Design and content of existingpolicies and programmes

Nutrition policies do not adequately respond to the challenges that

countries and regions are acing today; in particular, the double burden

o malnutrition (i.e. undernutrition, and obesity and diet-related NCDs).

Obesity and diet-related NCDs were the issues most requently mentionedby all countries, whereas improving inant and young child eeding was mostrequently mentioned by all countries within a particular region. Countriesin the Arican Region and the South-East Asia Region most requentlyaddressed undernutrition rather than obesity and diet-related NCDs in theirnational policies, whereas countries in the Eastern Mediterranean Region,the European Region and the Western Pacic Region more oten includedissues related to obesity and diet-related NCDs. Most countries in our regions(Arica, the Americas, South-East Asia and the Western Pacic) reportedbroad policies that covered all aspects o the double burden o malnutrition,rather than individual policies and strategies to address specic problems.

Nutrition policies oten do not include evidence-inormed interventions

in a comprehensive manner. Although the vast majority o countries hadnutrition policies, many o those did not include important interventions suchas complementary eeding, iron and olic acid supplementation and oodortication, or those addressing adult obesity.

Many nutrition policies do not adequately consider or address the

underlying and basic causes o malnutrition (e.g. ood insecurity,

inadequate health service and inadequate care or women and children).Inclusion o underlying causes o malnutrition in nutrition policies varied byregion. Countries in the Arican Region and the Region o the Americas most

commonly addressed these issues in their policies, whereas those in theEastern Mediterranean Region and the European Region rarely addressedthem. In countries with a high burden o stunting, those that had scaledup a majority o key interventions or improving maternal, inant and youngchild nutrition more oten had comprehensive policies to address bothimmediate and underlying causes than those that had not scaled up thesekey interventions. In all countries, the most common health-sector interventionwas a promotion o hand-washing. Deworming and malaria prevention ortreatment were most oten mentioned as part o nutrition programmes bycountries in the Arican Region and the South-East Asia Region, ollowed bythose in the Western Pacic Region. Most countries with high rates o maternal

undernutrition had relevant policies that included direct interventions, but thosepolicies oten did not address underlying issues, such as gender inequality.


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Nutrition policies are oten not ofcially adopted. Political support canbe secured more easily i policies are ocially adopted. Most o the policiesreported had been adopted, but with variation by region: policies in countriesin the Eastern Mediterranean Region were most oten ocially adopted, andthose in the Region o the Americas were least oten ocially adopted.

Food security strategies do not comprehensively address malnutrition inall its orms, including the vicious circle o malnutrition and oodborne

diseases. Food security was mentioned as part o nutrition-relevant policiesin most countries in many regions. But many ood security strategies did notinclude any nutrition goals or actions to address nutrition issues.

National development plans and poverty reduction strategy papers

are seldom considered as important policy documents or improving

nutrition. Only a ew countries reported such plans and strategies amongtheir main nutrition policy documents. Poverty reduction strategies have beenshown to be weak in addressing nutrition, in particular in countries with a

high burden o stunting where development and poverty alleviation shouldbe closely linked to the need or improving nutrition, particularly in the mostvulnerable.

Policies do not clearly state operational plans and programmes o

work; do not have clear goals, targets, timelines or deliverables; do not

speciy roles and responsibilities; do not identiy the capacity and areas

o competence required o the workorce; do not include process and

outcome evaluation with appropriate indicators; and do not have the

necessary or adequate budget or implementation.

Nutrition governance

Countries have inadequate coordination mechanisms to address existing

nutrition challenges. Most countries reported that they had mechanismsor coordinating nutrition activities; however, these mechanisms are notalways eective. Less than hal the countries with high rates o maternalundernutrition or womens obesity had relevant coordination mechanisms,and about one quarter o those with a double burden o child stunting andwomens obesity had coordination mechanisms or activities to address both

undernutrition and obesity. The Review showed that having such coordinationmechanisms is important; or example, in some countries with a high burdeno stunting, those that had scaled up the key interventions were more likely tohave relevant coordination mechanisms.

There is inadequate or ineective coordination within and between

ministries, and with UN agencies and other development partners.Adequate coordination is essential to ensure a multisectoral response tomalnutrition. In all the regions, coordination and administration o policyimplementation were usually done within the ministry o health, with variableinput rom ministries or departments o education, agriculture, ood,trade and social welare; the nance ministry or department was seldommentioned. Among the external partners, those most oten involved innutrition policy development and implementation were nongovernmental andcivil society organizations, and UN agencies.


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Coordination mechanisms are seldom included in high-level policy-making

rameworks or structures, such as a prime ministers or presidents

ofce, or a planning commission, in which all relevant sectors could be

involved. Few countries outside the South-East Asia Region reported thattheir coordination mechanisms or nutrition were established under the primeministers or presidents oce, suggesting that nutrition is not given the

highest priority. Moreover, the authority o those responsible or coordinationwas usually limited to allocation o responsibilities; it rarely covered control obudgets.

There are oten inconsistencies between policies at the national level

and programmes being implemented at the provincial or district level.

The existence o a policy at the national level does not ensure that action istaken and relevant programmes are implemented at the provincial or districtlevel. For example, although obesity and diet-related NCDs were oten parto national policies, related programmes were less oten implemented at theprovincial or district level. The Review also identied that some interventions

are being implemented even though they are not mentioned in the nationalpolicies. For example, zinc supplementation was given in more countries thanthose that had policies to address zinc deciencies. Another example relatesto the management o severe acute malnutrition, in that not all countries wherethe management o severe acute malnutrition is being implemented had anappropriate protocol or this intervention.

Implementation

A comprehensive set o interventions addressing the lie-course is notbeing implemented. O many interventions investigated in the Review, the onlyones implemented in most countries in all regions were breasteeding promotion,behaviour-change communication or counselling or complementary eeding,iron supplementation or pregnant women, salt iodization and certain schoolinterventions.

Nutrition interventions including many o the key interventions or maternal,

inant and young child nutrition are seldom implemented at scale. Apartrom breasteeding promotion, behaviour-change communication or counsellingor complementary eeding and iron supplementation or pregnant women, most

nutrition interventions were not implemented at national scale in most countries.Most countries with high levels o stunting had scaled up most o the relevantinterventions, but ew countries with high levels o maternal undernutrition or lowbirth weight had scaled up relevant maternal nutrition interventions.

The International Code o Marketing o Breast-milk Substitutes, subsequent

World Health Assembly resolutions and the Global Strategy on Inant and

Young Child Feeding are not being implemented adequately. Althoughinterventions such as breasteeding promotion and counselling or complementaryeeding were implemented at national scale in most countries, there were gapsin implementation o the ull set o actions recommended in the Global Strategyon Inant and Young Child Feeding. Most countries in the Eastern MediterraneanRegion reported extensive implementation o the Baby-riendly Hospital Initiative.Inant eeding in emergencies was addressed in national policies in less than athird o the countries.


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Vitamin and mineral supplementation and ortifcation programmes are

inconsistent and generally inadequate in countries in all regions in terms

o nutrient mix, target groups and coverage. Women are not reached

with important interventions beore they become pregnant. The mostcommon interventions were iron or iron and olic acid supplementation orwomen, vitamin A supplementation or children, salt iodization and wheat

four ortication. Other important interventions, such as zinc supplementationor children, were less requent or had inadequate coverage. Folic acidsupplementation or all women was not widely implemented, despite the actthat it could help to ensure adequate nutrition beore the start o pregnancy.

Implementation o programmes to address obesity and diet-related

NCDs varies widely by region, with low implementation in regions

where the double burden o malnutrition is an increasing concern.Most countries had policies to reduce obesity and diet-related NCDs, butthe interventions were not always comprehensive. The most commonlymentioned interventions related to providing inormation, such as ood-based

dietary guidelines, nutrition counselling in primary health care, ood labellingand promotion o healthy dietary practices through the media. Only one thirdo countries regulated the marketing o oods and non-alcoholic beverages tochildren, and only a ew countries had taken measures to reduce salt/sodiumor trans-atty acids in the diet. More and more countries are experiencingthe double burden o malnutrition, but countries that have high rates o bothchild stunting and womens obesity inconsistently addressed both aspectso malnutrition in their policies, and rarely implemented comprehensiveinterventions.

Settings such as schools and workplaces are not sufciently used to

reach and deliver nutrition interventions. In addition, when nutrition

interventions are being implemented in schools, they do not cover

the entire spectrum o nutrition problems. School health and nutritionprogrammes may improve the nutrition o adolescent girls, therebypreventing the intergenerational eects and causes o the double burdeno undernutrition, and obesity and diet-related NCDs. Most countries in allregions reported activities in pre-, primary and secondary schools but thoseactivities are not comprehensive programmes to improve all aspects o theschool environment that aect nutrition o school-age children. Less than onethird o countries mentioned workplace-based intervention programmes toreduce obesity and diet-related NCDs.

National capacity or public health nutrition is limited, especially amongnurses and the other community health workers who are primarily

responsible or delivering nutrition programmes. But the limited

capacities and a lack o human resources or implementing nutrition

programmes are also observed at all levels, including in the UN agencies

working in the countries. There is a lack o awareness and understandingo the importance o etal and inant nutrition or growth, development andlong-term health. Preventive programmes to combat maternal undernutritionare oten weak.

Financial resources or nutrition are lacking, resulting in reliance on

external development assistance, thus jeopardizing the sustainability onutrition programmes.Those responsible or improving nutrition usually donot have control over budgets. Most intervention programmes in this Review,except or ood ortication programmes, were unded by governments.


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Monitoring and evaluation

National surveys do not adequately include nutrition indicators, or

disaggregate sufciently to make it possible to understand and analyse

issues related to inequities. Relevant indicators related to determinants

o nutritional status used by other sectors should also be investigated,

to ensure intersectoral understanding and coherence in monitoring andevaluating nutrition-related indicators and determinants. Most countrieshad conducted national surveys, and monitored and evaluated programmesbeing implemented; however, the indicators used did not always provide theinormation necessary or monitoring and assessing the progress in nutrition,and the uptake and eects o the intervention programme being implemented.

National nutrition surveys are not conducted routinely in a timely manner.Only a ew countries reported recent national surveys, or that surveys wereconducted requently to assess trends in nutrition over time.

Most policies included monitoring and evaluation components; however,routine data reporting was insufcient, policy-makers were not well

inormed and the inormation required, in particular at the community

level, is not available. Although inormation was collected on nutritionaloutcome indicators or measures, it was not used eectively to inorm policy-makers about the eectiveness o interventions. Moreover, the data that werecollected were rarely communicated to the sta implementing programmes.


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1.Background


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Malnutrition in all its orms is closely linked, either directly or indirectly, to majorcauses o death worldwide. Malnutrition in all its orms is closely linked, eitherdirectly or indirectly, to major causes o death worldwide. Maternal and childundernutrition has long-term consequences or intellectual ability, economicproductivity, reproductive perormance and susceptibility to metabolic andcardiovascular disease (Black et al., 2008; Victora et al., 2008). There are evidence-

inormed interventions that, when implemented eectively, can dramatically reducethe rate o malnutrition (WHO, 2013a). In Brazil and China, or example, childundernutrition has more than halved in less than two decades. Nevertheless, globalprogress has been too slow to meet the nutrition target o Millennium DevelopmentGoal 1 (MDG1). This will in turn jeopardize attainment o the other MDGs, such asMDG2 on education, MDG3 on gender equality, MDG4 on child mortality, MDG5on maternal health, and MDG6 on human immunodeciency virus (HIV)/acquiredimmunodeciency syndrome (AIDS) and malaria, to which nutrition is closely linked(UNSCN, 2004).

International commitment to eliminate malnutrition has dramatically increased in

recent years. The United Nations (UN) Secretary-General, Mr Ban Ki-moon, haslaunched the Zero Hunger Challenge, which has ve objectives:

1. 100% access to adequate ood all year round;

2. zero stunted children under 2 years, and no more malnutrition in pregnancyand early childhood;

3. all ood systems are sustainable;

4. 100% growth in smallholder productivity and income, particularly or women;

5. zero loss or waste o ood, including responsible consumption (UN Secretary-General, 2012).

Other high-level UN initiatives that have ocused on nutrition include the revisedComprehensive Framework or Action (High Level Task Force on the Global FoodSecurity Crisis, 2011) and the Global Strategy or Womens and Childrens Health(UN Secretary-General, 2010). The UN General Assembly also convened theHigh-level Meeting on the Prevention and Control o Noncommunicable Diseases(NCDs), and adopted a political declaration that included reducing NCD riskactors, such as unhealthy diets (UN, 2011a).

In May 2010, the World Health Assembly adopted a resolution (WHA 63.23) thatincluded urging Member States to increase their political commitment to (WHO,2010a):

prevent and reduce malnutrition in all its orms;

strengthen and expedite sustainable implementation o the global strategy orinant and young child eeding;

develop or review current policy rameworks or addressing the double burdeno malnutrition;

scale up interventions to improve inant and young child nutrition;

strengthen nutrition surveillance.


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Two years later, in May 2012, the World Health Assembly adopted a resolution(WHA 65.6) that endorsed the Comprehensive Implementation Plan on Maternal,Inant and Young Child Nutrition, which includes six global targets or 2025(WHO, 2012):

1. 40% reduction in childhood stunting;

2. 50% reduction in anaemia in women o reproductive age;

3. 30% decrease in low birth weight;

4. 0% increase in childhood overweight;

5. an increase in the rate o exclusive breasteeding in the rst 6 months to atleast 50%;

6. a reduction in childhood wasting to less than 5%.

The resolution also included developing or, where necessary, strengtheningnutrition policies so that they comprehensively address the double burden omalnutrition and include nutrition actions in overall country health and developmentpolicy, and establishing eective intersectoral governance mechanisms in orderto expand the implementation o nutrition actions with particular emphasis on theramework o the Global Strategy on Inant and Young Child Feeding.

The agriculture sector has also recently committed to nutrition; or example,through the 2009 reorm o the Food and Agriculture Organization o theUnited Nations (FAO) Committee on World Food Security. The committee nowconstitutes an inclusive platorm o stakeholders who can work together in support

o country-led processes towards ensuring ood security and nutrition or all(Committee on World Food Security, 2009).

Ater various preparatory phases in 2009, the Scaling-up Nutrition (SUN)Movement was launched in 2010, to establish commitment to scaling-up-nutrition within countries and among partner agencies. As o May 2013, the SUNMovement has been endorsed by more than 100 organizations and 35 countries.The UN Standing Committee on Nutrition (UNSCN) and the Renewed Eortsagainst Child Hunger and Undernutrition (REACH) initiative acilitate the UNnetwork within the SUN Movement. This will help to ensure that all relevant UNagencies are working together within their respective mandates to scale up action

on nutrition.

Developed country governments have also given attention to nutrition at the highestlevel. For instance, the 1000 Days: Change a Lie, Change the Future movementwas launched in September 2010 by the United States (US) Secretary o StateMrs Hillary Clinton and the Irish Foreign Minister Mr Michael Martin (USDS,2010). The lie-course approach to nutrition promotes application o interventionswhen they are likely to have a long-term eect; that is, the window o opportunity,which is the period rom beore pregnancy to 24 months ater birth. Both the SUNMovement and the 1000 Days campaign promote action during this critical period.


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In 2011, G20 leaders committed to sustainably increase agricultural productionand productivity (paragraph 43 o the Cannes Declaration) (G20, 2011). Early in2012, Mexico, as G20 President, invited international organizations to examinepractical actions that could be undertaken to sustainably improve agriculturalproductivity growth, in particular on small amily arms. The Los Cabos G20Leaders Declaration, in paragraph 55, supports the SUN Movement and

encourages wider involvement o G20 members (G20, 2012). In 2012, the G8also launched the New Alliance or Food Security and Nutrition, which is a sharedcommitment to achieve sustained and inclusive agricultural growth, and to lit50 million people out o poverty over the next 10 years. This will be achieved byaligning the commitments o Aricas leadership to drive eective country plansand policies or ood security, by scaling up investments in ood security (Feedthe Future, 2012). The Prime Minister o the United Kingdom o Great Britainand Northern Ireland (UK), Mr David Cameron, has committed to reducing childmalnutrition rates in poor countries as Britain takes over the presidency o theG8 group o leading industrialized countries in 2013. A hunger summit held atNumber 10 Downing Street in August 2012 announced measures to reduce the

number o children let stunted by malnutrition worldwide by as much as 25 millionby 2016, when Rio de Janeiro stages the next Olympics (British Prime MinistersOce, 2012). The initiative will contribute to a UN target to reduce the number ostunted children by 70 million by 2025, in line with the targets established by theWorld Health Assembly.

In addition to these various global and country initiatives, there are a number orecent regional nutrition initiatives, such as the regional nutrition strategies andplans o action described in Box 1 (page 51), as well as the New Partnership orAricas Development (NEPAD) o 2001, the Comprehensive Arica AgricultureDevelopment Programme (CAADP) o 2003, and the 2009 CommonwealthHeads o Governments Statement on Commonwealth Action to Combat Non-Communicable Diseases(CHOGM, 2009).

National policies represent a commitment to act. To be eective, they shouldaddress the causes o all orms o malnutrition in the particular country. TheUnited Nations Childrens Fund (UNICEF) conceptual ramework is oten usedin identiying and analysing the causes o malnutrition (UNICEF, 1990). Theramework states that the underlying causes o malnutrition at household orcommunity level are household ood insecurity; inadequate care or women andchildren; and an unhealthy environment, including poor sanitation and hygiene andlack o services or health. The causes o malnutrition at national and internationallevel include poverty, inequity, civil unrest, poor governance, inadequate global

structures and lack o natural resources. For example, in some communities,malnutrition may be linked to alienation rom the land, or an obligation to growcash crops because o trade policies. Similarly, trade policies may encourage theproduction o oods high in ats and sugars, to the detriment o ruit and vegetableproduction, and may have a negative eect on local markets or resh produce.

Nutrition policies must also ocus on vulnerable groups, and reduce structuralactors that create health and nutritional inequities. The Commission on SocialDeterminants o Health (CSDH, 2008) ound that the basic and underlying causeso ill-health are not evenly spread among all members o a community or betweencommunities. Social stratication by income, education, gender and ethnicity

leads to dierential living and working conditions, and ood availability, and createsbarriers to adopting healthy behaviour. Ultimately, all o these actors aect healthand nutritional status.


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1 There are now 194 WHO Member States, since the Republic o South Sudan ocially became a Member State in lateSeptember 2011.

2 The Landscape Analysis was a review o the readiness o the 36 countries with a high burden o stunting to accelerate actionin nutrition. Readiness was assessed as a unction o both commitment (willingness to act) and capacity (ability to act). It

also included a review o meta-indicators o general conditions and contextual actors that can infuence the eectiveness onutrition activities. The Landscape Analysis involved three parallel activities: classication o countries according to readiness toact on the basis o a review o secondary data; in-depth country assessments, so ar undertaken in 18 countries (Burkina Faso,Comoros, Cte dIvoire, Egypt, Ethiopia, Ghana, Guatemala, Guinea, Indonesia, Mali, Madagascar, Mozambique, Namibia, Peru,South Arica, Sri Lanka, Timor-Leste and the United Republic o Tanzania) (http://apps.who.int/nutrition/landscape_analysis/country_assessments/en/index.html); and setting up the Nutrition Landscape Inormation System, in which all the WHO globalnutrition databases are dynamically linked to provide an integrated inormation system on nutrition (http://www.who.int/nutrition/nlis/en/index.html).

Virtually all countries in the world have ratied the 1989 Convention on the Rightso the Child, and have thereore committed themselves to upholding childrensright to the highest attainable standard o health, including adequate nutritiousood and the benets o breasteeding. The rights to ood and to health are speltout in General Comments 12 and 14 to the International Covenant on Economic,Social and Cultural Rights (CESCR, 1999, 2000). These rights, like any other

human right, place three types o obligation on governments: respect existingpractices whereby people enjoy their rights to ood and health or good nutrition;protect individuals or groups rom being deprived o access to adequate ood (e.g.by enacting ood saety legislation or national codes o marketing o breast-milksubstitutes); and ull as necessary the rights to ood and health by promotion,acilitation or provision. Promotion entails creating, maintaining and restoringthe health o a population; or example, by disseminating appropriate inormationon healthy liestyles and nutrition. Facilitation entails proactively strengtheningpeoples access to and use o resources, to ensure their livelihood, including oodsecurity and healthy behaviour. Provision implies that, when people are unableto enjoy their right to ood or to health or reasons beyond their control, such as

in natural or other disasters, the government has an obligation to provide, orexample, ood or medical care.

Thus, nutrition policies are by nature intersectoral. Thereore, the health sector andgovernment must have the necessary capacities and institutional support to workwith other sectors that have dierent interests to negotiate dierent goals, and toagree on areas o responsibility (and hence accountability). Lack o such supportcreates barriers to eective implementation o nutrition activities in countries.

The Global Nutrition Policy Review was undertaken during 20092010, to:

assess the extent to which countries have policies and programmes or keynutrition activities;

determine how those programmes were being implemented in terms o scaleand coverage, who was implementing them, and how they were monitored andevaluated.

Responses were received rom 119 Member States (62% o the 193 MemberStates at that time)1 and 4 territories to a questionnaire sent to all World HealthOrganization (WHO) Member States. The responses rom countries werecomplemented by a number o qualitative and quantitative studies. In particular,the experience and outcomes o in-depth country assessments undertaken as part

o the Landscape analysis on countries readiness to accelerate action in nutrition(Nishida, Shrimpton & Darnton-Hill, 2009)2 in 18 countries with a high burden ostunting in 20082012 provided insights on countries readiness or scaling up


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actions and identiying constraints to eective implementation o nutrition policiesand programmes. WHO regional oces and some countries provided examples ogood policy and programme practices, and successul outcomes.

The Global Nutrition Policy Review is one o a series o WHO initiatives to monitorcountries progress in developing and implementing national nutrition policies

and strategies. The WHO Global Database on National Nutrition Policies andProgrammes was developed in 1993 as a tool to monitor the implementation othe World Declaration and Plan o Action on Nutrition, which was adopted by the1992 International Conerence on Nutrition (FAO & WHO, 1992). That databasehas now been urther elaborated, incorporated and was launched as the Globaldatabase on the Implementation o Nutrition Action (GINA)3 on 28 November2012. Summaries o selected policy and programme indicators will also be madeavailable on the WHO Nutrition Landscape Inormation System.4

This report presents the current global nutrition challenges drawing data romvarious sources including existing WHO Global Nutrition Databases being

managed by the Department o Nutrition or Health and Development (Section 2),the methods and main outcomes o the Global Nutrition Policy Review, showingthe extent o policy and programme implementation and nutrition governance in119 WHO Member States and 4 territories which provided responses (Section3), the summary conclusions (Section 4) and the way orward (Section 5) .Although countries have dierent nutrition concerns, some interventions arerelevant globally; or example, those that address the window o opportunity rompregnancy until 2 years o age, such as optimal breasteeding and appropriatecomplementary eeding practices. Because many countries within a region havesimilar nutrition problems, data are disaggregated by region in most parts o thereport. The report also includes an assessment o how well current nutrition-related policies and programmes meet nutrition problems being aced by countries,and o policy and governance or the scaling-up o nutrition activities.

The international community must understand the challenges in implementingnutrition policies and programmes in order to provide support or the areas ogreatest need and the areas where they will be most eective. Understandingthe nutrition landscape and its architecture in countries, and identiyingways to overcome the challenges, will ensure eective use o resources. Thisreport is intended or stakeholders who are working with countries to implementnutrition policies and programmes; including international and bilateral agencies,nongovernmental organizations (NGOs), civil society and the private sector.

3 http://www.who.int/nutrition/gina/en/

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


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2.Current globalnutrition challenges


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9,0

8,0

7,0

6,0

5,0

4,0

3,0

2,0

1,0

0,0

Since 1990, lie expectancy at birth has increased in all regions, largely due toreductions in inant and child mortality. However, the gain in lie expectancy hasnot been even in all regions, with Arica having the shortest lie expectancy. Widevariations are also seen within countries, with rates o child mortality and stuntinggenerally higher among those in the lowest wealth quintile and those whose mothershave the least education (WHO, 2013b). In Latin America, the Caribbean and parts

o Asia, the disparity in rates o child underweight between rural and urban areasincreased between 1990 and 2008 (UN, 2010a). In South Asia, 60% o childrenin the poorest quintile are underweight, compared with 26% o those in the richestquintile; also, the reduction in underweight is much slower among children inpoorer households (UN, 2011b). Throughout the developing world, socioeconomicinequality in childhood malnutrition is independent o the average rates o malnutrition,especially or stunting (Van de Poel et al., 2008). At the same time, the largestincrease in overweight among preschool-age children has been seen in the lowermiddle-income group (WHO, 2011a).

2.1. Malnutrition and causes of deathand disability

In 2008, cardiovascular diseases (ischaemic heart and cerebrovascular diseases)were the leading causes o death worldwide, ollowed by respiratory conditionsand cancers (WHO, 2011b). A study by Lozano et al. (2012) identied these samecauses as the top causes in nutrition and diet are closely linked to these leadingcauses o death. For example, obesity increases the risk or ischaemic heartdisease, high salt/sodium intake increases the risk o cerebrovascular disease,and intake o ruit and vegetables helps to prevent the development o cancer.

Inectious diseases, including oodborne or waterborne diarrhoea, also aectmortality and disability. The vicious cycle o malnutrition and inectious disease iswell recognized; that is, inectious disease causes malnutrition, and malnutritionexacerbates inection. The overall death rate o adults (aged 15-59 years) in Aricais nearly twice as high as that in any other region o the world (Figure 1).

Inectous and parasitic diseases,

maternal and nutritional conditions

Noncommunicable diseases

Injuries

Figure 1. Mortality rates from major causes by WHO region, 2008.From WHO (2011a)

AFR, Arican Region;

AMR, Region o the Americas;

EMR, Eastern Mediterranean Region;

EUR, European Region;

SEAR, South-East Asia Region;

WPR, Western Pacic Region

AFR AMR EMR EUR SEAR WPR


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Figure 2. Causes of deaths among children under the age of 5 years, 2010. FromWHO (2013b)

4.2%Noncommunicable diseases(postneonatal)

3.2%Injuries (postneonatal)

11.7%Other

7.8%Congenital anomalies

1.8%Neonatal tetanus

2.2%

Diarrheal diseases

25%Neaonatalinections

22.6%Birth asphyxiaand birth trauma

28.9%Prematurity andlow birth weight

40.1%Neonatal deaths

12.9%Other

2.3%HIV/AIDS

1.4%Measles

8.5%Malaria

14%Diarrhoeal diseases(postneonatal)

13.3%Pneumonia(postneonatal)

Neonataldeaths

In 2011, 6.9 million children under 5 years o age died, mainly rom preventablecauses such as pneumonia, diarrhoea, malaria and neonatal conditions (WHO,2013b). Figure 2 shows the causes o death among children under 5 years oage in 2010. It has been estimated that undernutrition is an underlying causein 35% o child deaths4 (MDG4) (Black et al., 2008); and that maternal shortstature and iron deciency anaemia is a cause o 20% o maternal deaths

(MDG5) (UN, 2010b). Although substantial progress has been made in meetingthese two MDGs, no region is on track to achieve the required reductions o67% in child mortality under MDG4 and 75% in maternal mortality under MDG5by 2015 (UN, 2012). The greatest progress has been made in northern Arica,and in eastern and western Asia, where the child and maternal mortality rateshave been more than halved. The lowest reduction rates have been in sub-Saharan Arica and Oceania, areas that have some o the highest rates o childand maternal mortality.

5 This estimate is currently being updated with recent data and revised methodology, and will be published in the orthcomingLancetseries on nutrition (2013).


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2.2. Child malnutrition

Worldwide, in 2011, one in our children (26%, 165 million) was estimated tobe stunted, whereas one in six (16%, 101 million) was underweight, and one in12 (8%, 52 million) was wasted (UNICEF, WHO & World Bank, 2012).Theseprevalence rates are highly signicant or public health. Nearly 20 million children

suer rom severe acute malnutrition, which is a lie-threatening condition requiringurgent treatment (WHO et al., 2007).

Figure 3 shows the trends in child stunting, underweight, wasting and overweightin the period 1990-2010. Because o the large population in Asia, most o thechildren aected by stunting, underweight or wasting live in that region. In allregions, the rates o stunting are higher than those o underweight, although thereare variations, with rates being about 1.4 times higher in Asia, two times higher inArica, and our times higher in Latin America and the Caribbean. Stunting ratesare alling in all regions, but at a much slower rate in Arica than elsewhere. In1990, the highest rates were in Asia (48.4%), particularly in south-central Asia

(59.3%). By contrast, in 2010, they were highest in Arica (35.9%), particularlyin eastern Arica (42.5%). In Asia, Latin America and the Caribbean, the overallrates have almost halved between 1990 and 2010, and some subregions haveseen even greater decreases, the most notable being eastern Asia, where rateshave been reduced by 75%. In Latin America and the Caribbean, and in easternand western Asia, the reductions have brought the subregional estimates to below20%, which is the cut-o or public health concern (UNICEF, WHO & WorldBank, 2012).

In 2011, overweight aected 7% o preschool children (43 million). Figure 3shows that unlike the prevalences o stunting and underweight, the prevalence o

child overweight in 2010 was highest in developed countries (14.1%), ollowedby countries in Arica, and in Latin America and the Caribbean (both at 7.1%).The rate o increase over the past 20 years has been similar in developed anddeveloping countries, although some subregions had dramatic increases. Forexample, the prevalence o child overweight more than doubled between 1990and 2010 in southern Arica (rom 6.1% to 15.6%), western Arica (rom 1.9% to6.2%), south-eastern Asia (rom 1.8% to 5.8%), and western Asia (rom 4.4% to10.8%) (UNICEF, WHO & World Bank, 2012).

The rapid changes and subregional dierences in child growth and malnutritionbetween 1990 and 2010 indicate important variations in the distribution o thedeterminants. Notable was the act that a rise in overweight was not necessarily

associated with a all in underweight or stunting. For example, although the rateso underweight and stunting ell dramatically in eastern Asia, and were halved inLatin America and the Caribbean, the rates o overweight did not increase. Also, inwestern Arica, the rates o stunting and underweight ell less dramatically, but therates o overweight rose sharply.

6 The cut-o values or a prevalence that is considered to be o public health signicance are 20% or stunting, 10% orunderweight and 5% or wasting (WHO, 1995).


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Many children are born at a disadvantage, with a birth weight o less than 2.5 kg.Low birth weight is a marker o suboptimal intrauterine growth and poor maternalnutrition; it increases the risks or poorer outcomes in growth, development andhealth in both the short and the long term. Although the estimates o low birth weighthave some shortcomings, the global rates appear to have allen rom 18.0% in the1980s to 15.5% in the 2000s; nevertheless, the rates in some subregions appear

to have stagnated or even increased over the same period (Figure 4). The largestrelative reduction in low birth weight was seen in South-East Asia, where it droppedrom 18.0% to 11.6%. In Arica as a whole, the rate declined only slightly, rom15.0% to 14.3%, with little variation across the continent. The South Asia subregionstill has the highest rates o any subregion, despite a steep reduction in the rate olow birth weight, rom 34.0% to 27.0%. Recent analyses conducted by UNICEF(2012a) show that the global rates remains unchanged at 15%, and that progress isslow in regions or which sucient data are available to estimate trends.

Figure 4. Trends in low birth weight by UN region, 19802000.From UNSCN (2010)

40%

35%

30%

25%

20%

15%

10%

5%

0%1980s 1990s 2000s

Less developed world

Arica

East Asia

South Asia

South East Asia

Latin America and the Caribbean

2.3. Adult overweight and obesity

Globally, in 2008, one in three adults (34% o men, 35% o women) wasoverweight; that is, they had a body mass index (BMI) equal to or greater than25 kg/m2 (WHO, 2011a). Also, one in 10 men (10%) and more than one in10 women (14%) were obese; that is, they had a BMI equal to or greater than30 kg/m2. The prevalence o overweight and obesity in adults varied considerablyamong regions and income groups. The highest rates were ound in the Regiono the Americas, ollowed by the European Region, where more than 50% o theadult population were overweight and more than 20% were obese (Figure 5).Similar rates were ound among women in the Eastern Mediterranean Region,whereas the rates in the Arican Region, the South-East Asia Region and theWestern Pacic Region were generally lower. Adult overweight and obesity was

much more prevalent in upper middle-income and high-income groups than inlower middle-income and low-income groups. Obesity was more common inwomen than in men. The worldwide prevalence o obesity among women nearlydoubled between 1980 and 2008, rom 8% in 1980 to 14% (297 million womenover the age o 20) in 2008 (Finucane et al., 2011).


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Figure 5. Age-standardized prevalence of overweight and obesity in adultsaged 20+ years of age by WHO Region, 2008. From (WHO 2013b)

Male

Female

Both sexes

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Male

Female

Both sexes

Male

Female

Both sexes

Male

Female

Both sexes

Male

Female

Both sexes

Male

Female

Both sexes

Male

FemaleBoth sexes

AFR

AMR

EMR

EUR

SEAR

WPR

Global

AFR, Arican Region;






Obesity, BMI 30

Pre-obesity, BMI = 25.0 - 29.95.3

11.1

8.3

17.6

19.4

18.6

23.5

29.7

26.7

13

24.5

18.7

20.4

23.1

21.9

1.7

3.7

2.7

5.1

6.8

5.9

10

14

12.1

39.1

31.5

35.2

28.7

26

27.3

37.9

28.1

32.9

10

12

11

20.8

18

19.5

23.8

21.1

22.4


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2.4. Vitamin and mineral malnutrition

2.4.1 Iron deficiency and anaemia

Iron deciency is the most common nutritional deciency, with more than 2 billionpeople aected (WHO, 2001). Globally, anaemia aects 1.62 billion people, or24.8% o the worlds population. Anaemia in preschool-age children and in womenis a severe public health problem, with a prevalence o at least 40%, in mostcountries in the Arican Region and the South-East Asia Region, and in parts oLatin America (WHO & CDC, 2008)7 (Figures 68). In all countries, anaemia isat least a mild public health problem in at least one age group, especially amongpregnant women; and in most countries it is a moderate or severe public healthproblem.

The highest prevalence o anaemia is ound among preschool-age children(47.4%), and the lowest prevalence is among men (12.7%). The population groupin which the largest number o individuals is aected is non-pregnant women

(468.4 million). The Arican Region has the highest rates o all the regions, withanaemia aecting two out o three preschool-age children (67.6%), and aboutevery second pregnant (57.1%) and non-pregnant (47.5%) woman. The largestnumbers are in the South-East Asia Region, where 315 million individuals in thesethree population groups are aected (WHO & CDC, 2008). The rates o anaemiain non-pregnant women have not changed signicantly in Arica or in southcentralAsia since 1990, whereas they have declined in east Asia and Central America(UNSCN, 2010).

7 WHO is currently updating anaemia estimates, to be published later in 2013

Figure 6. Prevalence of anaemia in preschool-aged children, 19932005.From WHO & CDC (2008)

Normal (


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Figure 7. Prevalence of anaemia in pregnant women, 19932005.From WHO & CDC (2008)

Figure 8. Prevalence of anaemia in non-pregnant women, 19932005.From WHO & CDC (2008)

Normal (


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2.4.2 Vitamin A deficiency

Worldwide, subclinical vitamin A deciency (serum retinol, < 0.70 mol/l) aects 33%o preschool-age children (190 million) and 15.3% o pregnant women (19.1 million).The highest regional rates among preschool-age children are ound in the South-EastAsia Region (49.9%) and the Arican Region (44.4%), and among pregnant women

in the Western Pacic Region (21.5%) (WHO, 2009). Subclinical vitamin A deciencyis a severe public health problem ( 20% prevalence) among preschool-age childrenin most countries o Arica and in large parts o Asia; it is also a moderate public healthproblem (prevalence 10% to < 20%) in most countries o Latin America and easternEurope (Figure 9). Prevalence rates among preschool-age children have declinedsince 1990 in most areas except east, central and west Arica, although the extento the problem still varies widely (UNSCN, 2010). Vitamin A deciency is a severepublic health problem among pregnant women in most countries in northern Arica,and in west and central Asia; it is also a moderate public health problem in most othercountries o Arica, and in south and south-east Asia (Figure 10).

Clinical vitamin A deciency, or night blindness, is common among pregnant womenin developing countries, with a prevalence o 9.8% in the Arican Region and 9.9%in the South-East Asia Region. In each o those regions, more than 3 million pregnantwomen are estimated to be aected, equivalent to one third o all those aected in theworld (WHO, 2009).

Figure 9. Prevalence of subclinical vitamin A deficiency in preschool-aged children, 1995-2005.From WHO (2009)

Mild (2% -


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Figure 10. Prevalence of subclinical vitamin A deficiency in pregnant women,1995-2005. From WHO (2009)

2.4.3 Iodine deficiency

It has been estimated that 29.8% o school-age children and 28.5% o thegeneral population have insucient iodine intake (dened as the proportion o thepopulation with a urinary iodine concentration < 100 g/l), representing1.88 billion people (Andersson, Karumbunathan & Zimmermann, 2012). Thehighest rates are ound in the European Region (43.9% o school-age children,44.2% o the general population), ollowed by the Arican Region (39.3%o school-age children, 40.0% o the general population) and the Eastern

Mediterranean Region (38.6% o school-age children, 37.4% o the generalpopulation). The prevalence o iodine deciency decreased between 2003 and2011, due to strengthening o salt iodization programmes and better monitoring,and iodine deciency is now considered to be a public health problem in ewercountries. However, it is still a public health problem in 32 countries.

In a number o countries, the iodine intake is considered to be too high, puttingsusceptible people at risk or iodine-induced hyperthyroidism. Both deciency andexcess are present in the same regions, oten in neighbouring countries. Moderateor mild deciency is most common in Europe and Arica, and more than adequateintake or excess is most common in the Americas (Figure 11).

None (


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Figure 11. Prevalence of iodine deficiency or excess, 19932011

Reproduced with permission rom Andersson, Karumbunathan & Zimmermann (2012)

UIC, urinary iodine concentration

The estimates or the countries shown with cross-hatching are based on subnational data, as national coverage with iodized salt in these countries is incomplete, iodine intake varies

widely, and the populations o some regions are probably iodine-decient.

2.5. Infant and young child feedingAbout 40% o the countries that responded to the questionnaire reported high rateso early initiation o breasteeding. High rates were most common in countries inthe Eastern Mediterranean Region and the European Region, whereas low rateso early initiation were common among countries in the South-East Asia Region(Figure 12). Globally, only 38% o children under 6 months o age are exclusivelybreasted, ranging rom 47% in the South-East Asia Region to 25% in the EuropeanRegion (WHO, 2013b). More than 60% o countries reported low rates o exclusivebreasteeding. Only in the South-East Asia Region did the majority o countriesreport medium rates; by contrast, all the countries in the Eastern Mediterranean

Moderate iodine deciency (UIC 20-49 g/L)

Mild iodine deciency (UIC 50-99 g/L)

Optimal iodine nutrition (UIC 100-199 g/L)

Risk o iodine induced hyperthyroidism (UIC 200-299 g/L)

Risk o adverse health consequences (UIC > 300 g/L)

Subnational data*No data


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Figure 12. Prevalence of early initiation of breastfeeding (within 1 h of birth),by WHO region

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%AFR

(n=21)

AMR

(n=13)

EMR

(n=7)

EUR

(n=12)

SEAR

(n=7)

WPR

(n=10)

Total

(n=70)

%o

fcountries

24

38 38

31 31

38

29

14

57

25

17

58

43

29 2930

40

30 29 30

41

Low prevalence, 0-40%

Medium prevalence, 41-60%

High prevalence, 61-100%

AFR, Arican Region;






8 Until 2008, this indicator was 69 months, but when updated indicators or inant and young child eeding were published in2008, it was changed to 6-8 months (WHO et al., 2008). Figure 15 shows introduction o complementary oods within eitherinterval because not all countries had recalculated their data.

9 The indicator minimum acceptable diet or breasted children is dened as proportion o children aged 623 months who hadat least minimum dietary diversity and minimum meal requency the previous day (WHO et al., 2008).

Region reported low rates (Figure 13). More than hal the countries reportedhigh rates o continued breasteeding at 1 year o age. This was most common incountries in the Arican Region, and least common in countries in the EuropeanRegion (Figure 14).

More than 60% o countries reported that complementary oods were introduced

in a timely manner (i.e. at 68 months8

) (Figure 15). In 2010, WHO and partnersreviewed inormation on inant and young child eeding practices in 46 countries inrelation to a composite indicator o a minimum acceptable diet or breasted children9and ound that the rates were variable, ranging rom 2.9% to 65.7% (WHO, 2010b).


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Figure 13. Prevalence of exclusive breastfeeding of infants < 6 months,by WHO region

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%AFR(n=21)

AMR(n=16)

EMR(n=7)

EUR(n=19)

SEAR(n=8)

WPR(n=13)

Total(n=84)

%o

fcountries

67

100

89

11

25

75

62

65

26

8

15

2324

10

44 44

13




AFR, Arican Region;






Figure 14. Prevalence of continued breastfeeding at 1 year, by WHO region

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%AFR(n=18)

AMR(n=13)

EMR(n=7)

EUR(n=15)

SEAR(n=7)

WPR(n=10)

Total(n=70)

%o

fcountries

11

6

83

23

31

46

14

29

57

73

7

20

29

14

57

20 20

60

30

16

54




AFR, Arican Region;







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Figure 15. Prevalence of timely introduction of complementary foods (69 and68 months), by WHO region

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%AFR(n=19)

AMR(n=11)

EMR(n=5)

EUR(n=13)

SEAR(n=8)

WPR(n=10)

Total(n=66)

%o

fcountries

5

21

74

18 18

64

20

80

46

15

38

25

75

20

10

70

17 18

65




AFR, Arican Region;






2.6. Undernourishment

Few countries have ood consumption data that can be used to estimate the adequacyo dietary intake o all essential nutrients including energy. Data on global and regionalper capita ood supply in the ood balance sheets o the FAO show that, overall, per-capita energy consumption rose between 19901992 and 20102012 in all regions.At the same time, diets became more diverse, with a decrease in the proportiono cereals, roots and tubers, and increases in the proportions o ruit, vegetablesand animal products (FAO, 2012). However, the regional trends mask importantdierences; some countries, especially in Arica where the ood supply per capita wasalready very low, saw a decrease between 19901992 and 20102012 (FAO, 2013).

These ood supply data provide the only consistently collected global inormation

on ood consumption, estimated rom ood availability. Hence, they are a valuableresource or deriving trends over time and by region, despite the acknowledgedlimitations. Data on actual dietary intake o dierent individuals and population groupswould be more helpul in understanding dietary adequacy. However, actual oodconsumption data are sparse, especially at national level. Although ood balancesheets can indicate the national availability o macronutrients and micronutrients, thedistribution o such nutrients within countries and among population groups is otenuneven, resulting in undernutrition on one side and obesity on the other, especially inlow- and middle-income countries.

Undernourishment or hunger is dened by FAO as an estimated dietary energysupply below the minimum dietary energy requirement. The number and proportion opeople in a country who are undernourished is calculated rom the average amounto ood available or human consumption per person, the degree o inequality inaccess to that ood, and the minimum number o calories required or an averageperson. In 20112012, FAO improved the method used to estimate the prevalence


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o undernourishment, through a comprehensive revision o data on ood availability(including better estimation o ood losses), an improved basis or dietary energyrequirement, updated measures o ood access, and a new, unctional orm o thedistributions used to estimate the prevalence o undernourishment (FAO, 2012).

According to FAO, 868 million people were undernourished in 20102012 (12.5%),

down rom 1 billion people in 19901992 (18.6%) (Figures 16 and 17). Trends showa reduction in almost all regions during this period, although at slower rates since20072008, and not sucient to meet the MDG1 target o halving hunger between1990 and 2015 (FAO, 2012). One notable exception is Arica, where the numbero undernourished people increased steadily over the period. The global nancial,economic and ood price crises in 2008 drove many people into hunger, with womenand children being particularly aected (UNSCN, 2009). The spike in ood pricesprevented millions o people rom escaping poverty, because the poor spend a largeproportion o their income on ood, and because many poor armers are net buyers oood. Higher ood prices have two main eects on net buyers o ood: on income (dueto a reduction in the purchasing power o poor households), and on substitution (with

shits to less nutritious ood) (IBRD & World Bank, 2012). Civil unrest and confictsaround the world have drawn the attention o the general public to the injustice omalnutrition.

Figure 16. Trends in numbers of undernourished people, by FAO region.From FAO (2013)

1200

1000

800

600

400

200

0

1990-92

1991-93

1992-94

1993-95

1994-96

1995-97

1996-98

1997-99

1998-00

1999-01

2000-02

2001-03

2002-04

2003-05

2004-06

2005-07

2006-08

2007-09

2008-10

2009-11

2010-12

Numberofpeople

World

Arica

Asia


Proportionofpeople

30%

25%

20%

15%

10%

5%

0%

1990-92

1991-93

1992-94

1993-95

1994-96

1995-97

1996-98

1997-99

1998-00

1999-01

2000-02

2001-03

2002-04

2003-05

2004-06

2005-07

2006-08

2007-09

2008-10

2009-11

2010-12

Figure 17. Trends in the proportions of undernourished people, by FAO region.From FAO (2013)

World

Arica

Asia



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3.Methods and

findings of theGlobal NutritionPolicy Review


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3.1. Methods

A comprehensive seven-module questionnaire10 was prepared by the WHODepartment o Nutrition or Health and Development, with input rom otherdepartments, in particular those o Maternal, Newborn, Child and AdolescentHealth, and Ethics, Equity, Trade and Human Rights.

The purpose o Module 1 was to obtain an overview o existing national policiesand institutional environments related to nutrition. It included detailed tablesor summarizing existing policy documents, stakeholders, national surveys,coordination mechanisms and capacity or addressing each countrys mainnutrition-related problems (i.e. undernutrition, obesity and diet-related NCDs,inant and young child eeding practices, vitamin and mineral malnutrition, and theirunderlying actors). The other modules covered programme implementation issuesrelated to specic nutrition issues, as ollows:

Module 2 ocused on policies, strategies and interventions to address

maternal, inant and young child undernutrition, and on existing breasteedingand complementary eeding practices;

Module 3 covered regulatory and voluntary initiatives or implementing theInternational Code o Marketing o Breast-milk Substitutes and subsequentWorld Health Assembly resolutions;

Module 4 ocused on school programmes, including the Nutrition FriendlySchools Initiative;

Module 5 elicited inormation on vitamin and mineral nutrition, and the scale

o implementation and policy basis or supplementation and orticationprogrammes;

Module 6 covered the scale o implementation and policy basis or obesityand diet-related NCDs, and relevant trade-related strategies;

Module 7 covered ood security and agriculture strategies.

The questionnaire was designed to be both comprehensive and as concise aspossible, in order to capture all relevant inormation yet avoid giving countries toomuch work. Respondents were invited to provide additional inormation at theend o each module i they wished to do so. The questionnaire was translated

into Arabic,11 French, Spanish12 and Russian13 and was pilot-tested in selectedcountries beore nalization.

The questionnaire was disseminated to Member States through the WHOregional and country oces, and inormation was compiled between July 2009and November 2010. Countries were asked to select a responsible national ocalpoint, and ensure that all parts o the questionnaire were completed and sentback to respective WHO Regional Nutrition Advisers. Each module or sectionwithin a module was completed by the person responsible or the relevant issuesand programmes, with the support and coordination o the national ocal point.

10 The questionnaire can be obtained rom [email protected].

11 Translated by the WHO Eastern Mediterranean Regional Oce.

12 Translated by the WHO Regional Oce or the Americas.

13 Translated by the WHO European Regional Oce.


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The aliation and contact inormation o the person who provided the responsesor each module was requested, to acilitate ollow-up and verication o theinormation, i required. In relation to the questions in Module 3 concerningthe International Code o Marketing o Breast-milk Substitutes, respondentswere strongly encouraged to ask their legal department, other relevant unit othe ministry o health, or oce within the government structure to provide the

responses, in collaboration with other relevant departments or oces (e.g.nutrition, maternal and child health, and amily health).

Data were cleaned and interpreted in several steps. For example, documents notclearly identied as a policy, strategy, action plan or regulation were excluded. Thus,implementation protocols and survey reports were not included. Each responsewas careully reviewed, and clarications and verication o inormation were soughtrom respondents, to obtain missing inormation. Countries that had been unable toprovide a response during the survey period were contacted to determine whetherthey could provide inormation beore the data analyses were completed.

Data were compiled in an ACCESS database and analysed with ACCESS, SPSSand Excel. Data obtained rom this Review were also incorporated into the WHOGlobal Database on National Nutrition Policies and Programmes, which wasurther developed and elaborated as GINA, ocially launched in November 2012.

Other existing relevant qualitative and quantitative data were also reviewed, tocomplement the inormation obtained rom each country through the current Review.For example, the in-depth country assessments undertaken in 18 countries witha high burden o stunting14 between 2008 and 2012 (as part o the project onthe Landscape analysis on countries readiness to accelerate action in nutrition)provided inormation about the constraints to eective implementation o nutritionpolicies and programmes (Nishida, Shrimpton & Darnton-Hill, 2009). WHO regional

and country oces provided the country case studies presented in this report.

Data on implementation o the International Code o Marketing o Breast-milkSubstitutes and subsequent World Health Assembly resolutions were drawn roma recent report (WHO, 2013c), which is largely based on inormation receivedrom the countries that responded to Module 3 o the questionnaire plus someurther updates undertaken ater the data collection period o the Review. Dataon nutrition policy and coordination mechanisms in Europe were drawn rom theWHO European database on nutrition, obesity and physical activity, and otherreerences (Elmada, 2009; WHO, 2010c).

Section 3.2 provides analyses o overall nutrition policy environments based onthe responses received rom 123 countries. Section 3.3 presents the results o ananalysis o data rom a subset o 54 countries that completed all seven moduleso the questionnaire. This analys

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Revisao WHO-Global Nutrition Policy Review

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