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Proposed policy priorities for preventing obesity and diabetes in the Eastern Mediterranean Region

EMRO Technical Publications Series 46

46EMRO Technical Publications Series

Proposed policy priorities for preventing obesity and diabetes in the Eastern Mediterranean Region

WHO Library Cataloguing in Publication Data

Proposed policy priorities for preventing obesity and diabetes in the Eastern Mediterranean Region / Ala Alwan, Karen McColl, Ayoub Al-Jawaldeh, Philip James

p. ISBN: 978-92-9022-200-2 ISBN: 978-92-9022-201-9 (online) 1. Diabetes Mellitus - prevention & control 2. Obesity - prevention & control 3. Diabetes Complications 4. Eastern

Mediterranean Region I. Alwan, Ala II. Title III. Regional Office for the Eastern Mediterranean (NLM Classification: WK 835)

Acknowledgements

This document was developed through a series of consultations held at the WHO Regional Office for the Eastern Mediterranean, with participation from representatives of academia and scientific researchers. The authors of this publication are:Dr Ala Alwan, former WHO Regional Director, WHO Regional Office for the Eastern Mediterranean, Cairo, EgyptMs Karen McColl, Policy Consultant, United KingdomDr Ayoub Al-Jawaldeh, Regional Adviser, Nutrition, WHO Regional Office for the Eastern Mediterranean, Cairo, EgyptPhilip James, Honorary Professor of Nutrition, London School of Hygiene and Tropical Medicine, London, United Kingdom, The Regional Office would like to acknowledge the technical input and support of Dr Maha El-Adawy, Director of Health Protection and Promotion, WHO Regional Office for the Eastern Mediterranean; Dr Francesco Branca, Director of Nutrition for Development, WHO headquarters; and Dr Fiona Bull, Programme Manager, Surveillance and Population-based Prevention, WHO Prevention of Noncommunicable Diseases Management Team, WHO headquarters.

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Design and layout by YAT Communication

Contents Executive summary .................................................................................................................. 5

1. Introduction: Obesity and diabetes in the Eastern Mediterranean Region ............. 9

1.1 Burden of obesity and diabetes .............................................................................................................................. 9

1.2 Dietary risk factors driving the burden of obesity and diabetes .......................................................... 11

1.3 Urgent action to tackle obesity and diabetes in the Region .................................................................. 12

2. Methodology for identifying priority actions for preventing obesity and diabetes in the Region ......................................................................................................................... 13

3. Proposed priority areas for action and strategic interventions ............................... 13

4. Implementation of the proposed priority areas for action ........................................ 24

4.1 Multisectoral action is essential ............................................................................................................................... 24

4.2 Clear commitments to action and monitoring of progress .................................................................... 25

4.3 Feasibility issues and phased implementation ................................................................................................. 25

Annex 1. Methodology for identifying priority actions for preventing obesity and diabetes in the Region ..................................................................................................... 40

Annex 2. Summary of strategic interventions in 10 priority areas for action for the prevention of obesity and diabetes in the Eastern Mediterranean Region ................. 42

Annex 3. Examples of country experience with implementation of the proposed strategic interventions ............................................................................................................ 64

Annex 4. Feasibility considerations for implementing strategic interventions in 10 priority areas for action to prevent obesity and diabetes in the Eastern Mediterranean Region ............................................................................................................. 72

5

Executive summary

Executive summaryThe Eastern Mediterranean Region of the World Health Organization (WHO) has an extremely high prevalence of overweight and obesity in both adults and children, precipitating the highest regional prevalence of diabetes in the world.

With regional obesity and overweight prevalence rates well above the global average, half the Region’s adult women (50.1%) and more than two in five men (43.8%) were overweight or obese in 2014 (1). In several countries two thirds or more of adults (especially women) are overweight or obese.

High rates of childhood overweight in the Region give particular cause for concern. On average, 6.9% of children under five years are already overweight – higher than the global average of 6.2% – and in some countries more than 15% of children are affected (2). In many countries of the Region more than half of adolescents are overweight or obese.

Around 43 million people in the Region live with diabetes, and its prevalence has risen from 6% in 1980 to 14% in 2014, affecting more than 20% of adults in some countries. The Region has the highest death rates from diabetes of all WHO regions (1). The prevalence of diabetes is higher than might be expected given the levels of obesity – diabetes prevalence rates are about twice the rates shown for equivalent obesity prevalence rates in, for example, European Union countries, potentially reflecting a greater sensitivity to diabetes in the Region.

The increasing prevalence of overweight, obesity and diabetes is closely linked to a dramatic reduction in physical activity accompanied by marked changes in dietary patterns in the Region. Average intakes of energy and fat are above WHO-recommended levels, with substantially higher fat intakes in

the Region’s high-income countries. More than three quarters of the Region’s countries consume substantially higher levels of sugars than WHO recommends.

Such high prevalence rates of these conditions and the heavy burden of morbidity, disability and death they can cause threaten to generate a devastating financial burden for countries of the Region, overwhelming health services and undermining their economic and social well-being. Urgent action is therefore needed to tackle this alarming and escalating problem. Yet the Eastern Mediterranean has the highest proportion of countries of any region without any policies to combat diabetes (1).

Taking the recommendations of several recent initiatives on the prevention of obesity and diabetes1 into account, the WHO Regional Office for the Eastern Mediterranean has identified priorities for an approach to reduce exposure to unhealthy dietary risk factors for obesity and diabetes (See Annex 1 for the methodology). This document presents an initial proposal for 10 priority areas for action, which cover 37 strategic interventions to help prevent overweight, obesity and diabetes in the whole population – children, adolescents and adults. These areas for action and interventions are set out in Table 1.

All the priority areas and interventions proposed have a sufficiently strong case-based on research evidence and expert analysis of the measures – to warrant recommending their adoption (See Annex 2 for a summary of the

1 Such as the United Nations Political Declaration of the High Level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases (2011), the WHO Eastern Mediterranean Region Framework for action to implement the UN Political Declaration on Noncommunicable Diseases, including indicators to assess country progress by 2018, the Commission on Ending Childhood Obesity (2016), the political declaration and Framework for Action from the Second International Conference on Nutrition (2014) and WHO’s first Global Report on Diabetes (2016).

6

Proposed policy priorities for preventing obesity and diabetes

evidence). In addition, most of the interventions have been tried and tested in other countries or localities or adopted by innovative policy-makers, and growing country experience has bolstered the evidence base (See Annex 3 for examples of country implementation). Some of the proposed strategic interventions will be easier to implement than others and the challenges of their application, the financial implications, public acceptance and political feasibility very much depend on the particular country context (See Annex 4 for a summary of feasibility issues).

A phased approach may, therefore, be needed in some countries. The strongest candidate interventions for the first phase of action are indicated in Table 1, along with those that it may be more appropriate to implement in a second phase. Countries that are less affected by these feasibility constraints, however, are encouraged to implement all of the strategic interventions as soon as possible.

Detailed analysis of the effective measures and the responsibilities for implementing them has revealed that almost all the proposed interventions require simultaneous action by several government departments, in addition to the Ministry of Health, which should have an important coordination and monitoring role (3). The exact configuration of a cross-government approach will vary, but it is important to establish the highest level of political commitment and leadership and to ensure coordinated action across government with mechanisms to evaluate and drive progress by each government department.

This highlights more than ever the need for a whole-of-government and whole-of-society approach – backed by strong political commitment at the highest level – to tackling these major public health problems, which have multiple and inter-related risk factors and determinants.

Table 1. Summary of proposed priority areas of action and strategic interventions for preventing obesity and diabetes in the Eastern Mediterranean and their implementation phaseArea for action Interventions most suitable for first phase

implementation Interventions for which there is evidence of impact, but which it may be more appropriate to implement in a second phase

1 Fiscal measures 1.1 Progressively eliminate national subsidies for all types of fats/oils and sugar.

1.2 Implement an effective tax on sugar-sweetened beverages.

1.3 Consider an effective progressive tax on high fat foods and on high sugar foods.

2 Public procurement 2.1 Implement mandatory nutrition standards across all public institutions through (a) application of the regional nutrient profile model to assess the nutritional quality of different foods, (b) introduction of meal standards and (c) measures to eliminate the sale of foods or drinks high in fat, sugar or salt.

2.2 Issue mandatory guidelines for the revision of procurement to provide healthy food, including limiting the volume of fats/oils, sugar and salt entering public sector catering facilities in order to facilitate the necessary menu changes (e.g. so that meals provide not more than 25% energy from fats and less than 5% from free sugars).

2.3 Develop guidance and provide training to catering companies on appropriate catering methods in public institutions to reduce the use of frying and sweetening of foods and help with menu design.

2.4 Continue implementing these measures, scaling up coverage and monitoring impact.

7

Executive summary



3 Physical activity interventions

3.1 Promote healthy physical activity through mass media campaigns (see priority area 9) and ensure adequate legislation supporting delivery of daily physical activity for students in schools and universities.

3.2 Ensure comprehensive delivery of regular, quality physical education to all children, as a key component of education in schools.

3.3 Develop a set of standards/guidelines promoting physical activity in the workplace, including facility/building design, availability of sports facilities and programmes enabling access to facilities away from the workplace.

3.4 Increase availability of and accessibility for participation in formal and informal recreational and sporting activities, particularly providing opportunities for participation in programmes such as “Sports-for-All”, with emphasis on ensuring equality of access and opportunity for participation.

3.5 Develop and implement an urban planning policy to ensure that urban environments encourage people to rely less on personal motorized vehicles and support access to safe, gender-sensitive and age-friendly public transport, cycling and walking, including by provision of facilities, equipment, open and green public space and shared use of school facilities (both indoor and outdoor).


4 Food supply and trade

4.1 Conduct a situation analysis of the national and/or local food supply, including establishing the proportions of fats/oils and sugar used in the diet that are derived from imports and domestic production, along with the extent of food manufacture and processing within the country and the supply of fruit, vegetables and whole grains.

4.2 Facilitate the development of local food policies and encourage city authorities to sign the Milan Urban Food Policy Pact and implement its Framework for Action to develop, where possible, sustainable urban food systems.

4.3 Consider introducing standards or other legal instruments (e.g. compositional standards, tariffs, import restrictions, sales bans, planning laws, zoning policies) to reduce the volume and improve the quality of fats/oils and reduce sugars in the national and local food supply.

4.4 Consider removing agricultural subsidies for producers of sugars and oils (especially those oils high in saturated fatty acids), replacing them, where necessary, with other mechanisms to support farmers and growers.

5 Reformulation 5.1 Cooperate with other Member States to adopt a regional approach for engaging with food producers to drive food reformulation to eliminate trans fats and reduce progressively total and saturated fat, salt, sugars, energy and portion size in a substantial proportion of processed foods.

5.2 Engage with private sector providers of food in catering/food service outlets (including takeaways and street food traders) to establish a programme to eliminate trans fats and reduce progressively total and saturated fat, salt, sugars, energy and portion size, with defined quantified reductions in use of these ingredients.

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6 Marketing 6.1 Work with other countries in the Region to establish a coordinated approach, including appropriate legal advice, to reduce the impact of cross-border marketing.

6.2 Implement the WHO Set of Recommendations on Marketing of Foods and Non-alcoholic Beverages to Children and consider mandatory restrictions to eliminate all forms of marketing of foods high in fat, sugar and salt to children and adolescents (up to age 18) across all media, according to the Regional Action Plan to Address Unopposed Marketing of Unhealthy Food and Beverages.

6.3 Use the regional nutrient profile model, which categorizes the appropriate level of nutrients in foods, to identify foods to which the marketing restrictions should apply.

6.4 Conduct an assessment (preferably as part of a regional collaboration) of the impact of marketing of foods high in fat, sugar or salt to adults to illuminate the magnitude of marketing and define how best to restrict inappropriate practices.

6.5 Consider extending mandatory restrictions on marketing of unhealthy foods to whole population.

6.6 Legislate to allow retail promotion only of healthy foods.

7 Labelling 7.1 Implement a mandatory front-of-pack labelling scheme with elements to enable consumers to interpret information easily (such as colour coding or the use of terms such as “high”, “medium”, ”low”).

7.2 Enforce the labelling scheme and monitor its impact with the potential to strengthen the labelling with suitable health warnings.

8 Breastfeeding 8.1 Promote breastfeeding through mandatory baby-friendly health systems and effective community-based strategies.

8.2 Fully implement the International Code of Marketing of Breast-milk Substitutes and the WHO Guidance on ending inappropriate promotion of foods for infants and young children.

8.3 Empower women to exclusively breastfeed, by enacting progressively increasing remunerated time off work up to a goal of 6 months’ mandatory paid maternity leave, as well as policies that encourage women to breastfeed in the workplace including breastfeeding breaks and provision of suitable facilities.

9 Mass media campaigns

9.1 Implement appropriate social marketing campaigns, led by the public sector, on healthy diet and physical activity in order to build consensus, complement the other interventions in the package and encourage behaviour change.

9.2 Ensure sustained implementation of campaigns and monitor their impact.

10. Health sector interventions

10.1 Ensure provision of dietary counselling on nutrition, physical activity and healthy weight gain before and during pregnancy for prospective mothers and fathers.

10.2 integrate screening for overweight and other diabetes risk factors into primary health care and provide primary-care based counselling for high-risk individuals.

10.3 Establish or strengthen, as appropriate, a high-level multisectoral mechanism to define and oversee the implementation of food and physical activity policies for the prevention of obesity and diabetes.

10.4 Establish national targets for obesity and diabetes, along with SMART commitments for action, and work with WHO to develop and implement a monitoring framework for reporting on progress.

10.5 Implement evidence-based community-based interventions, addressing both healthy eating and physical activity, comprising different activities and targeting high-risk groups, to promote and facilitate behaviour change and prevent obesity and diabetes.

9

Introduction

1. Introduction: Obesity and diabetes in the Eastern Mediterranean RegionThere is an alarming and escalating burden of overweight, obesity and diabetes in the Eastern Mediterranean Region, closely linked to changing dietary patterns. Obesity and the most common type of diabetes are largely preventable and urgent action is needed to reduce exposure to their causal factors, such as unhealthy diet and physical inactivity.

1.1 Burden of obesity and diabetes

The prevalence of obesity and overweight is worryingly high in the Region – at 46.8%,

well above the global average. In 2014, half the Region’s adult women (50.1%) and more than two in five men (43.8%) were overweight or obese (1). In some countries of the Region two thirds or more of adults are overweight or obese, while other countries, in an earlier stage of the nutrition transition that often accompanies economic development, have moderate levels of overweight/obesity or have emerging overweight/obesity only in certain socioeconomic groups (Fig. 1 and 2).

High rates of childhood overweight give particular cause for concern. On average, 6.9% of children under five years are already overweight – higher than the global average of 6.2% – and in some countries more than 15% of children are affected. In many countries of the Region more than half of adolescents (13–18 years) are overweight or obese (2) (Fig. 3).

Fig. 1. Prevalence of female overweight and obesity in Eastern Mediterranean countries (latest integrated 2014 prevalence data for adult women)

Source: Data from NCD Risk Factor Collaboration. Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 million participants. Lancet. 2016; 387:1377-96.

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Young women who are overweight or obese before pregnancy are now having children who are immediately disadvantaged for life as they are at greater risk of later health problems,

including obesity (4). Diabetes during pregnancy not only exposes a mother to much greater risk, but also markedly increases her child’s chances of ill health in the future (5).

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Fig. 2. Prevalence of male overweight and obesity in Eastern Mediterranean countries (latest 2014 integrated prevalence data for adult men)

Source: Data from NCD Risk Factor Collaboration. Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 million participants. Lancet. 2016; 387:1377-96.

Fig. 3. Prevalence of adolescent overweight and obesity in Eastern Mediterranean countries (13–18 years, average for boys and girls, 2014)

Source: Recalculated from WHO Eastern Mediterranean Framework for health information systems and core indicators for monitoring health situtation and health system performance, 2015

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The Eastern Mediterranean Region has the highest prevalence of diabetes in the world (Fig. 4) (1). Around 43 million people in the Region live with this chronic disease, which, if not properly controlled, puts them at increased risk of serious complications, such as cardiovascular disease, vision loss, nerve damage, leg amputation or kidney failure, and of early death. More than 10% of deaths in adult women and 9% of deaths in adult men in the Region are attributable to high blood glucose (1). The prevalence of diabetes in the Region rose from 6% in 1980 to 14% in 2014 and now affects more than 20% of adults in some countries. In addition, there are many millions more with pre-diabetes,2 who are at increased risk of developing clinically evident

2 Impaired glucose intolerance and impaired fasting glycaemia are intermediate conditions in the transition between normal blood glucose levels and diabetes, although the transition is not inevitable.

diabetes within the next 5–10 years and who already have a greater risk of heart disease.

The risk of diabetes is recognized to increase as children and adults in particular gain weight. So the longer an adult has been overweight/obese and the more extreme their obesity, the greater their risk of diabetes. Yet in the Eastern Mediterranean Region, the prevalence of diabetes is about twice the rates found for equivalent prevalence rates of obesity in, for example, European Union countries (1) (Fig. 5), potentially reflecting a greater sensitivity of the population in the Region to diabetes if they gain weight.

Both obesity and diabetes were rare in the 1950s in most countries of the Region until the activity patterns and diet of the communities changed from the 1960s onwards with a

Introduction

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

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Fig. 4. Trends in the prevalence of diabetes, 1980–2014, by WHO Region

Source: (1).

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subsequent increase in body weight and increasing prevalence of diabetes.

The greater sensitivity to diabetes when adults gain weight may relate to the greater genetic sensitivity of the population but it is also recognized that early nutritional deficiencies affecting mothers in early pregnancy and children in early childhood can potentially increase the sensitivity of the community to the development of obesity and diabetes, as recently emphasized by the Commission on Ending Childhood Obesity (6). These effects seem to relate to the impact of a poor environment on the responsiveness of normal genes through so-called “epigenetic changes” that are only just becoming understood. It is also being emphasized that a woman needs be nutritionally well fed and of normal weight before conception to promote the well-

being of her child and avoid the problems of an increased risk of childhood obesity. The Region is, therefore, facing a huge challenge as future generations are increasingly affected by obesity and diabetes at a much earlier age. No country can afford the financial and social costs these changes will bring.

This alarming and escalating burden of obesity and diabetes in the Region is closely linked to the dietary changes of recent decades. The good news is that both obesity and type 2 diabetes are largely preventable – but multisectoral, population-based initiatives are needed to reduce exposure to the major causes, namely unhealthy diet and physical inactivity. The high levels of obesity and diabetes in the Region also suggest that substantial measures need to be taken soon to alleviate and reverse the current escalating burden of disease.

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Fig. 5. National diabetes prevalence rates in countries of the Eastern Mediterranean Region (EMR) and European Union (EU) country equivalent obesity rates

Source: Based on WHO STEPS data

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1.2 Dietary risk factors driving the burden of obesity and diabetes

Dietary factors causing unhealthy body weight gain and type 2 diabetes include high intakes of total fat and free sugars, excessive saturated fatty acid consumption and an inadequate intake of fibre-rich foods (1). In addition, high intake of sugary drinks, not just overall sugar intake, increases the likelihood of being overweight or obese, particularly among children, and is also associated with an increased risk of type 2 diabetes (1). WHO dietary recommendations for the prevention of type 2 diabetes include limiting saturated fatty acid intake to less than 10% of total energy intake (and for high-risk groups, less than 7%) and achieving adequate intake of dietary fibre (minimum daily intake of 20 g) through regular consumption of wholegrain cereals, legumes, fruits and vegetables (7). WHO is currently updating its guidelines on fat intake and carbohydrate intake, which will include recommendations on dietary fibre as well as fruits and vegetables. WHO strongly recommends that all individuals should reduce their intake of free sugars3 to less than 10% of total energy intake and suggests that “further reduction to 5% could have additional health benefits” (8). Given the heavy burden of disease in the Region and WHO evidence that both weight gain and dental disease seem to be progressively lower when intakes are further reduced, free sugar intake of less than 5% of total energy intake for every individual is considered the goal in order to achieve the dramatic improvement needed in children’s and adults’ health in countries of the Region.

Remarkable increases in total energy, fat and sugar intakes in countries throughout 3 This includes “all monosaccharides and disaccharides

added to foods by the manufacturer, cook, or consumer, plus sugars naturally present in honey, syrups, and fruit juices”.

the Eastern Mediterranean in recent decades mean that diets in the Region have gone in the opposite direction to all the national and WHO recommendations. Average intakes of energy and fat are above the WHO-recommended levels, with substantially higher fat intakes in the Region’s high-income countries. Thus, for example, in the 1950s and early 1960s the fat intake of the Bedouin in the Negev desert was 13% and their diet was rich in high fibre carbohydrate but low in sugar, and obesity and diabetes prevalence rates were very low (9), whereas now fat intakes are up to three times higher with much increased sugar intake. More than three quarters of the Region’s countries now consume substantially higher levels of sugar than the WHO-recommended daily intake of less than 5% from free sugars (10,11). This recommended level means that women should, on average, consume less than 25 g of free sugars per day and men less than 35 g per day. Average intakes in many countries already exceed 80 g per person daily (8).

Since excess body fat is a risk factor for type 2 diabetes, there is clearly benefit to be derived – with lower overweight and obesity rates – if coherent dietary measures are taken. In 2010, WHO proposed a series of evidence-based “best buy” interventions for tackling noncommunicable diseases (NCDs) and these were endorsed by the United Nations General Assembly’s political declaration on NCDs (12,13). The best buys for addressing unhealthy diet and physical inactivity were: reduced salt intake in food, replacement of trans fat with polyunsaturated fat, and raising public awareness on diet and physical activity through mass media. For cardiovascular diseases and diabetes, the best buys were counselling and multidrug therapy for people with a high risk of developing heart attacks and strokes, and treatment of heart attacks with aspirin (12). WHO’s first Global Diabetes Report, published in 2016, recommends

Introduction

14


prioritizing actions to prevent people becoming overweight and obese, implementing policies and programmes to promote breastfeeding and to increase the consumption of healthy foods, together with measures to discourage the consumption of unhealthy foods (1). The creation of supportive built and social environments is also recommended, in order to allow spontaneous as well as deliberate physical activity to improve health. These priorities can best be achieved through a combination of fiscal policies, legislation and regulations leading to environmental changes, as well as making the population aware of the changes and remedies needed.

1.3 Urgent action to tackle obesity and diabetes in the Region

Globally, countries are already working towards agreed global goals on maternal and infant nutrition and on the prevention of NCDs, and both these include halting the increase in overweight and obesity.4 The United Nations General Assembly convened a high-level meeting on NCDs in September 2011 attended by Heads of State and Government in which a political declaration was endorsed urging Member States to implement a comprehensive agenda to prevent and control the four major groups of NCDs, namely cardiovascular diseases, diabetes, cancer and chronic lung disease (13). The United Nations agenda covers high-impact, evidence-based and cost-effective measures (NCD best buys) to reduce risk factors including obesity and to create health-promoting environments through a whole-of-government and a whole-of-society effort. Subsequently, in 2012, the 4 The WHA global nutrition goals include a goal to halt the

increase in childhood overweight by 2025. The global NCD goals include a 25% relative reduction in overall mortality from NCDs (including diabetes) and halting the increase in obesity prevalence in adolescents and adults by 2025.

WHO Regional Committee for the Eastern Mediterranean endorsed a regional framework for action to translate the recommendations of the United Nations political declaration into a set of concrete population- and individual-based measures that Member States need to implement (14).

In November 2014, the Second International Conference on Nutrition (ICN2) adopted the Rome Declaration on Nutrition and its Framework for Action, which presented a set of 60 recommended actions, across sectors, to prevent malnutrition in all its forms, including overweight, obesity and diet-related NCDs (15,16). In early 2016, WHO’s Commission on Ending Childhood Obesity also made a series of recommendations to respond to the global crisis in childhood overweight (6).

Taking these recent recommendations and the regional framework for action into account, the WHO Regional Office for the Eastern Mediterranean has identified priorities for dietary change on a broad population-wide and regional basis to prevent obesity and diabetes in children, adolescents and adults. In that regard, this document presents 10 proposed priority areas for action involving 37 interventions.

With a focus on obesity and diabetes, these interventions have been selected to prioritize reducing the total amount of energy consumed from fat and sugar intakes, while recognizing that a shift from trans or saturated fats to unsaturated fats, reductions in salt intake and increases in fruit and vegetable consumption are also needed. These interventions should be seen as part of broader efforts to improve nutrition – especially since undernutrition is still prevalent in some countries of the Region – and to prevent other NCDs, including cardiovascular disease and cancer. Many of the priority interventions identified here would help prevent these other diseases by, for

15

3. Proposed priority areas for action and strategic interventions

Ten priority areas for action are proposed for the population-wide prevention of obesity and diabetes in the Eastern Mediterranean Region. Under these 10 areas, 37 strategic interventions are proposed for Member States’ consideration. These interventions focus mainly on a population-wide approach to address these major public health challenges, with a particular emphasis on food systems.

These recommendations are consistent with the WHO regional Framework for action to implement the United Nations Political Declaration on Noncommunicable Diseases and the 10 priority legal interventions for preventing NCDs identified for the Region (17). They also reflect the recommendations of the Commission on Ending Childhood Obesity and the ICN2 Framework for Action (6,16).

There are strong health and economic rationales for using fiscal measures, such as taxes and subsidies, which can both create incentives to reduce dietary risk factors for NCDs and generate government revenue, which could potentially be ring-fenced for health budgets (18). There is convincing evidence from modelling, experimental studies and from a growing body of country experiences that fiscal measures such as taxes and subsidies are very effective in shifting purchasing habits and thereby promoting dietary change (18–20).

Evidence is strongest and most consistent for the effectiveness of taxes on sugar-sweetened drinks, which are important contributors to calorie and free sugars intake (18). More than 10 countries (in addition to some sub-national or local jurisdictions) have introduced taxes on sugar-sweetened beverages. There is convincing and growing evidence that these

example, leading to reductions in intakes of salt and saturated fat or increases in fruit and vegetable consumption.

Priority area for action 1: Fiscal measures – Use judicious taxes and subsidies to promote healthier diets

Strategic interventions

1.1. Progressively eliminate all national subsidies for all types of fats/oils and sugar.

1.2. Implement an effective tax on sugar-sweetened beverages.

1.3. Consider an effective progressive tax on high fat foods and on high sugar foods.

2. Methodology for identifying priority actions for preventing obesity and diabetes in the Region

Starting with an informal regional meeting convened by the Regional Office in Geneva in May 2016, a process of identifying and defining effective, cost-effective and feasible interventions to address obesity and diabetes in the Eastern Mediterranean Region took place over the following eight months. The process involved consultation with policy experts and a review of the evidence on the key policy areas identified at the initial meeting. It culminated in the selection of 10 priority areas for action and 37 strategic interventions. This list was further developed, along with a summary of the evidence, case studies of implementation and feasibility considerations, into the current report. (The process is described in more detail in Annex 1).

Methodology for identifying priority actions for preventing obesity and diabetes in the Region

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taxes are effective in reducing purchases, in the range of 20–50% (18,20–25). There is also a demonstrable impact of nutrient-focused taxes, such as those on high fat and/or sugar foods, which may reduce consumption of the target foods but may also increase intakes of foods not targeted by the tax (18–20,26–30). Subsidies on healthy foods have also been shown to increase intakes, with evidence strongest for subsidies on fruits and vegetables (18).

Priority area for action 2: Public procurement – Implement policies for the procurement and provision of healthy food in public institutions


2.4. Implement mandatory nutrition standards across all public institutions through (a) application of the regional nutrient profile model to assess the nutritional quality of foods, (b) introduction of meal standards and (c) measures to eliminate the sale of foods or drinks high in fat, sugar or salt.

2.5. Issue mandatory guidelines for the revision of procurement to provide healthy food, including limiting the volume of fats/oils, sugar and salt entering public sector catering facilities in order to facilitate the necessary menu changes (e.g. so that meals provide not more than 25% energy from fats and less than 5% from free sugars).

2.6. Develop guidance and provide training to catering companies on appropriate catering methods in public institutions to reduce the use of frying and sweetening of foods and help with menu design.

2.7. Continue implementing these measures, scaling up coverage and monitoring impact.

WHO has issued a technical report on the design and implementation of fiscal policies that should help policy-makers ensure that these are designed carefully in order to avoid unintended consequences, particularly on poorer groups who may then purchase other untaxed or cheaper foods (18). It has been suggested that taxes are more effective when applied to foods for which there are close healthy alternatives and that a targeted tax may be even more effective when combined with a subsidy on fruits and vegetables (19,20).

With the potential to save between 139 and 1696 disability-adjusted life-years (DALYs) per million population after 20 years in six low- or middle-income countries, a package of fiscal measures is predicted to be cost saving, i.e. the country not only saves expenditure on treating obesity and diabetes and their complications, but these saved costs are greater than the costs of implementing the measures (31–34).

Food subsidies, often on high fat or sugar commodities, are common throughout the Region – existing in three quarters of countries and amounting, on average, to just less than 1% of gross domestic product in 2011 (35).

Priority area for action 3: Physical activity interventions – Implement policies, legislation and interventions to promote and facilitate health-enhancing physical activity


3.8. Promote healthy physical activity through mass media campaigns (see priority area 9) and ensure adequate legislation supporting delivery of daily physical activity for students in schools and universities.

3.9. Ensure comprehensive delivery of regular, quality physical education to all children as a key component of education in schools.

3.10. Develop a set of standards/guidelines promoting physical activity in the workplace, including facility/building design, availability of sports facilities and programmes enabling access to facilities away from the workplace.

3.11. Increase availability of and accessibility for participation in formal and informal recreational and sporting activities, particularly providing opportunities for participation in programmes such as “Sports-for-All”, with emphasis on ensuring equality of access and opportunity for participation.

3.12. Develop and implement an urban planning policy to ensure that urban environments encourage people to rely less on personal motorized vehicles, and support access to safe, gender-sensitive and age-friendly public transport, cycling and walking, including by provision of facilities, equipment, open and green public space and shared use of school facilities (both indoor and outdoor).

3.13. Continue implementing these measures, scaling up coverage and monitoring impact.

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Proposed priority areas for action and strategic interventions

expenditure means that procurement policies also have the potential to affect markets and bring about changes further up the supply chain.

There is international evidence that healthy food procurement policies can improve diets and health outcomes, particularly in studies done in schools (37–40), and experience shows that nutrition standards can be implemented across a wide range of public institutions. Many countries have introduced mandatory school food standards including bans on vending machines on school premises (41). Some countries have gone beyond nutrition standards to implement wider school procurement policies, linked to sustainability and boosting local markets (42,43). There are also examples of action at regional, national or local levels to improve public food beyond the school settings (44,45). See Annex 3 for examples of implementation.

Implementing healthy food procurement or nutrition standards could have cost implications for public food, but various strategies are available to keep costs down (42,46,47). There are, however, potentially high levels of return on investment in terms of health gains and the potential to bring about changes beyond health if social, environmental or economic objectives are also incorporated.

Physical inactivity is a risk factor for weight gain, type 2 diabetes and other NCDs, yet one third of men and half of the women in the Region do not undertake the minimum recommended levels of physical activity (48). Prevalence of physical inactivity ranges from about 30% to as high as 70% in some countries. Compared with other regions, women and younger adults in the Eastern Mediterranean Region are the least physically active in the world (48), but very few countries in the Region have programmes in place to increase physical activity. A high-level regional forum in 2014 agreed on a road map for promoting physical activity in the countries

These subsidies, often introduced to ensure food security, are in fact not particularly well targeted as a social protection measure and wealthier sectors of the population accrue a significant proportion of the benefits (35).In addition, such subsidies readily promote consumption of sugar or oils and can also encourage food manufacturers to use subsidized sugars or fats or ingredients derived from these commodities (e.g. high-fructose corn syrup or partially hydrogenated vegetable oils). The poorest groups are, therefore, particularly likely to suffer from the disease consequences of these measures.

Country experience in the Region shows that subsidies can be removed.5 It may be important to phase in the implementation to minimize public opposition, accompany it with explicit information campaigns that highlight the health benefits of such measures, and mitigate the impact on lower socioeconomic groups by replacing the subsidy with appropriate, nutrition-sensitive social protection measures, such as cash or food transfers, as advocated by the African Development Bank for at least one country in the Region (36).

Given the major dietary contribution of food eaten in schools, hospitals, residential care homes, universities, prisons, armed forces catering, government buildings and other publicly-funded venues or events, there is a strong case for ensuring that food served in these public institutions is always healthy.

“Healthy food procurement”6 can include application of nutritional standards/guidelines and may also – by changing what is served or sold – aim to promote healthy habits and preferences. The scale of government

5 Egypt, for example, has started to reform its food price subsidies (153).

6 The processes of procuring, distributing, selling and/or serving food in these institutions or distributing through social protection or welfare programmes, and ensuring it is healthy.

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involvement of both boys and girls in daily physical activity as part of a comprehensive education with a whole-school approach to activity before, during and after school hours with measures to reduce time in sedentary activities. For many children, particularly from disadvantaged backgrounds, physical education classes are their only regular physical activity, yet provision of physical education has been in decline globally (50). The right to quality physical education as an essential element of lifelong education is enshrined in UNESCO’s 1978 International Charter of Physical Education and Sport (50).

For adults, there is a need to develop practical guidelines from international experience to improve activity in the workplace, as well as linking these with other preventive health measures. It also recommended that “Sport for all” programmes be promoted and delivered, with a focus on outreach to vulnerable and disadvantaged groups, and should also be based on international experience.

Special arrangements may need to be made for women and new approaches are required so that adults, including older adults, of both sexes recognize the immense benefits of physical activity and meet the current recommended physical activity guidelines.

Urban design is one of the important areas for action. There has been rapid urbanization, dramatic changes in urban design and escalating car use in the often very hot climates of countries of the Region in the last 30–40 years (49).

It is now becoming clear from new analyses of urban design (51) that urban communities, currently expanding throughout the Region, need to incorporate appropriate, shaded walking spaces, preferably with trees, suitable parks and open spaces with congenial settings for walking which promote physical activity (52). There also needs to be a preferential

of the Region (49) and a regional Call to Action was issued, urging high-level decision-makers to implement multisectoral national plans of action (48).

The high prevalence of physical inactivity should not be seen to be an issue solely of individual responsibility, rather the environment in many countries has been designed, in effect, to minimize activity. Thus, governments should recognize their responsibility to change societal arrangements so that physical activity is promoted and not inhibited, through policy actions in the fields of health, education, workplace, sport, communication, urban design and transport.

Priority area for action 4: Food supply and trade – Use food standards, legal instruments and other approaches to improve the national and/or local food supply in this Region of net food-importing countries


4.14. Conduct a situation analysis of the national and/or local food supply, including establishing the proportions of fats/oils and sugar used in the diet that are derived from imports and domestic production, along with the extent of food manufacture and processing within the country and the supply of fruit, vegetables and whole grains.

4.15. Facilitate the development of local food policies and encourage city authorities to sign the Milan Urban Food Policy Pact and implement its Framework for Action to develop, where possible, sustainable urban food systems.

4.16. Consider introducing standards or other legal instruments (e.g. compositional standards, tariffs, import restrictions, sales bans, planning laws, zoning policies) to reduce the volume and improve the quality of fats/oils and reduce sugars in the national and local food supply.

4.17. Consider removing agricultural subsidies for producers of sugars and oils (especially those oils high in saturated fatty acids), replacing them, where necessary, with other mechanisms to support farmers and growers.

The high-level forum recommended legislative and implementation measures to ensure the

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investment in safe, gender-sensitive and age-friendly public transport and the restriction of private car use, as these measures are all associated with greater rates of walking and physical activity (53,54). High residential density in cities and diverse built environments promote widespread physical activity, particularly if public transport surpasses private car use. There is a need to consider specific environmental interventions targeting the built environment, with suitable policies that reduce barriers to physical activity and public transport and other policies to increase space for recreational activity.

Priority area for action 5: Reformulation – Implement a government-led programme of progressive reformulation, adapted to the national context, to eliminate trans fats and reduce progressively total and saturated fat, salt, sugars, energy and portion size


5.18. Cooperate with other Member States to adopt a regional approach for engaging with food producers to drive food reformulation to eliminate trans fats and reduce progressively total and saturated fat, salt, sugars, energy and portion size in a substantial proportion of processed foods.

5.19. Engage with private sector providers of food in catering/food service outlets (including takeaways and street food traders) to establish a programme to eliminate trans fats and reduce progressively total and saturated fat, salt, sugars, energy and portion size, with defined quantified reductions in use of these ingredients.

To be able to take action to improve the food supply, policy-makers need first to understand the food system (both at national and local levels) in order to understand where fats and sugars enter the food supply and how access to healthier foods can be improved. Major policy drivers, such as international trade agreements or agricultural policy, greatly influence what food is produced or imported and these policies have not always been consistent with nutrition objectives.

While, in theory, trade policies should support nutrition, in reality such policies may also sometimes undermine healthy diets by, for example, making foods high in fat, salt or sugar (HFSS) more accessible, reducing access to locally-produced nutritious foods or, by encouraging inward foreign direct investment by multinational food companies, facilitating greater exposure to soft drinks and processed foods (55,56). Trade agreements may hinder efforts to tackle obesogenic food environments (those promoting obesity) by constraining governments’ autonomy and the “policy space” available for implementing strong public health nutrition policies (57). Mechanisms are needed to ensure that nutrition concerns are taken into account in trade negotiations (55).

Policy-makers have access to a variety of policy or legal instruments to improve the nutritional quality of the food supply. Depending on the specific context, measures such as tariffs, import quotas, compositional standards or sales bans might be appropriate. Some countries, including some Pacific island states and Ghana, have used such instruments to reduce the availability or increase the price of fats and sugars in the food supply (58–61). International trade and legal expertise is important for the design of appropriate tools within the constraints of current World Trade Organization and other trade agreements. The magnitude of the obesity and diabetes problem in the Region, however, justifies such actions on public health grounds.

Agricultural subsidies, which have usually been designed to support agricultural producers and rarely take nutrition considerations into account, can also have an impact on the food supply and may influence rates of nutrition-related NCDs (62).

Although international trade and national policies are important drivers of the food supply, local policy-makers also have considerable scope to influence food systems


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at the city or regional level. Globally, more than 130 cities, including a handful from the Eastern Mediterranean have signed up to the Milan Urban Food Policy Pact, committing to developing sustainable food systems that, among other things, provide healthy and affordable food to all (63). To this end, a Framework for Action sets out nearly 40 strategic options as a starting point for cities to address the development of their own urban food systems.

The ICN2 Framework for Action recommends that countries encourage a progressive reduction of saturated fats, sugars, salt/sodium and trans fats from foods and beverages (16) and WHO identified reformulation as important for the prevention of NCDs (64).

Priority area for action 6: Marketing – Implement appropriate restrictions on marketing (including price promotions) of foods high in fat, sugar and salt


6.20. Work with other countries in the Region to establish a coordinated approach, including appropriate legal advice, to reduce the impact of cross-border marketing.

6.21. Implement the WHO Set of Recommendations on Marketing of Foods and Non-alcoholic Beverages to Children and consider mandatory restrictions to eliminate all forms of marketing of foods high in fat, sugar and salt to children and adolescents (up to age 18) across all media, according to the Regional Action Plan to Address Unopposed Marketing of Unhealthy Food and Beverages.

6.22. Use the regional nutrient profile model, which categorizes the appropriate level of nutrients in foods, to identify foods to which the marketing restrictions should apply.

6.23. Conduct an assessment (preferably as part of a regional collaboration) of the impact of marketing of foods high in fat, sugar or salt to adults to illuminate the magnitude of marketing and define how best to restrict inappropriate practices.

6.24. Consider extending mandatory restrictions on marketing of unhealthy foods to the whole population.

6.25. Legislate to allow retail promotion only of healthy foods.

Specifically for the prevention of obesity and diabetes, the process of reformulation to reduce dietary energy density by reducing the fat and sugar content of foods is a particular priority. There is very strong and extensive evidence from many salt reduction programmes that progressive reformulation to lower the concentration of a specific nutrient can reduce the levels in available foods and thereby lower population intakes (65). This experience with salt should be readily transferrable to other nutrients or ingredients. Country experience also shows that trans fats can be virtually removed from foods by effective national or local policy interventions (66).

Progressive reformulation is well tolerated by consumers and can gradually alter consumer preferences (67–69). There is also evidence that a mandatory approach to food reformulation is more cost effective than a voluntary approach (70), and that this is also effective in creating a level playing field for the food industry. Specifying and requiring progressive reductions of the selected nutrients (e.g. salt, fats and sugars) with government-set limits using a combined multinutrient approach, together with comprehensive stakeholder engagement and a commitment to transparent monitoring and evaluation, are all key components of successful reformulation programmes (70). In addition, reformulation programmes should be accompanied by front-of-pack labelling and consumer awareness campaigns.

The potential impact and cost–effectiveness of reformulation programmes will depend on the specific eating patterns in the national context, including aspects such as where and how fats and sugars are added to foods and the scale of the measures implemented. In order to have a meaningful impact, programmes need to cover a significant proportion of processed foods and strive for substantive reductions. Impact could be maximized by reformulating processed foods, cooking ingredients and food provided

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industry (6). This implies that in many countries mandatory changes are now required.

Country experience shows that measures to restrict marketing of HFSS foods to children and adolescents can reduce children’s exposure to such marketing, but the overall effectiveness depends on which foods are restricted, which age groups are protected, how audiences are targeted and what media and marketing techniques are covered (82–85). Research shows that mandatory restrictions on a national basis are more effective than the voluntary or self-regulatory approaches that have been adopted in many countries (86,87).

Priority area for action 8: Breastfeeding – Implement a package of policies and interventions to promote, protect and support breastfeeding


8.28. Promote breastfeeding through mandatory baby-friendly health systems and effective community-based strategies.

8.29. Fully implement the International Code of Marketing of Breast-milk Substitutes and the WHO Guidance on ending inappropriate promotion of foods for infants and young children.

8.30. Empower women to exclusively breastfeed, by enacting progressively increasing remunerated time off work up to a goal of 6 months’ mandatory paid maternity leave, as well as policies that encourage women to breastfeed in the workplace including breastfeeding breaks and provision of suitable facilities.

Modelling studies suggest that marketing restrictions would have a substantial health impact (especially in the longer term since most of the current measures target children). From a cost-benefit point of view, tackling adult obesity can bring much earlier financial benefits. Such measures have very low implementation costs and would be cost effective or cost saving (33,34).

To address these issues the WHO Regional Office for the Eastern Mediterranean has developed a regional action plan to address

in the food services sector (including takeaways which are a growing contributor to the diet in many countries in the Region). Analyses in high-income countries predict considerable population health benefits and estimate that reformulation (mainly salt) would be net cost-saving or very cost effective (70–75).

Populations of all ages are exposed to marketing of HFSS foods through a variety of different channels (e.g. print, broadcast, Internet, social media and others) and using a vast array of marketing techniques.7 There is convincing research that exposure to marketing for HFSS foods influences what and how much children eat (76–80).

Priority area for action 7: Labelling – Implement or revise standards for nutrition labelling to include front-of-pack labelling for all pre-packaged foods


7.26. Implement a mandatory front-of-pack nutrition labelling scheme with elements to enable consumers to interpret information easily (e.g. multiple colour-coded traffic lights, use of terms such as “high”, “medium”, “low”).

7.27. Enforce the labelling scheme and monitor its impact, with the potential to strengthen the labelling with suitable health warnings

Concern about the potential negative impact of such marketing led WHO to issue a Set of Recommendations on the Marketing of Foods and Non-Alcoholic Beverages to Children (81). The Commission on Ending Childhood Obesity noted that exposure to marketing of unhealthy foods is still a major issue despite the increasing number of voluntary efforts by

7 Marketing techniques include, for example, advertising, sponsorship, product placement, sales promotion, cross-promotions using celebrities, brand mascots or characters popular with children, web sites, packaging, labelling and point-of-purchase displays, e-mails and text messages, philanthropic activities tied to branding opportunities, and communication through “viral marketing” and by word-of-mouth (154).


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where children and adolescents comprise more than half of the population.

Some health advocates and government public health institutions have called for mandatory or voluntary restriction of price promotions on HFSS foods to bring about dietary improvements (75,88,89). Retail price promotions on HFSS foods are increasingly common throughout the Region, including in fast food chains (90). Analyses from high-income countries show that price promotions – such as temporary price reductions, ”multibuy” offers and “extra free” offers – selectively promote HFSS foods and drinks (88,91,92). No examples have been identified yet of regulatory implementation, but some United Kingdom (UK) retailers, for example, have voluntarily restricted price promotions on HFSS foods (88). Given the Region’s extraordinarily high rates of obesity and diabetes, consideration should be given to developing a coherent policy to restrict marketing inducements to eat unhealthy foods.

Three quarters of the world’s population is estimated to live in countries that legally require pre-packaged food labels which provide a breakdown of the nutrient content, and this nutrition information panel is usually on the back (or side) of the package (93). There is growing interest in making nutrition information more accessible, understandable and meaningful for all consumers, since research shows that women, people with higher levels of education and those on particular diets are more likely to use labels (22). Options that have been explored include various forms of front-of-pack labelling for pre-packaged foods, menu and display board labelling for food sold in restaurants/food service outlets, shelf labelling in shops, and specific warning labels on pre-packaged and/or restaurant food.

Many authoritative bodies have called for the introduction of rules on front-of-pack labelling, menu labelling and/or other interpretative labelling schemes (6,94,95). There is evidence

unopposed marketing of unhealthy food and beverages (unpublished) and a nutrient profile model to help Member States define foods for which marketing is to be restricted.8 Region-wide cooperation will be important because cross-border broadcast media dominate the Region, and a human rights-based approach and relevant international law should be applied. Any regional or national measures should incorporate clauses, first, to enable court action to be taken against companies based or incorporated under its jurisdiction but operating across borders and, second, to curtail the right of foreign companies to sue for loss of revenue under international investment law.9

Some countries have been sufficiently concerned about the impact of marketing of HFSS foods on the whole population (not just children) that they have introduced broader limitations on marketing of these foods.10 Restricting all marketing of HFSS foods is a way to protect adult health and to protect adolescents and children from exposure to marketing that is supposedly targeted only at adults. Given that no country has completely eliminated children’s exposure to marketing of HFSS foods by defining child audiences, a whole population approach might well be particularly relevant to the Eastern Mediterranean Region,

8 Nutrient profile model for the marketing of food and non-alcoholic beverages to children in the WHO Eastern Mediterranean Region. Cairo: WHO Regional Office for the Eastern Mediterranean; 2017 (http://applications.emro.who.int/dsaf/EMROPUB_2017_en_19632.pdf?ua=1, accessed 17 July 2017).

9 The United Nations Guiding principles on business and human rights and the Maastricht principles on the extraterritorial obligations of states in the area of economic, social and cultural rights apply here.

10 The Islamic Republic of Iran has prohibited all broadcast advertising of soft drinks and other food items; Ireland has a Code limiting the amount of broadcast advertising of HFSS foods to no more than 25% of advertising time; France requires advertisements for certain foods to carry a healthy diet message.

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that consumers like simple, interpretive, front-of-pack labels and that this can help them to make healthier choices (93,96,97). Evidence from several high-income countries suggests that interpretive front-of-pack labelling can drive food manufacturers to reformulate their products to make them healthier (40,98–100).

The government costs of introducing, explaining and enforcing compulsory food labelling – although the type of labelling is not specified – are generally estimated to be very low or low (33,34). It is predicted to be cost effective after 20 years and cost-saving after 50 years in low- and middle-income settings (34). It is estimated that the introduction of mandatory front-of-pack, menu and shelf labelling in the UK would be cost effective and would save 575 000 DALYs across the whole of the UK population (75).

It is estimated that universal breastfeeding would avert the deaths of 823 000 children under five years and 20 000 mothers every year (101). In addition to providing protection from respiratory infections, diarrhoeal disease and other common childhood illnesses, breastfeeding11 protects against overweight and obesity in children and adults (102,103). There is also some statistically significant evidence of protection for both the mother and her children against later diabetes (102,104). Some evidence that very early introduction of solid foods is associated with childhood overweight also exists (105,106).

There is highly significant evidence of the substantial positive impact of interventions on exclusive breastfeeding rates in various settings – including health systems and services, home

11 WHO recommends that infants should be exclusively breastfed (giving an infant only breastmilk and no other foods or liquids) for the first six months of life and that, thereafter, infants should receive nutritionally adequate and safe complementary foods, while continuing to breastfeed for up to two years or beyond. Optimal breastfeeding also comprises initiation of breastfeeding within one hour of life.

Priority area for action 9: Mass media campaigns – Conduct mass media campaigns on healthy diet and physical activity


9.31. Implement appropriate social marketing campaigns, led by the public sector, on healthy diet and physical activity in order to build consensus, complement the other interventions in the package and encourage behaviour change.

9.32. Ensure sustained implementation of campaigns and monitor their impact.

and family, community, and combinations of settings (107). There is modest evidence of workplace interventions that support, promote or protect breastfeeding on breastfeeding outcomes (107), and guaranteeing paid daily breastfeeding breaks for at least six months is associated with higher breastfeeding rates (108).

Marketing of breast-milk substitutes undermines breastfeeding (109) and national legislation to implement the International Code of Marketing of Breast-milk Substitutes has been shown to diminish the influence of marketing (110). Inappropriate promotion of baby foods also undermines optimal infant and young child feeding (111).

Countries should already be working towards the globally agreed target to increase the rate of breastfeeding in the first six months up to at least 50% by 2025 (Resolution WHA 65.6, 2012). WHO has set out the required actions:

1. Revitalize, expand and institutionalize the Baby-friendly Hospital Initiative in health systems.

2. Provide community-based strategies to support exclusive breastfeeding (e.g. tailored communication campaigns, home visits, support groups and counselling).

3. Implement, monitor and enforce legislation to implement the International Code of Marketing of Breast-milk


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maternity protection legislation and regulatory action to counter the marketing of breast-milk substitutes and inappropriate promotion of baby foods (114).

Mass media campaigns to raise public awareness on diet and physical activity are proposed as a WHO “best buy” for tackling unhealthy diet and physical inactivity (12). They also have a role to play in enhancing the public’s understanding of the need for other interventions in order to create a positive climate for policy action.

Long-term, intensive mass media campaigns can change health behaviour (115) and, more specifically, have been shown to be effective for promoting physical activity and moderately effective for promoting healthy diet (116). Intensive campaigns promoting one simple message are also moderately effective (116). Evidence shows that it is challenging to sustain effects after campaigns finish in the face of competing factors, such as pervasive food marketing across many forms of media, so long-term campaigns are more successful (115).

Health education and the use of so-called “nudge” techniques (positive reinforcement and indirect suggestions to try to achieve non-forced compliance) are far more effective if used in conjunction with other measures, such as those in the other priority areas for action (117). Experts advocating for the implementation of interventions such as reformulation, taxation or front-of-pack labelling also argue that accompanying education and information campaigns are required (31,97). Media and education have been used as part of successful multicomponent approaches at national and community levels, but it is difficult to assess the relative contribution of health education to the overall success (22).

Assessments of cost–effectiveness estimate that, after 20 years, such campaigns would be

Substitutes and subsequent relevant World Health Assembly resolutions and WHO’s Guidance on ending the inappropriate promotion of foods for infants and young children (112).

4. Enact mandatory paid maternity leave, ideally for 6 months, as well as policies that encourage women to breastfeed in the workplace and in public.

5. Invest in training and capacity-building in breastfeeding protection, promotion and support.

Priority area for action 10: Health sector interventions – Harness the health sector to enable change and to provide leadership on governance and accountability


10.6. Ensure provision of dietary counselling on nutrition, physical activity and healthy weight gain before and during pregnancy for prospective mothers and fathers.

10.7. Integrate screening for overweight and other diabetes risk factors into primary health care and provide primary care-based couselling for high-risk individuals.

10.8. Establish or strengthen, as appropriate, a high-level multisectoral mechanism to define and oversee the implementation of food and physical activity policies for the prevention of obesity and diabetes.

10.9. Establish national targets for obesity and diabetes, along with SMART commitments for action, and work with WHO to develop and implement a monitoring framework for reporting on progress.

10.10. Implement evidence-based community-based interventions, addressing both healthy eating and physical activity, comprising different activities and targeting high-risk groups, to promote and facilitate behaviour change and prevent obesity and diabetes.

Despite the existence of clear guidance and tools, the implementation of laws to protect and promote breastfeeding remains inadequate in most countries (113). There are, nonetheless, examples of countries that have achieved remarkable results through a range of health and community interventions,

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cost-effective in three of six low- or middle-income countries assessed. After 50 years, costs per DALY saved would drop to between US$ 1994 and US$ 15 211 and the intervention was estimated to be cost effective in four of the six low- or middle-income countries (34).

While most of the proposed priority areas for action depend largely on action from those outside the health sector, there remains a fundamentally important role for the health sector itself. It is important to harness the knowledge and skills of the health workforce – along with the respect and authority often accorded to health professionals – in order to promote, facilitate and support behaviour change.

Good nutrition and a healthy diet before and during pregnancy are important for the health of the mother and her child, and pregnancy may be an optimal time for behaviour change. Excessive weight gain during pregnancy is associated with many adverse short-term and long-term health outcomes for mother, including a higher risk of later obesity and gestational diabetes, and child. Propensity to obesity and diabetes appears to be, at least partially, programmed during early life – especially during the 1000-day period from conception to the child’s second birthday – and can be influenced by a mother’s nutritional status before and during pregnancy (4). Interventions on diet and/or exercise reduce the risk of excessive weight gain during pregnancy by around 20% (118) and WHO recommends counselling about healthy eating and keeping physically active during pregnancy (119). Interventions should be woman-centred, delivered in a non-judgemental manner and developed to ensure appropriate

weight gain.12 Cost implications of diet and exercise interventions are highly variable and, while diet and exercise counselling might have relatively low costs, available health service resources are critical for implementation.

In addition, physician counselling for at-risk groups has been shown to be effective (116) and cost effective (34) and is one of WHO’s “best buys” for preventing diabetes. Primary care-based counselling works best when the information is targeted and there is follow-up from trained personnel, while minimal contact interventions (such as health checks, single-visit counselling or distribution of information) are less effective (116). Primary care interventions are also effective when linked with other stakeholders, such as community groups or ongoing mass media campaigns.

Community-based interventions which comprise many different activities and address both diet and physical activity can be effective (116). Such interventions usually include a strong educational component and may target high-risk groups, such as those who are at a high risk of developing diabetes (116).

The health sector also has a vital – much broader – role to play in providing leadership, engaging other sectors and monitoring progress. While a cross-governmental approach is absolutely essential, the particular perspective and priorities of the Ministry of Health, and all those working in the health sector, will provide key incentives to drive progress in this area. The health sector will also be required to take a leading role in monitoring progress (see section 4 for more on these issues).

12 The definition of “normal” gestational weight gain is subject to regional variations, but should take into consideration pre-pregnant body mass index. According to the Institute of Medicine, women who are underweight at the start of pregnancy (i.e. BMI < 18.5 kg/m2) should aim to gain 12.5–18 kg, women who are normal weight at the start of pregnancy (i.e. BMI 18.5–24.9 kg/m2) should aim to gain 11.5–16 kg, women who are overweight (BMI 25–29.9 kg/m2) should aim to gain 7–11.5 kg and obese women (BMI ≥ 30 kg/m2) should aim to gain 5–9 kg.


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4. Implementation of the proposed priority areas for action

Ten priority areas and 37 interventions have been proposed as options for Eastern Mediterranean countries to take action on the growing burden of obesity and diabetes. All of these proposed interventions have a sufficiently strong case to warrant recommending their adoption and are considered to be proportionate responses to the major health and economic burden from these conditions in the Region. This case is based on consideration of the evidence for the effectiveness of these measures (see Annex 2) and practical experience of their implementation (see Annex 3). In a few cases where prior experience of country implementation does not exist, or where there are some evidence gaps, a strong logical basis for action together with international expert support are taken into account. Consideration has been given to implementation costs, along with feasibility issues and political acceptability of the proposed interventions (see Annex 4).

4.1 Multisectoral action is essential

It is very clear from the proposed interventions that action is also required outside the health sector. Health ministers will not be able to act alone. In all of the priority areas for action, the commitment and engagement of other ministries and government bodies will be essential. Fig. 6 illustrates the different sectors that may need to be involved (3). The exact configuration of ministries and other institutions – and their respective roles and responsibilities – will vary from one country to another, but the figure clearly shows the importance of multisectoral collaboration.

This highlights more than ever the need for a whole-of-government and whole-of-society approach to tackling these major public health

problems, which have multiple and inter-related risk factors and determinants.

Political commitment at the highest level is important and political dialogue and advocacy will be important for building that political commitment and enhancing social participation. Effective mechanisms for governance and multisectoral collaboration and coordination are essential. As recommended by the ICN2 Framework for Action, countries should strengthen or establish national cross-government, intersector, multi-stakeholder mechanisms at various levels (including robust safeguards against abuse and conflicts of interest). In order to be most effective, such mechanisms should involve collaboration at a very high level (e.g. ministerial, cabinet-level) and leadership at the highest political level is essential.

4.2 Clear commitments to action and monitoring of progress

Countries are encouraged to make clear commitments to take action on these priority areas and to report on their progress. Member States are urged to make country-specific commitments that are SMART – specific, measurable, achievable, relevant and time-bound – on the 10 areas for action proposed here.

These commitments should also feed into country commitments for action under the United Nations Decade of Action on Nutrition (2016–2025) (Resolution WHA 69.8, 2016) declared to help realize the commitments of the Rome Declaration of Nutrition (15). Countries making commitments for the Decade of Action will be able to showcase their role as nutrition champions taking urgent action for better diet and health–through inclusion of their written commitments in a public repository of international commitments–and will have access to technical support from WHO and the Food and Agriculture Organization of the United Nations.

27

To facilitate the process of measuring and reporting of progress, the WHO Regional Office for the Eastern Mediterranean will work with Member States to establish a monitoring framework and define indicators relevant to the SMART commitments.

4.3 Feasibility issues and phased implementation

All the priority areas and interventions proposed have a sufficiently strong case – based on research evidence and expert analysis of the measures – to warrant recommending their adoption (see Annex 2 for a summary of the evidence). In addition, most of the interventions have been tried and tested in other countries or localities or adopted by innovative policy-makers, and growing country experience has bolstered the evidence base (see Annex 3 for examples of country implementation). Some of the proposed strategic interventions will be easier to implement than others and the challenges of their application, the financial

implications, public acceptance and political feasibility very much depend on the particular country context (see Annex 4 for a summary of feasibility issues).

A phased approach may, therefore, be needed in some countries. The strongest candidate interventions for the first phase of action are shown in Section 5, along with those that it may be more appropriate to implement in a second phase. Countries that are less affected by these feasibility constraints – or which have already implemented many of the first phase interventions – are encouraged to move forward with implementation of all of the strategic interventions as quickly as possible. Importantly, countries should already be taking action and reporting on some of the interventions in both phases in order to meet existing global goals on nutrition and NCDs (e.g. all the breastfeeding interventions, including maternity protection legislation).

Fig. 6 Multisectoral action is needed to implement the proposed priority areas for action to prevent obesity and diabetes

Proposed WHO policies agreed at the UN General Assembly 2011.

President/Prime Minister

Coordinating Ministerial Mechanism/Council

Energy

Industry

Social Welfare

Justice/Security

Health

Regional and local

HEALTH POLICY GROUP

Nongovernmental organizations and

consumer representatives

Trade

Food

Education

Communication

Urban Planning

Housing

Environment

Transport

Sports

AgricultureTreasury

Foreign Affairs

The range of socio-economic/regional groups within the population

Health Services

government

Farming/food/retail/marketing/sports/ motor industry etc.

Private sector e.g.

WHO 2012: Options for strengthening and facilitating multisectoral action for the prevention and control of noncommunicable diseases(NCD) through effective partnership. Transmitted by the UN Secretary General to all Member states following the UN General Assembly approval for an action plan on NCDs

Proposed WHO policies agreed at the UN General Assembly 2011.

President/Prime Minister

Coordinating Ministerial Mechanism/Council

Energy

Industry

Social Welfare

Justice/Security

Health

Regional and local

HEALTH POLICY GROUP

Nongovernmental organizations and

consumer representatives

Trade

Food

Education

Communication

Urban Planning

Housing

Environment

Transport

Sports

AgricultureTreasury

Foreign Affairs

The range of socio-economic/regional groups within the population

Health Services

government

Farming/food/retail/marketing/sports/ motor industry etc.

Private sector e.g.

WHO 2012: Options for strengthening and facilitating multisectoral action for the prevention and control of noncommunicable diseases(NCD) through effective partnership. Transmitted by the UN Secretary General to all Member states following the UN General Assembly approval for an action plan on NCDs

Implementation of the proposed priority areas for action

28


Table 2. Summary of proposed priority areas of action and strategic interventions for preventing obesity and diabetes in the Eastern Mediterranean Region and their implementation phaseArea for action Interventions most suitable for first phase implementation Interventions for which there is

evidence of impact, but which it may be more appropriate to implement in a second phase

1 Fiscal measures 1.1 Progressively eliminate national subsidies for all types of fats/oils and sugar.

1.2 Implement an effective tax on sugar-sweetened beverages.

1.3 Consider an effective progressive tax on high fat foods and on high sugar foods.

2 Public procurement 2.1 Implement mandatory nutrition standards across all public institutions through (a) application of the regional nutrient profile model to assess the nutritional quality of different foods, (b) introduction of meal standards and (c) measures to eliminate the sale of foods or drinks high in fat, sugar or salt.

2.2 Issue mandatory guidelines for the revision of procurement to provide healthy food, including limiting the volume of fats/oils, sugar and salt entering public sector catering facilities in order to facilitate the necessary menu changes (e.g. so that meals provide not more than 25% energy from fats and less than 5% from free sugars).

2.3 Develop guidance and provide training to catering companies on appropriate catering methods in public institutions to reduce the use of frying and sweetening of foods and help with menu design.


3 Physical activity interventions

3.1 Promote healthy physical activity through mass media campaigns (see priority area 9) and ensure adequate legislation supporting delivery of daily physical activity for students in schools and universities.

3.2 Ensure comprehensive delivery of regular, quality physical education to all children, as a key component of education in schools.

3.3 Develop a set of standards/guidelines promoting physical activity in the workplace, including facility/building design, availability of sports facilities and programmes enabling access to facilities away from the workplace.

3.4 Increase availability of and accessibility for participation in formal and informal recreational and sporting activities, particularly providing opportunities for participation in programmes such as “Sports-for-All”, with emphasis on ensuring equality of access and opportunity for participation.

3.5 Develop and implement an urban planning policy to ensure that urban environments encourage people to rely less on personal motorized vehicles and support access to safe, gender-sensitive and age-friendly public transport, cycling and walking, including by provision of facilities, equipment, open and green public space and shared use of school facilities (both indoor and outdoor).


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4 Food supply and trade

4.1 Conduct a situation analysis of the national and/or local food supply, including establishing the proportions of fats/oils and sugar used in the diet that are derived from imports and domestic production, along with the extent of food manufacture and processing within the country and the supply of fruit, vegetables and whole grains.

4.2 Facilitate the development of local food policies and encourage city authorities to sign the Milan Urban Food Policy Pact and implement its Framework for Action to develop, where possible, sustainable urban food systems.

4.3 Consider introducing standards or other legal instruments (e.g. compositional standards, tariffs, import restrictions, sales bans, planning laws, zoning policies) to reduce the volume and improve the quality of fats/oils and reduce sugars in the national and local food supply.

4.4 Consider removing agricultural subsidies for producers of sugars and oils (especially those oils high in saturated fatty acids), replacing them, where necessary, with other mechanisms to support farmers and growers.

5 Reformulation 5.1 Cooperate with other Member States to adopt a regional approach for engaging with food producers to drive food reformulation to eliminate trans fats and reduce progressively total and saturated fat, salt, sugars, energy and portion size in a substantial proportion of processed foods.

5.2 Engage with private sector providers of food in catering/food service outlets (including takeaways and street food traders) to establish a programme to eliminate trans fats and reduce progressively total and saturated fat, salt, sugars, energy and portion size, with defined quantified reductions in use of these ingredients.

6 Marketing 6.1 Work with other countries in the Region to establish a coordinated approach, including appropriate legal advice, to reduce the impact of cross-border marketing.

6.2 Implement the WHO Set of Recommendations on Marketing of Foods and Non-alcoholic Beverages to Children and consider mandatory restrictions to eliminate all forms of marketing of foods high in fat, sugar and salt to children and adolescents (up to age 18) across all media, according to the Regional Action Plan to Address Unopposed Marketing of Unhealthy Food and Beverages.

6.3 Use the regional nutrient profile model, which categorizes the appropriate level of nutrients in foods, to identify foods to which the marketing restrictions should apply.

6.4 Conduct an assessment (preferably as part of a regional collaboration) of the impact of marketing of foods high in fat, sugar or salt to adults to illuminate the magnitude of marketing and define how best to restrict inappropriate practices.

6.5 Consider extending mandatory restrictions on marketing of unhealthy foods to whole population.

6.6 Legislate to allow retail promotion only of healthy foods.

7 Labelling 7.1 Implement a mandatory front-of-pack labelling scheme with elements to enable consumers to interpret information easily (such as colour coding or the use of terms such as “high”, “medium”, ”low”).

7.2 Enforce the labelling scheme and monitor its impact with the potential to strengthen the labelling with suitable health warnings.

(cont.)

Implementation of the proposed priority areas for action

30




8 Breastfeeding 8.1 Promote breastfeeding through mandatory baby-friendly health systems and effective community-based strategies.

8.2 Fully implement the International Code of Marketing of Breast-milk Substitutes and the WHO Guidance on ending inappropriate promotion of foods for infants and young children.

8.3 Empower women to exclusively breastfeed, by enacting progressively increasing remunerated time off work up to a goal of 6 months’ mandatory paid maternity leave, as well as policies that encourage women to breastfeed in the workplace including breastfeeding breaks and provision of suitable facilities.

9 Mass media campaigns

9.1 Implement appropriate social marketing campaigns, led by the public sector, on healthy diet and physical activity in order to build consensus, complement the other interventions in the package and encourage behaviour change.

9.2 Ensure sustained implementation of campaigns and monitor their impact.

10. Health sector interventions

10.1 Ensure provision of dietary counselling on nutrition, physical activity and healthy weight gain before and during pregnancy for prospective mothers and fathers.

10.2 integrate screening for overweight and other diabetes risk factors into primary health care and provide primary-care based counselling for high-risk individuals.

10.3 Establish or strengthen, as appropriate, a high-level multisectoral mechanism to define and oversee the implementation of food and physical activity policies for the prevention of obesity and diabetes.

10.4 Establish national targets for obesity and diabetes, along with SMART commitments for action, and work with WHO to develop and implement a monitoring framework for reporting on progress.

10.5 Implement evidence-based community-based interventions, addressing both healthy eating and physical activity, comprising different activities and targeting high-risk groups, to promote and facilitate behaviour change and prevent obesity and diabetes.

(cont.)

31

References

References1. Global report on diabetes. Geneva: World Health Organization; 2016.2. World Health Statistics 2016. Monitoring health for the SDGs. Geneva: World Health

Organization; 2016.3. United Nations General Assembly. Note by the Secretary-General transmitting the

report of the Director-General of the World Health Organization on options for strengthening and facilitating multisectoral action for the prevention and control of non-communicable diseases through effective partnership (A/67/373 2012) (http://www.who.int/nmh/events/2012/20121128.pdf?ua=1, accessed 2 February 2017).

4. Good maternal nutrition; the best start in life. Copenhagen: World Health Organization Regional Office for Europe; 2016.

5. Poston L, Harthoorn LF, van der Beek EM. Obesity in pregnancy: implications for the mother and lifelong health of the child. A Consensus Statement. Pediatr Res. 2011;69(2):175-80.

6. Report of the Commission on Ending Childhood Obesity. Geneva: World Health Organization; 2016.

7. Diet, nutrition and the prevention of chronic diseases. Geneva: World Health Organization; 2003 (Technical report series, No. 916).

8. Guideline : Sugars intake for adults and children. Geneva: World Health Organization; 2015.

9. Abu-Rabia A. Indigenous medicine among the Bedouin in the Middle East. New York: Berghahn Books; 2015.

10. Food and Agriculture Organization of the United Nations. FAOSTAT. Supply Utilization Accounts and Food Balances Domain: Food Balance Sheets. 2014 (http://faostat3.fao.org/download/FB/FBS/E, accessed 19 February 2017).

11. Food and Nutrition in Numbers 2014. Rome: Food and Agriculture Organization of the United Nations (FAO-UN); 2014 (http://www.fao.org/publications/card/en/c/9f31999d-be2d-4f20-a645-a849dd84a03e/, accessed 19 February 2017).

12. Global status report on noncommunicable diseases. Geneva: World Health Organization; 2010.

13. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. Resolution A/RES/66/2, UN General Assembly, 19 September 2011.

14. Framework for action to implement the United Nations Political Declaration on Noncommunicable Diseases. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2015.

15. Food and Agriculture Organization of the United Nations/World Health Organization. Second International Conference on Nutrition, Rome, 19-21 November 2014. Conference Outcome Document: Rome Declaration on Nutrition (http://www.fao.org/3/a-ml542e.pdf, accessed 1 February 2017).

32


16. Food and Agriculture Organization of the United Nations/World Health Organization. Second International Conference on Nutrition, Rome, 19–21 November 2014. Conference Outcome Document: Framework for Action (http://www.fao.org/3/a-mm215e.pdf, accessed 1 February 2017).

17. Gostin LO Abou-Taleb H, Roache SA, Alwan A.. Legal priorities for prevention of non-communicable diseases: innovations from WHO’s Eastern Mediterranean region. Public Health. 2017;144:4–12.

18. Fiscal policies for diet and the prevention of noncommunicable diseases. Technical Meeting Report 5–6 May 2015, Geneva, Switzerland. Geneva: World Health Organization Regional Office for Europe; 2016.

19. Using price policies to promote healthier diets. Copenhagen: World Health Organization Regional Office for Europe; 2015.

20. Thow AM, Downs S, Jan S. A systematic review of the effectiveness of food taxes and subsidies to improve diets: Understanding the recent evidence. Nutr Rev. 2014;72(9):551–65.

21. Powell LM, Chriqui JF, Khan T, Wada R, Chaloupka FJ. Assessing the potential effectiveness of food and beverage taxes and subsidies for improving public health: a systematic review of prices, demand and body weight outcomes. Obes Rev. 2013;14(2):110–28.

22. Mozaffarian D, Afshin A, Benowitz NL, Bittner V, Daniels SR, Franch HA, et al. Population Approaches to Improve Diet, Physical Activity, and Smoking Habits A Scientific Statement From the American Heart Association. Circulation. 2012 Sep 18;126(12):1514–63.

23. Sugar reduction : the evidence for action. Annexe 2: Review of behaviour changes resulting from experimental studies of fiscal methods. A mixed method review of behaviour changes resulting from experimental studies that examine the effect of fiscal measures targeted at high sugar food and non-alcoholic drink. London: Public Health England; 2015.

24. Colchero MA, Popkin BM, Rivera JA, Ng SW. Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. BMJ. 2016 Jan 6;352:h6704. doi: 10.1136/bmj.h6704

25. Taxes on sugar-sweetened beverages as a public health strategy: the experience of Mexico. Washington DC: Pan American Health Organization; 2015.

26. Popkin BM, Hawkes C. Sweetening of the global diet, particularly beverages: Patterns, trends, and policy responses. Lancet Diabetes Endocrinol. 2016;4(2):174-86. 10.1016/S2213-8587(15)00419-2

27. Biro A. Did the junk food tax make the Hungarians eat healthier? Food Policy. 2015;54:107–15.

28. Jensen JD, Smed S. The Danish tax on saturated fat: Short run effects on consumption and consumer prices of fats. FOI Working Paper 2012/14. Copenhagen: Institute of Food and Resource Economics University of Copenhagen; 2014.

33

References

29. Smed S, Scarborough P, Rayner M, Jensen JD. The effects of the Danish saturated fat tax on food and nutrient intake and modelled health outcomes: an econometric and comparative risk assessment evaluation. Eur J Clin Nutr. 2015 April;2016:1–6.

30. Bodker M, Pisinger C, Toft U, Jørgensen T. The rise and fall of the world’s first fat tax. Health Policy. 2015 Jun;119(6):737–42.

31. Hawkes C, Smith TG, Jewell J, Wardle J, Hammond RA, Friel S, et al. Smart food policies for obesity prevention. Lancet. 2015 Jun 13;385(9985):2410–21.

32. Sassi F. Obesity and the economics of prevention - fit not fat. Paris: Organisation for Economic Co-operation and Development; 2010.

33. Vos T, Carter R, Barendregt J, Mihalopoulos C, Veerman L, Magnus, et al. Assessing cost-effectiveness in prevention (ACE-Prevention): Final Report. Brisbane, University of Queensland and Melbourne, Deakin University; 2010.

34. Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-Barron V, et al. Tackling of unhealthy diets, physical inactivity, and obesity: Health effects and cost-effectiveness. Lancet. 2010 Nov 20;376(9754):1775–84.

35. Sdralevich C, Sab R, Zouhar Y, Albertin G. Subsidy reform in the Middle East and North Africa: recent progress and challenges ahead. Washinton DC: International Monetary Fund; 2014.

36. Ayadi M Ayadi M, Castel V, Lannes L, Abderrahim K, Mansour S, Jmal Y, et al. Food subsidies and direct social assistance: towards better targeting of monetary poverty and deprivations in Tunisia. African Development Bank, 2014 (https://www.afdb.org/fileadmin/uploads/afdb/Documents/Procurement/Project-related-Procurement/Food_Subsidies_and_Direct_Social_Assistance-_Towards_Better_Targeting_of_Monetary_Poverty_and_Deprivations_in_Tunisia.pdf, accessed 1 February 2017).

37. Niebylski ML, Lu T, Campbell NR, Arcand J, Schermel A, Hua D, et al. Healthy Food Procurement Policies and Their Impact. Int J Environ Res Public Health. 2014;11(3):2608–27.

38. Chriqui JF, Pickel M, Story M. Influence of school competitive food and beverage policies on obesity, consumption, and availability: a systematic review. JAMA Pediatr. 2014;168(3):279–86.

39. Power Up for Health. Impact of healthy food procurement policies/programs and nutrition standards on sales, intake and availability of healthier food, and body weight status overview. Evidence synthesis, July 2014 (https://powerupforhealth.files.wordpress.com/2015/03/food-procurement_power-up.pdf, accessed 1 February 2017).

40. Afshin A, Penalvo J, Del Gobbo L, Kashaf M, Micha R, Morrish K, et al. CVD prevention through policy: a review of mass media, food/menu labeling, taxation/subsidies, built environment, school procurement, worksite wellness, and marketing standards to improve diet. Curr Cardiol Rep. 2015;17(11).

41. Global nutrition policy review: what does it take to scale up nutrition action? Geneva: World Health Organization; 2013:122 (http://apps.who.int/iris/bitstream/10665/84408/1/9789241505529_eng.pdf, accessed 1 February 2017).

34


42. De Schutter O (United Nations special rapporteur on the right to food). The power of procurement: public purchasing in the service of realizing the right to food. Briefing Note 08 - April 2014 (http://reliefweb.int/sites/reliefweb.int/files/resources/20140514_procurement_en.pdf, accessed 1 February 2017).

43. Global Nutrition Report 2016: From promise to impact: ending malnutrition by 2030. Washington DC: International Food Policy Research Institute; 2016.

44. Noonan KG, Sell K, Miller D, Rubin D. Government purchasing to improve public health: theory practice and evidence (April 17, 2013). Public Health Law Research, March 13, 2013.

45. Lederer A, Curtis CJ, Silver LD, Angell SY, et al. Toward a healthier city: nutrition standards for New York City government. Am J Prev Med. 2014;46(4):423–8.

46. New York Academy of Medicine. Policy Brief : Healthy food procurement policy for New York State. March 2012 (http://www.dashny.org/wp-content/uploads/2016/01/HealthyFoodProcurementPolicy.pdf, accessed 2 February 2017).

47. Freudenberg N. Healthy-food procurement: using the public plate to reduce food insecurity and diet-related diseases. Lancet Diabetes Endocrinol. 2016;4(5):383–4.

48. Move for health: Promoting physical activity through the life course. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2014.

49. Promoting physical activity: A regional call to action. East Mediterr Health J. 2014 Jul 8;20(7):469–71.

50. Quality physical education: guidelines for policy-makers. Paris: United Nations Educational, Scientific and Cultural Organization; 2015.

51. Sallis JF Bull F, Burdett R, Frank LD, Griffiths P, Giles-Corti B. Use of science to guide city planning policy and practice: how to achieve healthy and sustainable future cities. Lancet. 2016 Dec 10;388(10062):2936–47.

52. de Blasio B. Healthier neighbourhoods through healthier parks. Lancet. 2016 Dec 10;388(10062):2850-1.

53. Kleinert S, Horton R. Urban design: an important future force for health and wellbeing. Lancet. 2016 Dec 10;388(10062):2848–50.

54. Goenka S, Andersen LB. Urban design and transport to promote healthy lives. Lancet (London, England). 2016 Dec 10;388(10062):2851–3.

55. Hawkes C. Enhancing coherence between trade policy and nutrition action: implementing the framework for action of the Second International Conference on Nutrition. Discussion Paper 1. Geneva: United Nations System Standing Committee on Nutrition; 2016 (http://www.unscn.org/files/ICN2_TPM/UNSCN_ENGLISH_Trade_and_Nutrition_Dec_2015.pdf, accessed 1 February 2017).

56. Stuckler D, McKee M, Ebrahim S, Basu S, et al. Manufacturing epidemics: The role of global producers in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco. PLoS Med. 2012;9(6):10.

57. Thow AM, McGrady B. Protecting policy space for public health nutrition in an era of international investment agreements. Bull World Health Organ. 2014;92(2):139–45.

35

References

58. Snowdon W, Thow AM. Trade policy and obesity prevention: Challenges and innovation in the Pacific Islands. Obes Rev. 2013;14 S2:150–8.

59. Thow AM, Swinburn B, Colagiuric S, Diligolevud M, Questede C, Vivilif P, et al. Trade and food policy: Case studies from three Pacific Island countries. Food Policy. 2010;35(6):556–64.

60. Thow AM, Annan R, Mensah L, Chowdhury SN. Development, implementation and outcome of standards to restrict fatty meat in the food supply and prevent NCDs: learning from an innovative trade/food policy in Ghana. BMC Public Health. 2014;14(1):249.

61. Thow AM, Quested C, Juventin L, Kun R, Khan AN, Swinburn B. Taxing soft drinks in the Pacific: Implementation lessons for improving health. Health Promot Int. 2011;26(1):55–64.

62. Dangour AD, Hawkesworth S, Shankar B, Watson L, Srinivasan CS, Morgan EH, et al. Can nutrition be promoted through agriculture-led food price policies? A systematic review. BMJ open, 2013, 3(6):e002937.

63. Milan Urban Food Policy Pact [website] (http://www.milanurbanfoodpolicypact.org/, accessed 1 February 2017).

64. WHO Global Coordination Mechanism Working Groups. Policy brief: producing and promoting more food products consistent with a healthy diet. Geneva: World Health organization; 2014 (http://www.who.int/nmh/ncd-coordination-mechanism/Policybrief32.pdf, accessed 1 February 2017).

65. Trieu K, Neal B, Hawkes C, Dunford E, Campbell N, Rodriguez-Fernandez R, et al. Salt reduction initiatives around the world - a systematic review of progress towards the global target. PLoS One. 2015;10(7):e0130247.

66. Downs SM, Thow AM, Leeder SR. The effectiveness of policies for reducing dietary trans fat: a systematic review of the evidence. Bull World Health Organ. 2012 November;2013(91):262-9.

67. Jaenke R, Barzi F, McMahon E, Webster J, Brimblecombe J. Consumer acceptance of reformulated food products: a systematic review and meta-analysis of salt-reduced foods. Crit Rev Food Sci Nutr, 2016, 8398(January 2016):0.

68. Bertino M, Beauchamp GK, Engeiman K. Long term reduction in dietary sodium alters the taste of salt. Am J Clin Nutr. 1982;36:1134–44.

69. Blais CA, Pangborn RM, Borhani NO, Ferrell MF, Prineas RJ, Laing B. Effect of dietary sodium restriction on taste responses to sodium chloride: a longitudinal study14. Am J Clin Nutr. 1986 Aug;44(2):232–43.

70. Effectiveness of food reformulation as a strategy to improve population health. Canberra: National Heart Foundation of Australia; 2012.

71. Cobiac LJ, Magnus A, Lim S, Barendregt JJ, Carter R, Vos T. Which interventions offer best value for money in primary prevention of cardiovascular disease? PLoS One. 2012;7(7).

36


72. Barton P, Andronis L, Briggs A, McPherson K, Capewell S. Effectiveness and cost effectiveness of cardiovascular disease prevention in whole populations: modelling study. BMJ. 2011 Jul 28;343:d4044.

73. List G. Processing and reformulation for nutrition labelling of trans fatty acids. Lipid Technology. 2004;16:173–6.

74. Joffres MR, Campbell NR, Manns B, Tu K. Estimate of the benefits of a population-based reduction in dietary sodium additives on hypertension and its related health care costs in Canada. Can J Cardiol. 2007 May 1;23(6):437–43.

75. Overcoming obesity : An initial economic analysis. Discussion paper. McKinsey Global Institute; 2014:120.

76. Boyland EJ, Nolan S, Kelly B, Tudur-Smith C, Jones A, Halford JC, et al. Advertising as a cue to consume: a systematic review and meta-analysis of the effects of acute exposure to unhealthy food and nonalcoholic beverage advertising on intake in children and adults. Am J Clin Nutr. 2016 Feb;103(2):519–33.

77. Osei-Assibey G, Dick S, Macdiarmid J, Semple S, Reilly JJ, Ellaway A, et al. The influence of the food environment on overweight and obesity in young children: a systematic review. BMJ Open. 2012 Dec 18;2(6).

78. Harris JL, Speers SE, Schwartz MB, Brownell KD. US Food Company Branded Advergames on the Internet: Children’s exposure and effects on snack consumption. J Child Media. 2012;6(1):51–68.

79. Scully M, Wakefield M, Niven P, Chapman K, Crawford D, Pratt IS, et al. Association between food marketing exposure and adolescents’ food choices and eating behaviors. Appetite. 2012 Feb;58(1):1–5.

80. Sugar reduction : the evidence for action. Annexe 3 : Review of behaviour changes resulting from marketing strategies. A mixed method review of behaviour changes resulting from marketing strategies targeted at high sugar food and non-alcoholic drink. London: Public Health England; 2015.

81. Set of recommendations on the marketing of foods and non-alcoholic beverages to children. Geneva: World Health Organization; 2010 (http://apps.who.int/iris/bitstream/10665/44416/1/9789241500210_eng.pdf, accessed 1 February, 2017).

82. Smithers LG, Lynch JW, Merlin T. Industry self-regulation and TV advertising of foods to Australian children. J Paediatr Child Health. 2014;50(5):386–92.

83. HFSS advertising restrictions: Final Review. London: Ofcom; 2010.84. Scarborough P, Payne C, Agu CG, Kaur A, Mizdrak A, Rayner M, et al. How

important is the choice of the nutrient profile model used to regulate broadcast advertising of foods to children? A comparison using a targeted data set. Eur J Clin Nutr. 2013 Aug;67(8):815–20.

85. Brinsden H, Lobstein T. Comparison of nutrient profiling schemes for restricting the marketing of food and drink to children. Pediatr Obes. 2013;8(4):325–37.

86. Galbraith-Emami S, Lobstein T. The impact of initiatives to limit the advertising of food and beverage products to children: a systematic review. Obes Rev. 2013 Dec;14(12):960–74.

37

References

87. Chambers SA, Freeman R, Anderson AS, MacGillivray S. Reducing the volume, exposure and negative impacts of advertising for foods high in fat, sugar and salt to children: A systematic review of the evidence from statutory and self-regulatory actions and educational measures. Prev Med. 2015 Jun;75:32–43.

88. More supermarket promotions on less healthy food. Which? 4 August 2016 [Press release] (https://press.which.co.uk/whichpressreleases/more-supermarket-promotions-on-less-healthy-food/, accessed 1 February 2017).

89. Tedstone A, Targett V, Allen R. Sugar reduction: the evidence for action. London: Public Health England; 2015.

90. Bakr A, Tawii C, Jarmalaite D, Sherif F, Hanana H, Levi T. Major consumer foodservice trends in MEA, 2016 [web site] (http://blog.euromonitor.com/2016/02/major-consumer-foodservice-trends-in-mea.html, accessed 1 February 2017).

91. Sugar reduction: the evidence for action. Annexe 4 : An analysis of the role of price promotions on the household purchases of food and drinks high in sugar. London: Public Health England; 2015.

92. Nakamura R, Suhrcke M, Jebb SA, Pechey R, Almiron-Roig E, Marteau TM, et al. Price promotions on healthier compared with less healthy foods: A hierarchical regression analysis of the impact on sales and social patterning of responses to promotions in Great Britain. Am J Clin Nutr. 2015 Apr;101(4):808–16.

93. Mandle J, Tugendhaft A, Michalow J, Hofman K. Nutrition labelling: a review of research on consumer and industry response in the global South. Glob Health Action. 2015;8(1):1–10.

94. Committee on Accelerating Progress in Obesity Food and Nutrition Board. Glickman D, Parker L, Sim LJ, Del Valle Cook H,Miller EA, editors. Accelerating progress in obesity prevention: solving the weight of the nation. Washington DC: National Academies Press (US); 2012.

95. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016 Aug 1;37(29):2315–81.

96. Hersey JC, Wohlgenant KC, Arsenault JE, Kosa KM, Muth MK. Effects of front-of-package and shelf nutrition labeling systems on consumers. Nutr Rev. 2013 Jan;71(1):1–14.

97. Hawley KL, Roberto CA, Bragg MA, Liu PJ, Schwartz MB, Brownell KD. The science on front-of-package food labels. Public Health Nutr. 2013 Mar;16(3):430–9.

98. Vyth EL, Steenhuis IH, Roodenburg AJ, Brug J, Seidell JC. Front-of-pack nutrition label stimulates healthier product development: a quantitative analysis. Int J Behav Nutr Phys Act. 2010 Sep 8;7:65.

99. Young L, Swinburn B. Impact of the pick the tick food information programme on the salt content of food in New Zealand. Health Promot Int. 2002;17(1):13–9.

38


100. Eckel RH, Borra S, Lichtenstein AH, Yin-Piazza SY; Trans Fat Conference Planning Group. Understanding the complexity of trans fatty acid reduction in the American diet: American Heart Association Trans Fat Conference 2006: report of the Trans Fat Conference Planning Group. Circulation. 2007;115(16):2231–46.

101. Victora CG, Rollins NC, Murch S, Krasevec J, Bahl R. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016 May 21;387(10033):2089–90.

102. Horta BL, de Mola CL, Victora CG. Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure, and type-2 diabetes: systematic review and meta-analysis. Acta Paediatr. 2015 Dec;104(467):30–7.

103. Yan J, Liu L, Zhu Y, Huang G, Wang PP. The association between breastfeeding and childhood obesity: a meta-analysis. BMC Public Health. 2014 Dec 13;14:1267. doi: 10.1186/1471-2458-14-1267.

104. Chowdhury R, Sinha B, Sankar MJ, Taneja S, Bhandari N, Rollins N, et al. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta Paediatr. 2015 Dec;104(467):96–113.

105. Weng SF, Redsell SA, Swift JA, Yang M, Glazebrook CP. Systematic review and meta-analyses of risk factors for childhood overweight identifiable during infancy. Arch Dis Child. 2012;97(12):1019–26.

106. Pearce J, Taylor MA, Langley-Evans SC. Timing of the introduction of complementary feeding and risk of childhood obesity: a systematic review. Int J Obes (Lond). 2013 Oct;37(10):1295–306.

107. Sinha B, Chowdhury R, Sankar MJ, Martines J, Taneja S, Mazumder S, et al. Interventions to improve breastfeeding outcomes: A systematic review and meta-analysis. Acta Paediatr. 2015;104 Suppl 467:114–34.

108. Heymann J, Raub A, Earle A. Breastfeeding policy: a globally comparative analysis. Bull World Health Organ. 2013 Jun 1;91(6):398–406.

109. Piwoz EG, Huffman SL. The impact of marketing of breast-milk substitutes on WHO-Recommended breastfeeding practices. Food Nutr Bull. 2015;36(4):1–14.

110. Infant and Young Child Feeding Programme Review - Consolidated report of six country programme review. New York: United Nations Children’s Fund; 2010.

111. Resolution WHA63.23. Infant and young child nutrition. In: Sixty-Third World Health Assembly, Geneva, 17-21 May 2010. Resolutions and Decisions Annexes.

112. Maternal, infant and young child nutrition. Guidance on ending the inappropriate promotion of foods for infants and young children. Report by the Secretariat. Geneva: World Health Organization; 2016 (A69/7 Add.1) (http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_7Add1-en.pdf?ua=1, accessed 1 February 2017).

113. World Health Organization, United Nations Children’s Fund and International Baby Food Action Network. Marketing of breast-milk substitutes: national implementation of the International Code. Status Report 2016. Geneva: World Health Organization; 2016.

39

References

114. World Health Organization and United Nations Children’s Fund. Global nutrition targets 2025. Breastfeeding Policy Brief (WHO/MNH/NHD 14.7). Geneva: World Health Organization; 2014.

115. Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. Lancet. 2010;376(9748):1261–71.

116. Interventions on diet and physical activity: What works summary report. Geneva: World Health Organization; 2009:48.

117. House of Lords. Science and Technology Select Committee. 2nd Report of Session 2010-12. Behaviour Change. London: The Stationery Office Limited; 2011 (https://www.publications.parliament.uk/pa/ld201012/ldselect/ldsctech/179/179.pdf, accessed 1 February 2017).

118. Muktabhant B, Lawrie TA, Lumbiganon P, Laopaiboon M. Diet or exercise, or both, for preventing excessive weight gain in pregnancy. Cochrane Database Syst Rev. 2015; (6):CD007145.

119. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: World Health Organization; 2016.

120. Summary report on developing an action plan for preventing obesity and diabetes in the Eastern Mediterranean Region, Geneva, 31 May–1 June 2016. Cairo: WHO Regional Office for the Eastern Mediterranean; 2017 (http://applications.emro.who.int/docs/IC_Meet_Rep_2017_EN_19541.pdf?ua=1, accessed 1 February 2017).

121. Laine J, Kuvaja-Köllner V, Pietilä E, Koivuneva M, Valtonen H, Kankaanpää E. Cost-effectiveness of population-level physical activity interventions: a systematic review. Am J Health Promot. 2014;29(2):71-80.

122. Scaling up action against noncommunicable diseases: How much will it cost? Geneva: World Health Organization; 2011:51.

123. Centers for Disease Control and Prevention. Strategies to prevent obesity and other chronic diseases: The CDC Guide to Strategies to Increase Physical Activity in the Community. Atlanta, GA: U.S. Department of Health and Human Services; 2011.

124. Proper K, Van Mechelen W. Effectiveness and economic impact of worksite interventions to promote physical activity and healthy diet. Background paper prepared for the WHO/WEF Joint Event on Preventing Noncommunicable Diseases in the Workplace (Dalian/China, September 2007). Geneva: World Health Organization; 2007:1-63.

125. Roux L, Pratt M, Tengs TO, Yore MM, Yanagawa TL, Van Den Bos J, et al. Cost effectiveness of community-based physical activity interventions. Am J Prev Med. 2008;35(6):578-88.

126. Holla-Bhar R, Iellamo A, Gupta A, Smith JP, Dadhich JP. Investing in breastfeeding - the world breastfeeding costing initiative. Int Breastfeed J. 2015;10(1):1–12. 10.1186/s13006-015-0032-y.

127. Dodd JM, Ahmed S, Karnon J, Umberger W, Deussen AR, Tran T, et al. The cost-effectiveness of providing antenatal lifestyle advice for women who are overweight or obese: the LIMIT randomised trial. BMC Obesity. 2015;2(1):14.

40


128. Breisinger IC, Al-Riffai P, Ecker O; Abuismail R, Waite J, Abdelwahab N, et al. Tackling Egypt’s rising food insecurity in a time of transition. Cairo: International Food Policy Research Institute and World Food Programme; 2013 (Joint IFPRI-WFP Country Policy Note) (http://documents.wfp.org/stellent/groups/public/documents/ena/wfp257519.pdf, accessed 1 February 2017).

129. Hyde M. Morsy issues broad tax increases, including energy, soft drinks, cigarettes, alcohol. Egypt Independent, 9 December 2012 http://www.egyptindependent.com//news/morsy-issues-broad-tax-increases-including-energy-soft-drinks-cigarettes-alcohol-0, accessed 1 February 2017).

130. Review of NCDs and Mental Health Programme in the Islamic Republic of Iran. Mission report. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2016.

131. GCC to impose heavy tax on tobacco, soft drinks. Middle East Monitor, 9 January 2017 (https://www.middleeastmonitor.com/20170109-gcc-to-impose-heavy-tax-on-tobacco-soft-drinks/, accessed 2 February 2017).

132. World Cancer Research Fund International. NOURISHING Framework [web page] (http://www.wcrf.org/int/policy/nourishing-framework, accessed 1 February 2017).

133. Improving the food environment through nutrition standards: a guide for government procurement. Atlanta GA: Centers for Disease Control and Prevention, Division for Heart Disease and Stroke; 2010.

134. Programme of the Maltese Presidency of the Council of the European Union (1 January 2017–30 June 2017) (https://www.eu2017.mt/en/Documents/NationalProgramme_EN.pdf, accessed 1 February 2017).

135. Factsheets on health-enhancing physical activity in the 28 European Union Member States of the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2015.

136. Promoting physical activity in the workplace. London: National Institute for Health and Care Excellence; 2008 (Public health guideline [PH13].

137. National Institute for Health and Care Excellence. Physical activity and the environment. NICE public health guideline: 28 January 2008 (https://www.nice.org.uk/guidance/ph8/resources/physical-activity-and-the-environment-55460874949, accessed 1 February 2017).

138. Creating Healthy NHS Workplaces: A toolkit to support the implementation of the NICE workplace guidance. London: NHS Employers; September 2015. (http://www.nhsemployers.org/~/media/Employers/Documents/Retain and improve/Health and wellbeing/Creating healthy workplaces toolkit.pdf, accessed 1 February 2017).

139. A guide for population-based approaches to increasing levels of physical activity: implementation of the WHO Global Strategy on Diet, Physical Activity and Health. Geneva: World Health Organization; 2007.

140. Hourani HM Al, Naffa S, Fardous T. National commitment to action on social determinants of health in Jordan: Addressing obesity. Background paper 18 for the World Conference on Social Determinants of Health. Rio de Janeiro, 19–21 October

41

References

2011 (http://www.who.int/sdhconference/resources/draft_background_paper18_jordan.pdf, accessed 11 February 2017).

141. National Nutrition Strategy - Strategic Study 2014-2050. Muscat: Ministry of Health, Sultanate of Oman; 2014.

142. Sharp fall in palm oil imports. Financial Tribune - First Iranian English Economic Daily, 2 July 2016. (https://financialtribune.com/articles/economy-domestic-economy/44673/sharp-fall-in-palm-oil-imports, accessed 1 February 2017).

143. Zatonski W, Campos H, Willett W. Rapid declines in coronary heart disease mortality in Eastern Europe are associated with increased consumption of oils rich in alpha-linolenic acid. Eur J Epidemiol. 2008;23(1):3–10.

144. HM Government. Childhood Obesity: A Plan for Action, 2016 (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/546588/Childhood_obesity_2016__2__acc.pdf, accessed 1 Febuary 2017).

145. Global nutrition report 2015: Actions and accountability to advance nutrition and sustainable development. Washington DC: International Food Policy Research Institute; 2015.

146. European Union. EU Pledge [website] (http://www.eu-pledge.eu/, accessed 1 February 2017).

147. Assessing national capacity for the prevention and control of noncommunicable diseases: report of the 2015 global survey. Geneva: World Health Organization; 2016:30.

148. Hungry for Change? Which? healthier choices progress report 2009. London: Which?; 2009 (http://www.which.co.uk/static/html/pdfs/hungry_for_change.pdf, accessed 11 February 2017).

149. International Labour Organization. C183 - Maternity Protection Convention, 2000 (No. 183) [web page] (http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:55:0::NO::P55_TYPE,P55_LANG,P55_DOCUMENT,P55_NODE:REV,en,C183,/Document, accessed 1 February 2017).

150. World Health Organization. Global database on implementation of nutrition actions (GINA) [web site] (http://www.who.int/nutrition/gina/en/, accessed 1 February 2017).

151. Stratégie de Prévention et de lutte contre l’obésité 2013-2017 Programmation des Actions [Prevention strategy to tackle obesity 2013-2017. Plan of action]. Tunis: Ministry of Health; 2014.

152. Tuomilehto J, Lindström J, Eriksson JG, Valle TT, Hämäläinen H, Ilanne-Parikka P, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344(18):1343–50.

153. 2016 Global food policy report survey. Washington DC, International Food Policy Research Institute (IFPRI); 2016.

154. Persson M, Soroko S, Musicus A, Lobstein T. A junk-free childhood 2012: the 2012 report of the StanMark project on standards for marketing food and beverages to children in Europe. London: International Association for the Study of Obesity, 2012:1–29.

42


Annex 1. Methodology for identifying priority actions for preventing obesity and diabetes in the RegionThe proposed interventions have been identified through a number of steps outlined below.

Informal regional meeting on developing an action plan for preventing obesity and diabetes in the Eastern Mediterranean Region An informal regional meeting was organized by the Regional Office and held in Geneva in May 2016 to discuss the feasibility of different evidence-based interventions to prevent obesity and diabetes (120). Participants benefited from extensive analysis of the effectiveness and the costs of different interventions, with WHO and many other institutions having undertaken systematic reviews and assembled evidence from many different sectors.

Senior policy officials and experts assessed these interventions in different sectors. These included the scale of change required, costs of implementation, cost–effectiveness of measures, government departments involved, industrial sectors affected, potential implementation problems, robustness of evidence for the measure and the political challenges involved.

A series of recommendations emerged from the meeting.

1. Enforce the legal strategies and policies that regulate the marketing of breast-milk substitutes and unhealthy complementary foods to eliminate the conflict of interest

and control the misconduct related to national food procurements and supplies.

2. Develop/reinforce coherent policies between trade, industry and health to ensure healthy food supply partnership with private sectors to support implementation of WHO’s agenda on diabetes and obesity without conflict of interest.

3. Strengthen regional and national multistakeholder and multisectoral committees to harmonize the monitoring processes and implementation of the WHO strategies.

4. Restrict marketing, advertising and sponsorship across all media (including digital) platforms for all fat/sugar rich foods and drinks to children.

5. Progressively eliminate any subsidies by national governments for certain food items, i.e. sugar, fat.

6. Encourage companies to progressively reformulate sugar-rich drinks to lower sugar content.

7. Conduct vibrant media campaigns and explanations linked to health benefit aiming to change the political acceptance of the need for radical policies.

From these recommendations nine policy areas were identified and recommended for further exploration.

Evidence summary

In response to the recommendations of the Geneva meeting, a review was commissioned to summarize the evidence of the effectiveness, cost–effectiveness and country experience for nine specific policy areas identified (Table A1.).

43

Annex 1

Table A1. Potential priority areas for action requiring a summary of evidence

Priority area Potential interventions on which evidence to be summarized

1. Breastfeeding Protection, promotion and support of breastfeeding and regulatory control of breast-milk substitutes and complementary foods.

2. Regulating marketing a) Restrictions on marketing, advertising and sponsorship across all media (including digital) platforms for all fat/sugar-rich foods and drinks to children.

b) Restrictions on marketing, advertising and sponsorship across all media (including digital) platforms for all fat/sugar-rich foods and drinks to adults.

3. Fiscal measures a) Progressive elimination of any subsidies by national governments for certain food items, i.e. sugar, fat.

b) Tax(es) to raise the price of sweetened soft drinks and beverages. c) Tax(es) on fat(s).

4. Price promotions Action to limit price promotions on foods high in fat, sugar or salt (HFSS) in supermarkets, catering or street markets.

5. Public procurement Action on publicly-funded food – standards for foods in public institutions and improving public procurement.

6. Reformulation a) Progressive reformulation of sugar-rich drinks to lower sugar intakes.b) Progressive reformulation of HFSS foods.

7. Mass media Mass media campaigns to increase political/public acceptance of these initiatives.

8. Labelling Introduction of new standards for nutrition labelling (front-of-pack labelling, colour-coded schemes, menu labelling, warning labels), including:(1) examination of evidence on whether front-of-pack nutrition labels

attract attention more readily than more complete, mandated nutrition information (the Nutrition Facts Panel) and

(2) determination of whether label design characteristics, specifically colour-coding and/or coding with facial icons, increase attention to the front-of-pack label.

9. Trade Development of trade-related policy approaches to create a less obesogenic food environment.

The review generally focused on key systematic reviews (published in English after 2010) and reported pooled results from recent meta-analyses where possible.

Evidence review meeting

A further meeting was held in Cairo in August 2016 to review the findings of the rapid summary of evidence, while also taking account of the particular context of the Eastern Mediterranean Region. With input from external advisors, the meeting considered the potential specific impact in the regional context and questions of feasibility.

A list of priority areas for action and strategic interventions was then identified. This list was further developed, along with a summary of the evidence, case studies of implementation and feasibility considerations into the current report.

44


Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

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ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

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save

d)

Cos

t–ef

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ess

(U

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ved)

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(im

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US$

1)

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in

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lead

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invo

lved

)

Fisc

al m

easu

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use

of t

axes

an

d su

bsid

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to

prom

ote

heal

thie

r di

ets

Exte

nsiv

e ev

iden

ce

that

food

pri

ce p

olic

ies

influ

ence

con

sum

er

purc

hase

s, t

here

by

affe

ctin

g he

alth

(i

nclu

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ris

k of

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d di

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139

to 1

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d pe

r m

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pula

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af

ter

20 y

ears

in

6 LM

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50 y

ears

: 355

to

5 89

8 D

ALY

s pe

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n14

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tral

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70 0

00

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aver

ted

over

life

tim

e of

20

03 p

opul

atio

n13

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t sa

ving

aft

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20 o

r 50

yea

rs

in 6

LM

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and

cost

effe

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e in

2

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s13

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y lo

w

impl

emen

tati

on c

osts

(F

rom

US$

0.0

1 to

0.

02 p

er c

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6

LMIC

s, r

isin

g to

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S$ 0

.11

in 1

HIC

as

sess

ed)

Lead

: Pri

me

Min

iste

r’s

Offi

ce/

Min

istr

y of

Fi

nanc

eO

ther

s: T

rade

/In

dust

ry/S

uppl

y In

dust

ry

Prog

ress

ivel

y el

imin

ate

all

natio

nal s

ubsid

ies

for

all

type

s of

fats

/oils

and

sug

ar

Subs

idie

s on

hig

h fa

t or

sug

ar

com

mod

ities

are

pre

vale

nt

thro

ugh

the

Reg

ion

Cle

ar e

vide

nce

that

sel

ectiv

e su

bsid

izat

ion

incr

ease

s co

nsum

ptio

n of

sub

sidize

d co

mm

oditi

esC

ount

ry e

xper

ienc

e sh

ows

that

sub

sidie

s ca

n be

re

mov

ed. S

hifti

ng s

ubsid

ies

to

unsa

tura

ted

fats

, per

se,

is n

ot

effe

ctiv

e fo

r ob

esity

/dia

bete

s pr

even

tion

Lead

: Prim

e M

inist

er’s

Offi

ce/M

inist

ry o

f Fi

nanc

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ther

s: Tr

ade/

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stry

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ply

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stry

13 H

ighl

y co

st-e

ffect

ive

is le

ss th

an p

er c

apita

GD

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r DA

LY sa

ved;

cos

t-ef

fect

ive

is 1-

3 tim

es p

er c

apita

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P pe

r DA

LY; m

ore

than

3 ti

mes

per

cap

ita G

DP

is no

t cos

t-ef

fect

ive.

14 A

ll fig

ures

rel

atin

g to

6 L

MIC

s (w

ith E

ngla

nd a

s com

para

tor)

are

from

an

anal

ysis

by O

rgan

isatio

n fo

r Ec

onom

ic C

oope

ratio

n an

d D

evel

opm

ent (

31).

Unl

ess o

ther

wise

cite

d, fi

gure

s for

A

ustr

alia

are

from

the

AC

E Pr

even

tion

Proj

ect (

30) a

nd fi

gure

s for

the

UK

are

from

an

anal

ysis

by M

cKin

sey

Gro

up In

tern

atio

nal (

73).

45

Annex 2

Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

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rdab

ility

(im

plem

enta

tion

cos

t in

U

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er c

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ery

low

=

<US$

0.5

0; q

uite

low

=



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1)

Gov

ernm

ent

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inis

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part

men

ts

invo

lved

)

Impl

emen

t an

effe

ctiv

e ta

x on

sug

ar-s

wee

tene

d be

vera

ges

Con

vinc

ing

evid

ence

from

m

odel

ling

and

coun

try

expe

rienc

e th

at p

urch

ases

are

re

duce

d by

tax

es

Lead

: Prim

e M

inist

er’s

Offi

ce/M

inist

ry o

f Fi

nanc

eO

ther

s: Tr

ade/

Indu

stry

/Sup

ply

Indu

stry

Con

sider

an

effe

ctiv

e pr

ogre

ssiv

e ta

x on

hig

h fa

t fo

ods

and

on h

igh

suga

r fo

ods

Con

sider

able

evi

denc

e fr

om

mod

ellin

g an

d de

mon

stra

ble

impa

ct fr

om e

xper

ienc

e in

in

divi

dual

cou

ntrie

s

UK:

203

000

DA

LYs

over

life

time

of 2

004

pop

for

10%

tax

on

HFS

S fo

ods

Cos

t-ef

fect

ive:

U

S$ 1

800

per

DA

LY

save

d in

UK

for

10%

ta

x on

HFS

S fo

ods

Lead

: Prim

e M

inist

er’s

Offi

ce/M

inist

ry o

f Fi

nanc

eO

ther

s: Tr

ade/

Indu

stry

/Sup

ply

Indu

stry

Publ

ic

proc

urem

ent

Proc

urem

ent

and

prov

isio

n of

hea

lthy

fo

od in

pub

lic

inst

itut

ions

(e.

g.

scho

ols,

hos

pita

ls,

mili

tary

, pri

sons

, ot

her

gove

rnm

ent

inst

itut

ions

)

Food

ser

ved

in p

ublic

in

stit

utio

ns is

a s

izea

ble

cont

ribu

tor

to d

iet

for

man

y gr

oups

in

coun

trie

s ac

ross

the

R

egio

n.

Inte

rnat

iona

l evi

denc

e sh

ows

that

hea

lthy

food

pr

ocur

emen

t po

licie

s ca

n im

prov

e di

ets

and

heal

th o

utco

mes

, pa

rtic

ular

ly a

mon

g st

udie

s do

ne in

sch

ools

No

esti

mat

es

avai

labl

eN

o co

st–

effe

ctiv

enes

s an

alys

es a

vaila

ble

No

gene

ric

esti

mat

es

of im

plem

enta

tion

co

sts.

Inve

stm

ent

will

be

req

uire

d, b

ut s

cale

of

gov

ernm

ent

buyi

ng

can

be h

arne

ssed

to

keep

cos

ts d

own

Lead

: Min

istr

y of

Fin

ance

/Pr

ocur

emen

t/Su

pplie

sO

ther

: All

gove

rnm

ent

depa

rtm

ents

46


Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Impl

emen

t m

anda

tory

nu

triti

on s

tand

ards

acr

oss

all p

ublic

inst

itutio

ns,

thro

ugh

(a)

appl

icat

ion

of t

he R

egio

nal n

utrie

nt

profi

le m

odel

to

asse

ss

the

nutr

ition

al q

ualit

y of

diff

eren

t fo

ods

(b)

intr

oduc

tion

of m

eal

stan

dard

s, an

d (c

) m

easu

res

to e

limin

ate

the

sale

of

food

s or

drin

ks h

igh

in fa

t, su

gar

or s

alt

Cou

ntry

exp

erie

nce

show

s th

at n

utrit

ion

stan

dard

s ca

n be

im

plem

ente

d ac

ross

a w

ide

rang

e of

pub

lic in

stitu

tions

to

brin

g nu

triti

onal

impr

ovem

ents

Lead

: Foo

d st

anda

rds

auth

ority

O

ther

: Hea

lth,

Trad

e/In

dust

ry/

Supp

ly, C

ham

ber

of

Com

mer

ce, F

ood

insp

ectio

n au

thor

ities

Issue

man

dato

ry g

uide

lines

fo

r th

e re

visio

n of

pr

ocur

emen

t to

pro

vide

he

alth

y fo

od, in

clud

ing

limiti

ng t

he v

olum

e of

fats

/oi

ls, s

ugar

and

sal

t en

terin

g pu

blic

sec

tor

cate

ring

faci

litie

s in

ord

er t

o fa

cilit

ate

the

nece

ssar

y m

enu

chan

ges

(e.g

. so

that

mea

ls pr

ovid

e no

t m

ore

than

25%

en

ergy

from

fats

and

less

th

an 5

% fr

om fr

ee s

ugar

s)

Lead

: Min

istry

of

Fina

nce/

Proc

urem

ent/

Supp

lies

Oth

er: A

ll go

vern

men

t de

part

men

ts

47

Annex 2

Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Dev

elop

gui

danc

e an

d pr

ovid

e tr

aini

ng t

o ca

terin

g co

mpa

nies

on

appr

opria

te

cate

ring

met

hods

in p

ublic

in

stitu

tions

to

redu

ce

the

use

of fr

ying

and

sw

eete

ning

of f

oods

and

he

lp w

ith m

enu

desig

n

Lead

: Min

istry

of

Hea

lth a

nd

mun

icip

aliti

esO

ther

: All

gove

rnm

ent

depa

rtm

ents

Con

tinue

impl

emen

ting

thes

e m

easu

res,

scal

ing

up

cove

rage

and

mon

itorin

g im

pact

Phys

ical

act

ivit

y in

terv

enti

ons

Impl

emen

t po

licie

s,

legi

slat

ion

and

inte

rven

tion

s to

pr

omot

e an

d fa

cilit

ate

heal

th-e

nhan

cing

ph

ysic

al a

ctiv

ity

Prom

otin

g ph

ysic

al a

ctiv

ity

and

heal

thy

diet

is o

ne o

f W

HO

’s “

best

buy

s” fo

r N

CD

pre

vent

ion

No

esti

mat

es

iden

tifie

dT

here

is a

n em

ergi

ng

body

of e

vide

nce

sugg

esti

ng t

hat

phys

ical

act

ivit

y in

terv

enti

ons

may

be

cost

-effe

ctiv

e (1

2),

alth

ough

the

num

ber

of s

tudi

es r

emai

ns

limit

ed (1

21)

WH

O e

stim

ated

tha

t th

e an

nual

cos

t pe

r pe

rson

of p

rom

otin

g pu

blic

aw

aren

ess

abou

t di

et a

nd p

hysi

cal a

ctiv

ity

wou

ld b

e U

S$ 0

.038

(on

th

e ba

sis

of U

S$ 2

008)

(1

22)

Lead

: Pre

side

nt/

Prim

e M

inis

ter’

s O

ffice

wit

h M

inis

try

of H

ealt

hO

ther

: Tre

asur

y/Fi

nanc

e, In

dust

ry,

Educ

atio

n,

Com

mun

icat

ion,

U

rban

Pla

nnin

g,

Hou

sing

, En

viro

nmen

t,

Tran

spor

t an

d Sp

ort

48


Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Prom

ote

heal

thy

phys

ical

ac

tivity

thr

ough

mas

s m

edia

cam

paig

ns (

see

actio

n 9

belo

w)

and

ensu

re a

dequ

ate

legi

slatio

n su

ppor

ting

deliv

ery

of d

aily

ph

ysic

al a

ctiv

ity fo

r st

uden

ts

in s

choo

ls an

d un

iver

sitie

s

Mas

s m

edia

cam

paig

ns t

o pr

omot

e ph

ysic

al a

ctiv

ity

and

heal

thy

diet

are

co

nsid

ered

a “

best

buy

” by

W

HO

(12

). Sc

hool

-bas

ed

inte

rven

tions

sho

w c

onsis

tent

im

prov

emen

ts in

kno

wle

dge,

at

titud

es a

nd b

ehav

iour

and

, in

som

e ca

ses,

phys

ical

and

cl

inic

al o

utco

mes

(12

)

Mas

s m

edia

cam

paig

ns

on p

hysic

al a

ctiv

ity

are

estim

ated

to

be

very

cos

t-ef

fect

ive

(122

). Sc

hool

hea

lth

educ

atio

n pr

ogra

mm

es

to p

rom

ote

phys

ical

ac

tivity

hav

e be

en

foun

d to

be

cost

-ef

fect

ive

(121

), w

hile

W

HO

est

imat

ed

prom

otin

g ph

ysic

al

activ

ity in

sch

ools

wou

ld c

ost

>3

times

G

DP

per

pers

on

(cla

ssifi

ed a

s “le

ss c

ost-

effe

ctiv

e”)

(122

).

Prom

otin

g ph

ysic

al a

ctiv

ity

thro

ugh

mas

s m

edia

is

estim

ated

to

have

a v

ery

low

cos

t (<

US$

0.5

0 pe

r ca

pita

), w

hile

pro

mot

ing

phys

ical

act

ivity

in s

choo

ls w

ould

hav

e a

high

er c

ost

(> U

S$ 1

per

cap

ita o

n th

e ba

sis o

f US$

200

8) (

122)

Lead

: Pre

siden

t/Pr

ime

Min

ister

’s O

ffice

with

M

inist

ry o

f Edu

catio

n;

Com

mun

icat

ion

Ensu

re c

ompr

ehen

sive

deliv

ery

of r

egul

ar, q

ualit

y ph

ysic

al e

duca

tion

to

all c

hild

ren,

as

a ke

y co

mpo

nent

of e

duca

tion

in

scho

ols

Enha

nced

phy

sical

edu

catio

n (P

E) in

terv

entio

ns (

incr

ease

d tim

e du

ring

PE c

lass

es w

here

st

uden

ts a

re a

ctiv

e, a

dditi

onal

PE

cla

sses

in t

he s

choo

l tim

etab

le o

f lon

ger

PE c

lass

es)

are

effe

ctiv

e (1

23)

A s

yste

mat

ic r

evie

w

of s

choo

l-bas

ed

inte

rven

tions

(in

clud

ing

PE)

have

bee

n fo

und

to

be v

ery

cost

-effe

ctiv

e,

at a

cos

t ra

ngin

g fr

om

US$

0.0

6 to

0.7

9 pe

r M

ET-h

our

(a w

ay o

f es

timat

ing

phys

ical

ac

tivity

) ga

ined

per

pe

rson

per

day

(12

1)

Lead

: Min

istry

of

Educ

atio

n

49

Annex 2

Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Dev

elop

a s

et o

f sta

ndar

ds/

guid

elin

es p

rom

otin

g ph

ysic

al a

ctiv

ity in

the

w

orkp

lace

, incl

udin

g fa

cilit

y/bu

ildin

g de

sign,

ava

ilabi

lity

of s

port

s fa

cilit

ies

and

prog

ram

mes

ena

blin

g ac

cess

to

faci

litie

s aw

ay

from

the

wor

kpla

ce

Evid

ence

tha

t m

ulti-

com

pone

nt p

rogr

amm

es t

o pr

omot

e ph

ysic

al a

ctiv

ity in

th

e w

orkp

lace

are

effe

ctiv

e in

impr

ovin

g he

alth

-rel

ated

ou

tcom

es (

12,1

24)

Prom

otin

g ph

ysic

al

activ

ity in

wor

ksite

s is

estim

ated

to

be q

uite

co

st e

ffect

ive

(<3

times

GD

P pe

r ca

pita

pe

r D

ALY

pre

vent

ed)

(122

)

Prom

otin

g ph

ysic

al a

ctiv

ity

in w

orks

ites

is es

timat

ed

to c

ost

>U

S$ 1

per

cap

ita

(on

the

basis

of U

S$ 2

008)

(1

22)

Lead

: Pre

siden

t/Pr

ime

Min

ister

’s O

ffice

with

M

inist

ry o

f Hea

lth;

Min

istry

of I

ndus

try

Incr

ease

ava

ilabi

lity

of a

nd

acce

ssib

ility

for

part

icip

atio

n in

form

al a

nd in

form

al

recr

eatio

nal a

nd s

port

ing

activ

ities

, par

ticul

arly

pr

ovid

ing

oppo

rtun

ities

fo

r pa

rtic

ipat

ion

in

prog

ram

mes

suc

h as

“S

port

s-fo

r-All”

, with

em

phas

is on

ens

urin

g eq

ualit

y of

acc

ess

and

oppo

rtun

ity fo

r pa

rtic

ipat

ion

Evid

ence

tha

t cr

eatin

g or

en

hanc

ing

acce

ss t

o pl

aces

for

phys

ical

act

ivity

is e

ffect

ive

in

raisi

ng t

he p

ropo

rtio

n of

the

po

pula

tion

who

are

phy

sical

ly

activ

e (1

23)

The

rel

ativ

e co

st a

nd c

ost-

effe

ctiv

enes

s w

ill de

pend

on

the

pre

cise

mea

sure

s, bu

t a

US

stud

y fo

und

that

“e

nhan

ced

acce

ss t

o ph

ysic

al a

ctiv

ity in

form

atio

n an

d op

port

uniti

es”

to b

e co

st-e

ffect

ive

and

to o

ffer

good

va

lue

for

mon

ey (

125)

Lead

: Min

istry

of

Spor

t w

ith M

inist

ry o

f H

ealth

Oth

er: T

reas

ury/

Min

istry

of F

inan

ce

50


Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Dev

elop

and

impl

emen

t an

urb

an p

lann

ing

polic

y to

ens

ure

that

urb

an

envi

ronm

ents

enc

oura

ge

peop

le t

o re

ly le

ss o

n pe

rson

al m

otor

ized

vehi

cles

an

d su

ppor

t ac

cess

to

safe

, ge

nder

-sen

sitiv

e an

d ag

e-fr

iend

ly p

ublic

tra

nspo

rt,

cycl

ing

and

wal

king

, in

clud

ing

by p

rovi

sion

of

faci

litie

s, eq

uipm

ent,

publ

ic

open

and

gre

en s

pace

an

d sh

ared

use

of s

choo

l fa

cilit

ies

(bot

h in

door

and

ou

tdoo

r)

City

pla

nnin

g ap

proa

ches

tha

t su

ppor

t w

alki

ng, c

yclin

g an

d pu

blic

tra

nspo

rt w

ith a

saf

e in

fras

truc

ture

and

prio

ritize

th

em o

ver

priv

ate

mot

orize

d tr

ansp

ort

are

mos

t ef

fect

ive

(51)

. Sm

all-s

cale

urb

an d

esig

n po

licie

s (in

clud

ing

impr

ovin

g st

reet

ligh

ting,

mak

ing

cros

sings

sa

fer,

traf

fic c

alm

ing,

impr

ovin

g th

e ap

pear

ance

of s

tree

ts

and

prov

idin

g co

ntin

uous

pe

dest

rian

pave

men

ts)

are

effe

ctiv

e in

faci

litat

ing

wal

king

(1

23).

Polic

ies

to c

hang

e th

e bu

ilt e

nviro

nmen

t ha

ve b

een

estim

ated

to

be t

he m

ost

cost

-effe

ctiv

e st

rate

gy fo

r in

crea

sing

phys

ical

act

ivity

am

ong

larg

e po

pula

tions

be

caus

e, a

lthou

gh t

hey

ofte

n re

quire

sub

stan

tial

inve

stm

ent,

thei

r be

nefit

s ar

e lo

ng-la

stin

g (1

21).

Cre

atio

n of

new

cyc

le o

r pe

dest

rian

trai

ls re

quire

s bu

dget

inve

stm

ent

but

prov

ides

goo

d va

lue

per

hour

of

phy

sical

act

ivity

gai

ned

(US$

0.2

43 p

er M

et-h

our

gain

ed)

(121

)

Lead

: Urb

an P

lann

ing,

H

ousin

g, En

viro

nmen

t, Tr

ansp

ort

and

Spor

t

Con

tinue

impl

emen

ting

thes

e m

easu

res,

scal

ing

up

cove

rage

and

mon

itorin

g im

pact

Food

sup

ply

and

trad

eU

se fo

od s

tand

ards

, leg

al

inst

rum

ents

and

oth

er

appr

oach

es t

o im

prov

e th

e na

tion

al a

nd/o

r lo

cal f

ood

supp

ly in

thi

s R

egio

n of

net

food

-im

port

ing

coun

trie

s

Evid

ence

from

sev

eral

co

untr

ies

show

s th

at

trad

e po

licy

tool

s an

d/or

st

anda

rds

can

be e

ffect

ive

in r

educ

ing

the

avai

labi

lity

or in

crea

sing

the

pri

ce o

f fa

ts a

nd s

ugar

s in

the

food

su

pply

No

esti

mat

es o

f im

pact

iden

tifie

dN

o co

st–e

ffect

ive

anal

yses

iden

tifin

ess

No

cost

est

imat

es

iden

tifie

dLe

ad: F

ood

stan

dard

s au

thor

ity

Oth

er: F

orei

gn

Affa

irs,

Hea

lth,

C

usto

ms,

Fin

ance

, Tr

ade/

Indu

stry

/Su

pply

51

Annex 2

Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Faci

litat

e th

e de

velo

pmen

t of

loca

l foo

d po

licie

s an

d en

cour

age

city

aut

horit

ies

to s

ign

the

Mila

n U

rban

Fo

od P

olic

y Pa

ct a

nd

impl

emen

t its

Fra

mew

ork

for A

ctio

n to

dev

elop

, w

here

pos

sible

, sus

tain

able

ur

ban

food

sys

tem

s

Con

sider

intr

oduc

ing

stan

dard

s or

oth

er

lega

l ins

trum

ents

(e.

g.

com

posit

iona

l sta

ndar

ds,

tarif

fs, im

port

res

tric

tions

, sa

les

bans

, pla

nnin

g la

ws,

zoni

ng p

olic

ies)

to

redu

ce

the

volu

me

and

impr

ove

the

qual

ity o

f fat

s/oi

ls an

d re

duce

sug

ars

in t

he

natio

nal a

nd lo

cal f

ood

supp

ly

Con

sider

rem

ovin

g ag

ricul

tura

l sub

sidie

s fo

r pr

oduc

ers

of s

ugar

s an

d oi

ls (e

spec

ially

tho

se o

ils

high

in s

atur

ated

fatt

y ac

ids)

, rep

laci

ng t

hem

, w

here

nec

essa

ry, w

ith o

ther

m

echa

nism

s to

sup

port

fa

rmer

s an

d gr

ower

s

52


Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Ref

orm

ulat

ion

Impl

emen

t a

gove

rnm

ent-

led

prog

ram

me

of

prog

ress

ive

refo

rmul

atio

n,

adap

ted

to t

he n

atio

nal

cont

ext,

to e

limin

ate

tran

s fa

ts a

nd r

educ

e pr

ogre

ssiv

ely

tota

l and

sa

tura

ted

fat,

salt,

sug

ars,

ener

gy a

nd p

ortio

n siz

e

The

re is

str

ong

and

exte

nsiv

e ev

iden

ce fr

om e

xper

ienc

e w

ith s

alt

redu

ctio

n th

at

prog

ress

ive

refo

rmul

atio

n ca

n re

duce

leve

ls of

spe

cific

in

gred

ient

s in

food

s an

d re

duce

pop

ulat

ion

inta

kes

of

thos

e in

gred

ient

s/nu

trie

nts

The

re is

evi

denc

e th

at

volu

ntar

y ef

fort

s ar

e le

ss

effe

ctiv

e th

an m

anda

tory

ap

proa

ches

. Evi

denc

e ha

s id

entifi

ed t

he k

ey c

ompo

nent

s of

suc

cess

ful r

efor

mul

atio

n pr

ogra

mm

es:

• Pr

ogre

ssiv

e re

duct

ions

•

Gov

ernm

ent-

set

targ

et

leve

ls ha

ve t

o be

set

by

food

ca

tego

ry

• M

ultin

utrie

nt r

educ

tions

(t

otal

fat,

suga

r, sa

lt)

• A

ccom

pani

ed b

y fr

ont-

of-

pack

labe

lling

and

cons

umer

aw

aren

ess

• G

over

nmen

t-le

d an

d co

mpr

ehen

sive

stak

ehol

der

enga

gem

ent

• C

omm

itmen

t to

mon

itorin

g an

d ev

alua

tion

UK

estim

ate:

1.7

m

illion

DA

LYs

over

lif

etim

e of

200

4 po

pula

tion

for

incr

emen

tal r

educ

tion

of e

nerg

y in

pac

kage

d fo

od, d

rink

and

rest

aura

nt fo

ods

Hig

hly

cost

effe

ctiv

e (U

K es

timat

e U

S$ 2

60

0 pe

r D

ALY

sav

ed)

Lead

: Min

istry

of

Trad

e/In

dust

ry/

Supp

ly, fo

od s

tand

ards

au

thor

ity a

nd M

inist

ry

of H

ealth

53

Annex 2

Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Coo

pera

te w

ith o

ther

M

embe

r St

ates

to

adop

t a

regi

onal

app

roac

h fo

r en

gagi

ng w

ith fo

od

prod

ucer

s to

driv

e fo

od

refo

rmul

atio

n to

elim

inat

e tr

ans

fats

and

red

uce

prog

ress

ivel

y to

tal a

nd

satu

rate

d fa

t, sa

lt, s

ugar

s, en

ergy

and

por

tion

size

in

a su

bsta

ntia

l pro

port

ion

of

proc

esse

d fo

ods

Lead

: Min

istry

of

Trad

e/In

dust

ry/

Supp

ly, fo

od s

tand

ards

au

thor

ity a

nd M

inist

ry

of H

ealth

Enga

ge w

ith p

rivat

e se

ctor

pro

vide

rs o

f foo

d in

cat

erin

g/fo

od s

ervi

ce

outle

ts (

incl

udin

g ta

keaw

ays

and

stre

et fo

od t

rade

rs)

to e

stab

lish

a pr

ogra

mm

e to

elim

inat

e tr

ans

fats

and

re

duce

pro

gres

sivel

y to

tal

and

satu

rate

d fa

t, sa

lt,

suga

rs, e

nerg

y an

d po

rtio

n siz

e, w

ith d

efine

d qu

antifi

ed

redu

ctio

ns in

use

of t

hese

in

gred

ient

s

Lead

: Min

istry

of

Trad

e/In

dust

ry/S

uppl

y, M

inist

ry o

f Hea

lth a

nd

mun

icip

aliti

es (

food

in

spec

tors

)

54


Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Mar

keti

ngIm

plem

ent

appr

opri

ate

rest

rict

ions

on

mar

keti

ng (

incl

udin

g pr

ice

prom

otio

ns)

of

food

s hi

gh in

fat,

sug

ar

and

salt

Con

vinc

ing

rese

arch

th

at e

xpos

ure

to

mar

keti

ng fo

r H

FSS

food

s in

fluen

ces

child

ren’

s di

ets.

Cou

ntry

ex

peri

ence

sho

ws

that

re

stri

ctio

ns c

an r

educ

e ch

ildre

n’s

expo

sure

to

suc

h m

arke

ting

. R

esea

rch

on c

ount

ry

impl

emen

tati

ons

show

s th

at m

anda

tory

re

stri

ctio

ns a

re m

ost

effe

ctiv

e R

etai

l pri

ce p

rom

otio

ns

on H

FSS

food

s ar

e in

crea

sing

ly c

omm

on

thro

ugho

ut t

he R

egio

n,

and

evid

ence

from

H

ICs

show

s th

at p

rice

pr

omot

ions

sel

ecti

vely

pr

omot

e H

FSS

food

s an

d ca

n in

crea

ses

suga

r in

take

See

belo

w fo

r es

tim

ates

for

som

e sp

ecifi

c in

terv

enti

ons

Cos

t-sa

ving

, hig

hly

cost

-effe

ctiv

e or

co

st-e

ffect

ive

(see

be

low

for

spec

ific

esti

mat

es)

Ver

y lo

w c

ost

impl

emen

tati

on (

see

belo

w)

Lead

: Tra

de/

Indu

stry

/Sup

ply/

Adv

erti

sing

re

gula

tory

bod

ies

and

mun

icip

alit

ies

Oth

er: H

ealt

h

55

Annex 2

Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Wor

k w

ith o

ther

cou

ntrie

s in

the

Reg

ion

to e

stab

lish

a co

ordi

nate

d ap

proa

ch,

incl

udin

g ap

prop

riate

le

gal a

dvic

e, t

o re

duce

the

im

pact

of c

ross

-bor

der

mar

ketin

g

Cro

ss-b

orde

r br

oadc

ast

mar

ketin

g do

min

ates

Reg

iona

l m

edia

out

lets

. Adv

ertis

ing

expe

nditu

re a

naly

ses

show

th

at p

an-A

rab

med

ia

mar

ketin

g of

HFS

S fo

ods

is ex

tens

ive

and

esca

latin

g ra

pidl

y

Impl

emen

t th

e W

HO

Set

of

Rec

omm

enda

tions

on

Mar

ketin

g of

Foo

ds a

nd

Non

-alc

ohol

ic B

ever

ages

to

Chi

ldre

n an

d co

nsid

er

man

dato

ry r

estr

ictio

ns

to e

limin

ate

all f

orm

s of

m

arke

ting

of fo

ods

high

in

fat,

suga

r an

d sa

lt to

ch

ildre

n an

d ad

oles

cent

s (u

p to

age

18)

acr

oss

all m

edia

, acc

ordi

ng t

o th

e re

gion

al A

ctio

n Pl

an

to A

ddre

ss U

nopp

osed

M

arke

ting

of U

nhea

lthy

Food

and

Bev

erag

es

Cou

ntry

exp

erie

nce

show

s th

at r

estr

ictin

g ad

vert

ising

on

ly fo

r pa

rtic

ular

med

ia (

e.g.

te

levi

sion

and

radi

o) d

o no

t re

duce

ove

rall

expo

sure

to

mar

ketin

g. T

here

is e

vide

nce

that

chi

ldre

n ar

e in

crea

singl

y ex

pose

d to

HFS

S m

arke

ting

thro

ugh

digi

tal a

nd s

ocia

l m

edia

Ex

tens

ive

coun

try

expe

rienc

e sh

ows

that

lim

ited

defin

ition

s of

tar

get

audi

ence

s (e

.g. t

he

hour

s of

chi

ldre

n’s

tele

visio

n)

are

inef

fect

ive

38 t

o 28

8 D

ALY

s sa

ved

per

milli

on

popu

latio

n af

ter

20

year

s in

6 L

MIC

s; 65

8 to

5 8

23 D

ALY

s pe

r m

illion

afte

r 50

yea

rs

Cos

t sa

ving

, hig

hly

cost

-effe

ctiv

e or

cos

t-ef

fect

ive

in 6

LM

ICs

afte

r 20

and

50

year

s

Very

low

cos

t [U

S$ 0

.04

to

0.13

per

hea

d in

6 L

MIC

s fo

r ob

esity

pre

vent

ion.

In

1 h

igh

inco

me

coun

try

(Eng

land

) =

US$

0.3

0/he

ad]

Use

the

reg

iona

l nut

rient

pr

ofile

mod

el, w

hich

ca

tego

rizes

the

app

ropr

iate

le

vel o

f nut

rient

s in

food

s, to

iden

tify

food

s to

whi

ch

the

mar

ketin

g re

stric

tions

sh

ould

app

ly

Cou

ntry

exp

erie

nce

show

s th

at g

over

nmen

t-le

d nu

trie

nt

profi

les

are

mor

e ef

fect

ive

in

rest

rictin

g m

arke

ting

of H

FSS

food

s

Lead

: Min

istry

of H

ealth

w

ith a

dver

tisin

g re

gula

tory

bod

ies

56


Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Con

duct

an

asse

ssm

ent

(pre

fera

bly

as p

art

of a

re

gion

al c

olla

bora

tion)

of

the

impa

ct o

f mar

ketin

g of

fo

ods

high

in fa

t, su

gar

or

salt

to a

dults

to

illum

inat

e th

e m

agni

tude

of m

arke

ting

and

defin

e ho

w b

est

to

rest

rict

inap

prop

riate

pr

actic

es.

Ove

r 50

% o

f the

Reg

ion’

s po

pula

tion

are

child

ren

or

adol

esce

nts.

No

coun

try

has

com

plet

ely

elim

inat

ed c

hild

ren’

s ex

posu

re

to m

arke

ting

of H

FSS

food

s by

impl

emen

ting

rest

rictio

ns

on m

arke

ting

to c

hild

ren,

sin

ce c

hild

ren

and

adol

esce

nts

rem

ain

expo

sed

to m

arke

ting

targ

eted

at

adul

ts

UK

estim

ate:

401

00

0 D

ALY

s ov

er

lifet

ime

of 2

004

popu

latio

n fr

om

rest

rictin

g hi

gh-c

alor

ie

food

adv

ertis

ing

to

redu

ce e

xpos

ure

to

mar

ketin

g

Hig

hly

cost

-effe

ctiv

eU

K es

timat

e: R

estr

ictin

g hi

gh-c

alor

ie fo

od

adve

rtisi

ng t

o re

duce

ex

posu

re t

o m

arke

ting

wou

ld c

ost

US$

50

per

DA

LY s

aved

.

Con

sider

ext

endi

ng

man

dato

ry r

estr

ictio

ns o

n m

arke

ting

of u

nhea

lthy

food

s to

who

le p

opul

atio

n

Legi

slate

to

allo

w r

etai

l pr

omot

ions

onl

y of

hea

lthy

food

s

Ret

ail p

rice

prom

otio

ns o

n H

FSS

food

s ar

e in

crea

singl

y co

mm

on t

hrou

ghou

t th

e R

egio

n.A

naly

ses

from

hig

h-in

com

e co

untr

ies

show

tha

t pr

ice

prom

otio

ns s

elec

tivel

y pr

omot

e H

FSS

food

s an

d af

fect

a h

igh

prop

ortio

n of

all

food

pur

chas

es, w

ith

iden

tified

incr

ease

s in

sug

ar

cons

umpt

ion

cons

isten

t w

ith

prom

otio

n of

obe

sity

and

diab

etes

UK

estim

ate:

561

000

D

ALY

s ov

er li

fetim

e of

200

4 po

pula

tion

from

reg

ulat

ing

pric

e pr

omot

ions

on

high

-ca

lorie

food

s

Hig

hly

cost

-effe

ctiv

eU

K es

timat

e: U

S$ 2

00

per

DA

LY s

aved

fr

om r

egul

atin

g pr

ice

prom

otio

ns o

n hi

gh-

calo

rie fo

ods

Lead

: Tra

de/

Indu

stry

/Sup

ply

and

mun

icip

aliti

esO

ther

: Hea

lth

57

Annex 2

Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Labe

lling

Impl

emen

t or

rev

ise

stan

dard

s fo

r nu

trit

ion

labe

lling

to

incl

ude

fron

t-of

-pac

k la

belli

ng

for

all p

re-p

acka

ged

food

s

Evid

ence

tha

t co

nsum

ers

like

sim

ple,

inte

rpre

tive

, fr

ont-

of-p

ack

labe

ls

and

that

thi

s ca

n he

lp

them

to

mak

e he

alth

ier

choi

ces.

358

to 1

176

DA

LYs

per

mill

ion

popu

lati

on fo

r co

mpu

lsor

y fo

od

labe

lling

aft

er 2

0 ye

ars

in 6

LM

ICs;

A

fter

50

year

s:

1089

to

4099

D

ALY

s pe

r m

illio

n po

pula

tion

. U

K: 5

75 0

00

DA

LYs

over

lif

etim

e of

200

4 po

pula

tion

for

labe

lling

on

all

pack

aged

food

s,

men

us a

nd s

helf-

choi

ces

in fa

st

food

res

taur

ants

an

d w

ork

plac

e;A

ustr

alia

: 32

000

DA

LYs

over

lif

etim

e of

200

3 po

pula

tion

for

fron

t-of

-pac

k la

belli

ng

Hig

hly

cost

-ef

fect

ive

or

cost

-effe

ctiv

e af

ter

20 y

ears

in 6

LM

ICs;

Cos

t sa

ving

or

hig

hly

cost

-ef

fect

ive

afte

r 50

ye

ars.

Cos

t sa

ving

or

hig

hly

cost

-ef

fect

ive

in H

ICs

(UK

, Aus

tral

ia)

Ver

y lo

w: U

S$ 0

.05

to 0

.23

(200

5) in

6

LMIC

s; V

ery

low

(<

AS$

0.5

0 pe

r ca

pita

) in

Aus

tral

ia

Lead

: Foo

d st

anda

rds

auth

orit

y an

d M

inis

try

of H

ealt

hO

ther

: Tra

de/

Indu

stry

/Sup

ply,

C

usto

ms

58


Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Impl

emen

t m

anda

tory

fr

ont-

of-p

ack

nutr

ition

la

bellin

g sc

hem

e w

ith

elem

ents

to

enab

le

cons

umer

s to

inte

rpre

t ea

sily

(e.g

. mul

tiple

col

our-

code

d tr

affic

ligh

ts, u

se o

f te

rms “

high

”, “m

ediu

m”,

“l

ow”)

Evid

ence

from

sev

eral

co

untr

ies

sugg

ests

tha

t in

terp

retiv

e fr

ont-

of-p

ack

labe

lling

can

driv

e fo

od

man

ufac

ture

rs t

o re

form

ulat

e th

eir

prod

ucts

to

mak

e th

em

heal

thie

r

Enfo

rce

the

labe

lling

sche

me

and

mon

itor

its

impa

ct w

ith t

he p

oten

tial t

o st

reng

then

the

labe

lling

with

su

itabl

e he

alth

war

ning

s

59

Annex 2

Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Bre

astf

eedi

ngIm

plem

ent

a pa

ckag

e of

pol

icie

s an

d in

terv

enti

ons

to

prom

ote,

pro

tect

and

su

ppor

t br

east

feed

ing

Subs

tant

ial e

vide

nce

that

br

east

feed

ing

prot

ects

ag

ains

t ov

erw

eigh

t an

d ob

esit

y in

chi

ldre

n an

d ad

ults

and

som

e st

atis

tica

lly s

igni

fican

t ev

iden

ce o

f pro

tect

ion

for

both

mot

hers

and

ch

ildre

n ag

ains

t la

ter

diab

etes

.H

ighl

y si

gnifi

cant

ev

iden

ce o

f sub

stan

tial

im

pact

of i

nter

vent

ions

on

exc

lusi

ve

brea

stfe

edin

g ra

tes

823

000

deat

hs

per

year

ave

rted

in

75

high

-m

orta

lity

LMIC

s if

scal

ed u

p to

nea

r un

iver

sal l

evel

s;

plus

22

216

lives

pe

r ye

ar s

aved

by

incr

easi

ng

brea

stfe

edin

g du

rati

on t

o 12

m

onth

s in

HIC

s an

d 2

year

s pe

r ch

ild in

LM

ICs.

In

addi

tion

, 20

000

annu

al d

eath

s in

w

omen

(br

east

ca

ncer

) w

ould

be

avoi

ded

No

spec

ific

cost

-ef

fect

ive

anal

yses

of

pro

mot

ing

brea

stfe

edin

g fo

r pr

even

tion

of

obe

sity

an

d di

abet

es.

Con

side

rabl

e lit

erat

ure

exis

ts

on s

izea

ble

econ

omic

ben

efits

of

incr

easi

ng

brea

stfe

edin

g

Cos

t es

tim

ates

fo

r sc

alin

g up

in

terv

enti

ons

to p

rom

ote

brea

stfe

edin

g va

ry

imm

ense

ly. O

ne

glob

al e

stim

ate

for

a pa

ckag

e of

mea

sure

s is

US$

130

per

live

bi

rth

(126

)

Lead

: Min

istr

y of

H

ealt

h

Prom

ote

brea

stfe

edin

g th

roug

h m

anda

tory

bab

y-fr

iend

ly h

ealth

sys

tem

s an

d ef

fect

ive

com

mun

ity-b

ased

st

rate

gies

Con

vinc

ing

evid

ence

of

posit

ive

impa

ct o

n ex

clus

ive

brea

stfe

edin

g

Estim

ated

cos

ts o

f US$

28

per

live

birt

h fo

r ba

by-

frie

ndly

hos

pita

l ini

tiativ

e im

plem

enta

tion,

tra

inin

g he

alth

wor

kers

and

co

mm

unity

sup

port

(12

6)

Lead

: Min

istry

of

Hea

lth

60


Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Fully

impl

emen

t th

e In

tern

atio

nal C

ode

of

Mar

ketin

g of

Bre

ast-

milk

Su

bstit

utes

and

WH

O

Gui

danc

e on

end

ing

inap

prop

riate

pro

mot

ion

of

food

s fo

r in

fant

s an

d yo

ung

child

ren

Exte

nsiv

e ev

iden

ce t

hat

mar

ketin

g of

bre

ast-

milk

su

bstit

utes

and

inap

prop

riate

pr

omot

ion

of fo

ods

for

infa

nts

and

youn

g ch

ildre

n un

derm

ines

opt

imal

infa

nt

and

youn

g ch

ild fe

edin

g, w

ith

pote

ntia

l neg

ativ

e im

pact

on

brea

stfe

edin

g, ob

esity

and

N

CD

s. C

ount

ry e

xper

ienc

e sh

ows

that

nat

iona

l leg

islat

ion

to r

egul

ate

such

mar

ketin

g ca

n be

effe

ctiv

e in

red

ucin

g m

arke

ting

influ

ence

.

Cos

ts o

f im

plem

entin

g th

e In

tern

atio

nal C

ode

estim

ated

at

US$

3.6

0 pe

r liv

e bi

rth

as a

one

-off

cost

an

d U

S$ 0

.70

per

live

birt

h an

nual

ly fo

r tr

aini

ng a

nd

mon

itorin

g (1

26)

Lead

: Min

istry

of

Trad

e/In

dust

ry w

ith

Min

istry

of H

ealth

an

d fo

od s

tand

ards

au

thor

ity

Empo

wer

wom

en t

o ex

clus

ivel

y br

east

feed

, by

ena

ctin

g pr

ogre

ssiv

ely

incr

easin

g re

mun

erat

ed

time

off w

ork

up t

o a

goal

of

6 m

onth

s’ m

anda

tory

pa

id m

ater

nity

leav

e, a

s w

ell

as p

olic

ies

that

enc

oura

ge

wom

en t

o br

east

feed

in

the

wor

kpla

ce in

clud

ing

brea

stfe

edin

g br

eaks

an

d pr

ovisi

on o

f sui

tabl

e fa

cilit

ies

Mod

est

evid

ence

of a

po

sitiv

e im

pact

on

excl

usiv

e br

east

feed

ing.

Posit

ive

coun

try

expe

rienc

e of

gua

rant

eein

g pa

id d

aily

bre

astfe

edin

g br

eaks

on

bre

astfe

edin

g ou

tcom

es

Estim

ated

gov

ernm

ent

cost

of

US$

94

per

live

birt

h pe

r ye

ar t

o en

act

mat

erni

ty

entit

lem

ents

for

6 m

onth

s (1

26).

Lead

: Min

istry

of

Labo

ur/W

ork

and

Pens

ions

61

Annex 2

Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Mas

s m

edia

ca

mpa

igns

Con

duct

mas

s m

edia

ca

mpa

igns

on

heal

thy

diet

and

phy

sica

l ac

tivi

ty

Long

-ter

m, i

nten

sive

m

ass

med

ia c

ampa

igns

ha

ve b

een

show

n to

be

effe

ctiv

e fo

r pr

omot

ing

phys

ical

act

ivit

y an

d m

oder

atel

y ef

fect

ive

for

prom

otin

g he

alth

y di

et.

Inte

nsiv

e ca

mpa

igns

pr

omot

ing

one

sim

ple

mes

sage

are

als

o m

oder

atel

y ef

fect

ive.

246

to 1

361

DA

LYs

per

mill

ion

popu

lati

on in

6

LMIC

s;U

K: C

ould

sav

e 49

000

DA

LYs

over

life

tim

e of

20

04 p

opul

atio

n

Hig

hly

depe

nden

t on

con

text

: wou

ld

not

be c

ost-

effe

ctiv

e, c

ost-

effe

ctiv

e or

hig

hly

cost

-effe

ctiv

e in

6

LMIC

s af

ter

20 y

ears

; aft

er

50 y

ears

hig

hly

cost

effe

ctiv

e or

co

st-e

ffect

ive

in

4 co

untr

ies,

not

co

st-e

ffect

ive

in 2

co

untr

ies.

Mor

e lik

ely

to

be h

ighl

y co

st-

effe

ctiv

e In

HIC

s (U

K: U

S$ 2

00 p

er

DA

LY s

aved

)

Qui

te lo

w in

LM

ICs

(gen

eric

est

imat

e fo

r LM

ICs

cost

s U

S$ 0

.038

per

per

son

per

year

(122

); Es

tim

ates

in t

he 6

LM

ICs

rang

e fr

om

US$

0.2

7 to

0.8

0 pe

r he

adH

ighe

r co

sts

in a

hi

gh-in

com

e co

untr

y (E

ngla

nd =

US$

2.3

2 pe

r he

ad)

(34)

Lead

: Min

istr

y of

Info

rmat

ion,

M

inis

try

of

Hea

lth,

Min

istr

y of

Spo

rt a

nd

Min

istr

y of

Ed

ucat

ion

Impl

emen

t ap

prop

riate

so

cial

mar

ketin

g ca

mpa

igns

, le

d by

the

pub

lic s

ecto

r, on

he

alth

y di

et a

nd p

hysic

al

activ

ity in

ord

er t

o bu

ild

cons

ensu

s, co

mpl

emen

t th

e ot

her

inte

rven

tions

in

the

pack

age

and

enco

urag

e be

havi

our

chan

ge

62


Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Ensu

re s

usta

ined

im

plem

enta

tion

of

cam

paig

ns a

nd m

onito

r th

eir

impa

ct

Evid

ence

sho

ws

that

it is

ch

alle

ngin

g to

sus

tain

effe

cts

afte

r ca

mpa

igns

fini

sh, in

the

fa

ce o

f com

petin

g fa

ctor

s, su

ch

as p

erva

sive

food

mar

ketin

g ac

ross

man

y fo

rms

of m

edia

Hea

lth

sect

or

inte

rven

tion

sH

arne

ss t

he h

ealt

h se

ctor

to

enab

le

chan

ge a

nd t

o pr

ovid

e le

ader

ship

on

gov

erna

nce

and

acco

unta

bilit

y

Evid

ence

tha

t he

alth

se

ctor

inte

rven

tion

s ca

n be

effe

ctiv

e, p

arti

cula

rly

nutr

itio

n co

unse

lling

du

ring

pre

gnan

cy a

nd

prim

ary-

care

bas

ed

coun

selli

ng fo

r at

ris

k gr

oups

(se

e be

low

)

No

over

all

esti

mat

es

iden

tifie

d, s

ee

belo

w fo

r so

me

spec

ific

esti

mat

es

No

over

all

esti

mat

es

avai

labl

e. S

ome

esti

mat

ed t

hat

diet

ary

advi

ce t

o pr

egna

nt w

omen

an

d pr

imar

y-ca

re

base

d co

unse

lling

fo

r at

-ris

k gr

oups

w

ould

be

cost

ef

fect

ive

No

over

all e

stim

ates

id

enti

fied,

see

bel

ow

for

som

e sp

ecifi

c es

tim

ates

Lead

: Pre

side

nt/

Prim

e M

inis

ter’

s O

ffice

wit

h M

inis

try

of H

ealt

hO

ther

: Tre

asur

y/Fi

nanc

e, T

rade

, Fo

reig

n A

ffair

s,

Indu

stry

, Ene

rgy,

So

cial

Wel

fare

, Ju

stic

e/Se

curi

ty,

Agr

icul

ture

, Fo

od, E

duca

tion

, C

omm

unic

atio

n,

Urb

an P

lann

ing,

H

ousi

ng,

Envi

ronm

ent,

Tr

ansp

ort

and

Spor

t

63

Annex 2

Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Ensu

re p

rovi

sion

of d

ieta

ry

coun

sellin

g on

nut

ritio

n,

phys

ical

act

ivity

and

hea

lthy

wei

ght

gain

bef

ore

and

durin

g pr

egna

ncy

for

pros

pect

ive

mot

hers

and

fa

ther

s

Inte

rven

tions

on

diet

and

/or

exe

rcise

red

uce

the

risk

of

exce

ssiv

e w

eigh

t ga

in d

urin

g pr

egna

ncy

by a

roun

d 20

%

(118

) an

d W

HO

rec

omm

ends

co

unse

lling

abou

t he

alth

y ea

ting

and

keep

ing

phys

ical

ly

activ

e du

ring

preg

nanc

y (1

19). T

he C

omm

issio

n on

End

ing

Chi

ldho

od

Obe

sity

reco

mm

ende

d th

at

prec

once

ptio

n co

unse

lling

also

be

pro

vide

d to

pro

spec

tive

pare

nts

(6)

Econ

omic

ass

essm

ent

of a

n ra

ndom

ized

cont

rolle

d tr

ial i

n N

ew

Zea

land

foun

d it

high

ly

prob

able

tha

t an

tena

tal

diet

ary

advi

ce t

o ov

erw

eigh

t or

obe

se

wom

en w

ould

be

cost

-ef

fect

ive

(127

)

Lead

: Min

istry

of

Hea

lth

Inte

grat

e sc

reen

ing

for

over

wei

ght

and

othe

r di

abet

es r

isk fa

ctor

s in

to

prim

ary

heal

th c

are

and

prov

ide

prim

ary-

care

bas

ed

coun

sellin

g fo

r hi

gh r

isk

indi

vidu

als

Phys

icia

n co

unse

lling

for

at-r

isk

grou

ps is

one

of t

he m

ost

effe

ctiv

e in

terv

entio

ns (

116)

an

d is

one

of W

HO

’s “b

est

buys

” fo

r pr

even

ting

diab

etes

Phys

icia

n co

unse

lling

for

at r

isk g

roup

s is

estim

ated

to

save

up

to 6

988

DA

LYs

per

milli

on p

opul

atio

n af

ter

20 y

ears

, risi

ng

to 1

6 64

4 af

ter

50

year

s (3

4)

Cos

t-ef

fect

iven

ess

of

this

inte

rven

tion

is de

pend

ent

on m

ost

of t

he p

opul

atio

n ha

ving

reg

ular

acc

ess

to

prim

ary

care

(34

)

Cos

t pe

r he

ad v

arie

s fr

om

US$

0.2

0 to

4.4

0 pe

r he

ad

in s

ix L

MIC

s (3

4)

Lead

: Min

istry

of

Hea

lth

64

Proposed policy priorities for preventing obesity and diabetesA

nnex

2. S

umm

ary

of s

trat

egic

inte

rven

tion

s in

10

prio

rity

are

as fo

r ac

tion

for

the

prev

enti

on o

f obe

sity

and

dia

bete

s in

the

Eas

tern

Med

iter

rane

an R

egio

nA

rea

for

acti

onSt

rate

gic

inte

rven

tion

sEx

tent

and

str

engt

h of

ev

iden

cePo

tent

ial h

ealt

h im

pact

(D

ALY

s sa

ved)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Esta

blish

or

stre

ngth

en, a

s ap

prop

riate

, a h

igh-

leve

l m

ultis

ecto

ral m

echa

nism

to

defi

ne a

nd o

vers

ee t

he

impl

emen

tatio

n of

food

and

ph

ysic

al a

ctiv

ity p

olic

ies

for

the

prev

entio

n of

obe

sity

and

diab

etes

Glo

bally

, cou

ntrie

s ha

ve

inad

equa

te c

oord

inat

ion

mec

hani

sms,

and

coor

dina

tion

with

in a

nd b

etw

een

min

istrie

s an

d ot

her

part

ners

is

inad

equa

te o

r in

effe

ctiv

e (4

1). W

HO

has

long

re

com

men

ded

that

cou

ntrie

s im

plem

ent

cros

s-go

vern

men

t, m

ultis

ecto

ral g

over

nanc

e m

echa

nism

s to

ste

er a

ctio

n on

di

et a

nd n

utrit

ion

Lead

: Pre

siden

t/Pr

ime

Min

ister

’s O

ffice

with

M

inist

ry o

f Hea

lthO

ther

: Tre

asur

y/Fi

nanc

e, T

rade

, Fo

reig

n A

ffairs

, In

dust

ry, E

nerg

y, So

cial

W

elfa

re, J

ustic

e/Se

curit

y, A

gric

ultu

re,

Food

, Edu

catio

n,

Com

mun

icat

ion,

U

rban

Pla

nnin

g,

Hou

sing,

Envi

ronm

ent,

Tran

spor

t an

d Sp

ort

Esta

blish

nat

iona

l tar

gets

for

obes

ity a

nd d

iabe

tes,

alon

g w

ith S

MA

RT c

omm

itmen

ts

for

actio

n, a

nd w

ork

with

W

HO

to

deve

lop

and

impl

emen

t a

mon

itorin

g fr

amew

ork

for

repo

rtin

g on

pr

ogre

ss

Gov

ernm

ents

tha

t pr

iorit

ize

nutr

ition

in p

olic

y do

cum

ents

sp

end

mor

e m

oney

on

nutr

ition

, but

, by

2016

, on

ly 3

0% o

f cou

ntrie

s ha

d se

t ta

rget

s fo

r ob

esity

and

di

abet

es in

the

ir na

tiona

l NC

D

plan

s (4

3)

Lead

: Pre

siden

t/Pr

ime

Min

ister

’s O

ffice

with

M

inist

ry o

f Hea

lthO

ther

: As

abov

e

Impl

emen

t ev

iden

ce-

base

d co

mm

unity

-bas

ed

inte

rven

tions

, add

ress

ing

both

hea

lthy

eatin

g an

d ph

ysic

al a

ctiv

ity, c

ompr

ising

di

ffere

nt a

ctiv

ities

and

ta

rget

ing

high

-risk

gro

ups,

to p

rom

ote

and

faci

litat

e be

havi

our

chan

ge a

nd

prev

ent

obes

ity a

nd

diab

etes

Com

mun

ity-b

ased

in

terv

entio

ns w

hich

com

prise

m

any

diffe

rent

act

iviti

es a

nd

addr

ess

both

die

t an

d ph

ysic

al

activ

ity c

an b

e ef

fect

ive

(116

). Su

ch in

terv

entio

ns u

sual

ly

incl

ude

a st

rong

edu

catio

nal

com

pone

nt a

nd m

ay t

arge

t hi

gh-r

isk g

roup

s, su

ch a

s th

ose

who

are

at

a hi

gh r

isk o

f de

velo

ping

dia

bete

s (1

16)

DA

LYs:

Disa

bilit

y A

djus

ted

Life

Year

s; G

DP:

gro

ss d

omes

tic p

rodu

ct; H

FSS:

high

in fa

t, sa

lt or

sug

ar; H

ICs:

high

-inco

me

coun

trie

s; LM

ICs:

low

- or

mid

dle-

inco

me

coun

trie

s; M

ET: m

etab

olic

equ

ival

ent

of t

ask;

NC

D: n

onco

mm

unic

able

di

seas

e; U

K: U

nite

d Ki

ngdo

m.

65

Ann

ex 2

. Sum

mar

y of

str

ateg

ic in

terv

enti

ons

in 1

0 pr

iori

ty a

reas

for

acti

on fo

r th

e pr

even

tion

of o

besi

ty a

nd d

iabe

tes

in t

he E

aste

rn M

edit

erra

nean

Reg

ion

Are

a fo

r ac

tion

Stra

tegi

c in

terv

enti

ons

Exte

nt a

nd s

tren

gth

of

evid

ence

Pote

ntia

l hea

lth

impa

ct (

DA

LYs

save

d)

Cos

t–ef

fect

iven

ess

(U

S$ p

er D

ALY

sa

ved)

Affo

rdab

ility

(im

plem

enta

tion

cos

t in

U

S$ p

er c

apit

a: v

ery

low

=

<US$

0.5

0; q

uite

low

=



US$

1)

Gov

ernm

ent

inst

itut

ions

in

volv

ed (

lead

bod

y,

othe

r m

inis

trie

s/de

part

men

ts

invo

lved

)

Esta

blish

or

stre

ngth

en, a

s ap

prop

riate

, a h

igh-

leve

l m

ultis

ecto

ral m

echa

nism

to

defi

ne a

nd o

vers

ee t

he

impl

emen

tatio

n of

food

and

ph

ysic

al a

ctiv

ity p

olic

ies

for

the

prev

entio

n of

obe

sity

and

diab

etes

Glo

bally

, cou

ntrie

s ha

ve

inad

equa

te c

oord

inat

ion

mec

hani

sms,

and

coor

dina

tion

with

in a

nd b

etw

een

min

istrie

s an

d ot

her

part

ners

is

inad

equa

te o

r in

effe

ctiv

e (4

1). W

HO

has

long

re

com

men

ded

that

cou

ntrie

s im

plem

ent

cros

s-go

vern

men

t, m

ultis

ecto

ral g

over

nanc

e m

echa

nism

s to

ste

er a

ctio

n on

di

et a

nd n

utrit

ion

Lead

: Pre

siden

t/Pr

ime

Min

ister

’s O

ffice

with

M

inist

ry o

f Hea

lthO

ther

: Tre

asur

y/Fi

nanc

e, T

rade

, Fo

reig

n A

ffairs

, In

dust

ry, E

nerg

y, So

cial

W

elfa

re, J

ustic

e/Se

curit

y, A

gric

ultu

re,

Food

, Edu

catio

n,

Com

mun

icat

ion,

U

rban

Pla

nnin

g,

Hou

sing,

Envi

ronm

ent,

Tran

spor

t an

d Sp

ort

Esta

blish

nat

iona

l tar

gets

for

obes

ity a

nd d

iabe

tes,

alon

g w

ith S

MA

RT c

omm

itmen

ts

for

actio

n, a

nd w

ork

with

W

HO

to

deve

lop

and

impl

emen

t a

mon

itorin

g fr

amew

ork

for

repo

rtin

g on

pr

ogre

ss

Gov

ernm

ents

tha

t pr

iorit

ize

nutr

ition

in p

olic

y do

cum

ents

sp

end

mor

e m

oney

on

nutr

ition

, but

, by

2016

, on

ly 3

0% o

f cou

ntrie

s ha

d se

t ta

rget

s fo

r ob

esity

and

di

abet

es in

the

ir na

tiona

l NC

D

plan

s (4

3)

Lead

: Pre

siden

t/Pr

ime

Min

ister

’s O

ffice

with

M

inist

ry o

f Hea

lthO

ther

: As

abov

e

Impl

emen

t ev

iden

ce-

base

d co

mm

unity

-bas

ed

inte

rven

tions

, add

ress

ing

both

hea

lthy

eatin

g an

d ph

ysic

al a

ctiv

ity, c

ompr

ising

di

ffere

nt a

ctiv

ities

and

ta

rget

ing

high

-risk

gro

ups,

to p

rom

ote

and

faci

litat

e be

havi

our

chan

ge a

nd

prev

ent

obes

ity a

nd

diab

etes

Com

mun

ity-b

ased

in

terv

entio

ns w

hich

com

prise

m

any

diffe

rent

act

iviti

es a

nd

addr

ess

both

die

t an

d ph

ysic

al

activ

ity c

an b

e ef

fect

ive

(116

). Su

ch in

terv

entio

ns u

sual

ly

incl

ude

a st

rong

edu

catio

nal

com

pone

nt a

nd m

ay t

arge

t hi

gh-r

isk g

roup

s, su

ch a

s th

ose

who

are

at

a hi

gh r

isk o

f de

velo

ping

dia

bete

s (1

16)

DA

LYs:

Disa

bilit

y A

djus

ted

Life

Year

s; G

DP:

gro

ss d

omes

tic p

rodu

ct; H

FSS:

high

in fa

t, sa

lt or

sug

ar; H

ICs:

high

-inco

me

coun

trie

s; LM

ICs:

low

- or

mid

dle-

inco

me

coun

trie

s; M

ET: m

etab

olic

equ

ival

ent

of t

ask;

NC

D: n

onco

mm

unic

able

di

seas

e; U

K: U

nite

d Ki

ngdo

m.

Annex 3

Ann

ex 3

. Exa

mpl

es o

f cou

ntry

exp

erie

nce

wit

h im

plem

enta

tion

of t

he p

ropo

sed

stra

tegi

c in

terv

enti

ons

Pri

orit

y ar

ea fo

r ac

tion

Prop

osed

str

ateg

ic in

terv

enti

ons

Exam

ples

of c

ount

ry e

xper

ienc

e of

impl

emen

tati

on

Fisc

al m

easu

res

1.1

Prog

ress

ivel

y el

imin

ate

all n

atio

nal s

ubsid

ies

for

all t

ypes

of f

ats/

oils

and

suga

r.T

hree

– q

uart

er o

f the

cou

ntrie

s in

the

Reg

ion

subs

idize

food

com

mod

ities

, ofte

n in

clud

ing

suga

r an

d oi

ls (3

5).

The

Isla

mic

Rep

ublic

of I

ran

and

Egyp

t ha

ve r

educ

ed o

r re

mov

ed s

uch

subs

idie

s an

d re

plac

ed t

hem

with

mea

sure

s, su

ch a

s ca

sh t

rans

fers

, tha

t ar

e kn

own

to p

rovi

de m

ore

effe

ctiv

e so

cial

pro

tect

ion

for

poor

er fa

milie

s (1

28).

1.2

Impl

emen

t an

effe

ctiv

e ta

x on

sug

ar-s

wee

tene

d be

vera

ges.

Glo

bally

, by

2016

, mor

e th

an 3

0 na

tiona

l or

sub-

natio

nal a

utho

ritie

s ha

d in

trod

uced

, or

wer

e pl

anni

ng, t

axes

on

suga

r-sw

eete

ned

drin

ks –

incl

udin

g Eg

ypt,

Islam

ic R

epub

lic o

f Ira

n an

d th

e G

ulf C

oope

ratio

n C

ounc

il St

ates

in t

he E

aste

rn M

edite

rran

ean

Reg

ion

(129

–131

). A

fter

one

year

of M

exic

o’s

tax

on s

ugar

-sw

eete

ned

drin

ks (

equi

vale

nt t

o ab

out

a 10

% p

rice

incr

ease

) pu

rcha

ses

wer

e do

wn

by 1

2% o

n av

erag

e (a

nd b

y as

muc

h as

17%

in p

oore

r ho

useh

olds

) an

d ov

er U

S$ 9

milli

on h

ad b

een

colle

cted

in e

xcise

dut

y, an

incr

ease

of 5

1%

(24)

.

1.3

Con

sider

an

effe

ctiv

e pr

ogre

ssiv

e ta

x on

hig

h fa

t fo

ods

and

high

sug

ar fo

ods.

The

re is

an

emer

ging

cou

ntry

exp

erie

nce,

alth

ough

not

as

wel

l dev

elop

ed a

s th

e ex

perie

nce

on t

axin

g su

gar-s

wee

tene

d dr

inks

.H

unga

ry’s

Publ

ic H

ealth

Tax

on

food

s hi

gh in

sug

ars

or s

alt

and

on s

ugar

-sw

eete

ned

and

ener

gy d

rinks

has

res

ulte

d in

a d

rop

in c

onsu

mpt

ion

of t

axed

pro

duct

s (b

y as

muc

h as

25–

30%

acc

ordi

ng t

o so

me

estim

ates

) (1

8,27

). The

Gov

ernm

ent

also

enc

oura

ged

man

ufac

ture

rs t

o re

form

ulat

e th

eir

prod

ucts

and

rai

sed

arou

nd €

60

milli

on in

201

3 fo

r go

vern

men

t he

alth

spe

ndin

g (6

).D

enm

ark’s

sat

urat

ed fa

t ta

x, a

lthou

gh s

hort

-live

d, r

educ

ed fa

t co

nsum

ptio

n by

10–

15%

and

ra

ised

€ 13

4 m

illion

in le

ss t

han

a ye

ar (

28,2

9). F

inla

nd’s

tax

on s

wee

ts, ic

e cr

eam

and

sof

t dr

inks

rai

sed

€ 20

4 m

illion

in 2

013

(19)

.

66


Ann

ex 3

. Exa

mpl

es o

f cou

ntry

exp

erie

nce

wit

h im

plem

enta

tion

of t

he p

ropo

sed

stra

tegi

c in

terv

enti

ons

Pri

orit

y ar

ea fo

r ac

tion

Prop

osed

str

ateg

ic in

terv

enti

ons

Exam

ples

of c

ount

ry e

xper

ienc

e of

impl

emen

tati

on

Publ

ic p

rocu

rem

ent

2.1

Impl

emen

t m

anda

tory

nut

ritio

n st

anda

rds

acro

ss

all p

ublic

inst

itutio

ns t

hrou

gh (

a) a

pplic

atio

n of

the

reg

iona

l nut

rient

pro

file

mod

el, (

b)

intr

oduc

tion

of m

eal s

tand

ards

and

(c)

mea

sure

s to

elim

inat

e th

e sa

le o

f foo

ds o

r dr

inks

hig

h in

fa

t, su

gar

or s

alt.

Nat

iona

l act

ion

on p

ublic

ly-fu

nded

food

has

gen

eral

ly fo

cuse

d on

sch

ools.

By

2013

, 47

coun

trie

s gl

obal

ly r

epor

ted

natio

nal p

olic

ies

for

scho

ol m

eals

base

d on

nat

iona

l die

tary

gu

idel

ines

and

17

had

natio

nwid

e ba

ns o

n ve

ndin

g m

achi

nes

on s

choo

l pre

mise

s (4

1).

In t

he R

egio

n, t

he Is

lam

ic R

epub

lic o

f Ira

n, Jo

rdan

, Kuw

ait

and

the

Uni

ted

Ara

b Em

irate

s, fo

r ex

ampl

e, h

ave

intr

oduc

ed n

utrit

ion

stan

dard

s fo

r he

alth

y sc

hool

mea

ls an

d in

trod

uced

re

stric

tions

on

prov

ision

or

sale

of u

nhea

lthy

food

s in

sch

ools

(132

).T

he c

once

pt o

f int

rodu

cing

nut

ritio

n st

anda

rds

acro

ss a

ll pu

blic

ly-fu

nded

food

is a

ttra

ctin

g in

crea

sing

atte

ntio

n an

d th

ere

are

som

e pi

onee

ring

exam

ples

.N

ew Yo

rk C

ity, f

or e

xam

ple,

est

ablis

hed

nutr

ition

sta

ndar

ds fo

r al

l foo

ds p

urch

ased

or

serv

ed in

all

of t

he C

ity’s

3000

sch

ools,

hos

pita

ls, c

hild

care

or

resid

entia

l car

e fa

cilit

ies

and

priso

ns in

200

8. A

ll pr

ocur

emen

t co

ntra

cts

cont

ain

a m

anda

tory

cla

use

to s

ay t

hat

any

food

pr

ovid

ed m

ust

mee

t th

e st

anda

rds

(45)

.

2.2

Issue

man

dato

ry g

uide

lines

for

the

revi

sion

of

proc

urem

ent

to p

rovi

de h

ealth

y fo

od, in

clud

ing

limiti

ng t

he v

olum

e of

fats

/oils

, sug

ar a

nd s

alt

ente

ring

publ

ic s

ecto

r ca

terin

g fa

cilit

ies

in o

rder

to

faci

litat

e th

e ne

cess

ary

men

u ch

ange

s (e

.g. s

o th

at m

eals

prov

ide

not

mor

e th

an 2

5% e

nerg

y fr

om fa

ts a

nd le

ss t

han

5% fr

om fr

ee s

ugar

s).

Som

e na

tiona

l, or

subn

atio

nal, a

utho

ritie

s ar

e ta

king

act

ion

on t

he r

ules

and

gui

delin

es o

n pr

ocur

emen

t fo

r pu

blic

inst

itutio

ns t

o en

sure

tha

t th

e fo

ods

serv

ed in

the

se in

stitu

tions

are

he

alth

y.Br

azil’s

app

roac

h to

pro

cure

men

t of

sch

ool f

ood

com

bine

d nu

triti

on s

tand

ards

with

a

requ

irem

ent

for

30%

of s

choo

l foo

d bu

dget

s to

be

spen

t in

loca

l far

mer

s’ m

arke

ts (

43).

The

Sta

te o

f Mas

sach

uset

ts in

the

Uni

ted

Stat

es o

f Am

eric

a (U

SA)

set

nutr

ition

al s

tand

ards

fo

r al

l foo

d pu

rcha

sed

by s

tate

age

ncie

s (in

clud

ing

hosp

itals,

pris

ons

and

child

care

ser

vice

s)

and

thei

r co

ntra

ctor

s (4

4).

2.3

Dev

elop

gui

danc

e an

d pr

ovid

e tr

aini

ng t

o ca

terin

g co

mpa

nies

on

appr

opria

te c

ater

ing

met

hods

in p

ublic

inst

itutio

ns t

o re

duce

the

use

of

fryi

ng a

nd s

wee

teni

ng o

f foo

ds a

nd h

elp

with

m

enu

desig

n.

Publ

ic in

stitu

tions

are

like

ly t

o re

quire

sup

port

to

be a

ble

to m

ake

the

nece

ssar

y ch

ange

s to

co

mpl

y w

ith n

ew n

utrit

iona

l sta

ndar

ds a

nd/o

r pr

ocur

emen

t gu

idel

ines

.In

the

USA

, the

fede

ral g

over

nmen

t ha

s de

velo

ped

a na

tiona

l con

trac

t te

mpl

ate

for

heal

thy

food

pro

cure

men

t (1

33).

In E

urop

e, M

alta

is d

evel

opin

g so

me

volu

ntar

y gu

idin

g pr

inci

ples

fo

r fo

od p

rocu

rem

ent,

initi

ally

focu

sing

on s

choo

ls bu

t fo

r fu

ture

use

in o

ther

sec

tors

(13

4).

2.4

Con

tinue

impl

emen

ting

thes

e m

easu

res,

scal

ing

up c

over

age

and

mon

itorin

g im

pact

.

Phys

ical

act

ivity

3.1

Prom

ote

heal

thy

phys

ical

act

ivity

thr

ough

mas

s m

edia

cam

paig

ns (

see

prio

rity

area

9)

and

ensu

re a

dequ

ate

legi

slatio

n su

ppor

ting

deliv

ery

of d

aily

phy

sical

act

ivity

for

stud

ents

in s

choo

ls an

d un

iver

sitie

s.

Man

y co

untr

ies

have

legi

slatio

n re

quiri

ng a

cer

tain

num

ber

of h

ours

to

be d

edic

ated

to

phys

ical

act

ivity

in t

he s

choo

l cur

ricul

um.

In D

enm

ark,

for

exam

ple,

par

liam

ent

revi

sed

the

law

in 2

014

to m

ake

it co

mpu

lsory

for

scho

ols

to o

ffer

an a

vera

ge o

f 45

min

utes

of p

hysic

al a

ctiv

ity p

er s

choo

l day

in p

rimar

y an

d lo

wer

-sec

onda

ry e

duca

tion

and

to a

dd a

n ex

tra

phys

ical

edu

catio

n le

sson

per

sch

ool

wee

k in

gra

de 1

. Chi

ldca

re fa

cilit

ies

are

also

req

uire

d to

incl

ude

“bod

y an

d m

otio

n” in

the

ir cu

rric

ula

(135

).

3.2

Ensu

re c

ompr

ehen

sive

deliv

ery

of r

egul

ar,

qual

ity p

hysic

al e

duca

tion

to a

ll ch

ildre

n, a

s a

key

com

pone

nt o

f edu

catio

n in

sch

ools.

67

Annex 3

Ann

ex 3

. Exa

mpl

es o

f cou

ntry

exp

erie

nce

wit

h im

plem

enta

tion

of t

he p

ropo

sed

stra

tegi

c in

terv

enti

ons

Pri

orit

y ar

ea fo

r ac

tion

Prop

osed

str

ateg

ic in

terv

enti

ons

Exam

ples

of c

ount

ry e

xper

ienc

e of

impl

emen

tati

on

Phys

ical

act

ivity

3.3

Dev

elop

a s

et o

f sta

ndar

ds/g

uide

lines

pro

mot

ing

phys

ical

act

ivity

in t

he w

orkp

lace

, incl

udin

g fa

cilit

y/bu

ildin

g de

sign,

ava

ilabi

lity

of s

port

s fa

cilit

ies

and

prog

ram

mes

ena

blin

g ac

cess

to

faci

litie

s aw

ay fr

om t

he w

orkp

lace

.

In t

he U

nite

d Ki

ngdo

m (

UK)

, the

Nat

iona

l Ins

titut

e fo

r H

ealth

and

Car

e Ex

celle

nce

(NIC

E)

issue

d gu

idel

ines

on

prom

otin

g ph

ysic

al a

ctiv

ity in

the

wor

kpla

ce fo

r N

atio

nal H

ealth

Se

rvic

e or

gani

zatio

ns in

Eng

land

, whi

ch e

mpl

oy m

ore

than

hal

f a m

illion

peo

ple

(136

,137

). In

201

5, t

his

guid

ance

was

tra

nsla

ted

into

pra

ctic

al a

dvic

e an

d re

com

men

datio

ns a

s pa

rt o

f a

tool

kit

on h

ealth

y w

orkp

lace

(13

8).

In a

gov

ernm

ent-

supp

orte

d in

itiat

ive

in T

haila

nd, p

rivat

e an

d pu

blic

sec

tor

empl

oyer

s pr

ovid

e th

eir

empl

oyee

s w

ith t

rain

ing

and

time

to e

ngag

e in

var

ious

typ

es o

f phy

sical

ac

tiviti

es (

139)

.

3.4

Incr

ease

ava

ilabi

lity

of a

nd a

cces

sibilit

y fo

r pa

rtic

ipat

ion

in fo

rmal

and

info

rmal

rec

reat

iona

l an

d sp

ortin

g ac

tiviti

es, p

artic

ular

ly p

rovi

ding

op

port

uniti

es fo

r pa

rtic

ipat

ion

in p

rogr

amm

es

such

as “

Spor

ts-fo

r-All”

, with

em

phas

is on

en

surin

g eq

ualit

y of

acc

ess

and

oppo

rtun

ity fo

r pa

rtic

ipat

ion.

In Jo

rdan

, as

part

of a

mul

tisec

tora

l par

tner

ship

, Gre

ater

Am

man

Mun

icip

ality

ope

ned

four

pu

blic

gar

dens

at

spec

ific

times

for

wom

en o

nly

so t

hat

they

can

wal

k an

d pa

rtic

ipat

e in

ex

erci

se (

140)

. In

Bah

rain

, the

re h

ave

been

effo

rts

to r

each

agr

eem

ents

bet

wee

n th

e M

inist

ry o

f Hea

lth

and

shop

ping

mal

ls to

pro

vide

mal

ls as

a p

ublic

ven

ue fo

r sp

orts

(48

).

3.5

Dev

elop

and

impl

emen

t an

urb

an p

lann

ing

polic

y to

ens

ure

that

urb

an e

nviro

nmen

ts e

ncou

rage

pe

ople

to

rely

less

on

pers

onal

mot

orize

d ve

hicl

es a

nd s

uppo

rt a

cces

s to

saf

e, g

ende

r-se

nsiti

ve a

nd a

ge-fr

iend

ly p

ublic

tra

nspo

rt, c

yclin

g an

d w

alki

ng, in

clud

ing

by p

rovi

sion

of fa

cilit

ies,

equi

pmen

t, pu

blic

ope

n an

d gr

een

spac

es a

nd

shar

ed u

se o

f sch

ool f

acilit

ies

(bot

h in

door

and

ou

tdoo

r).

Nat

iona

l and

loca

l aut

horit

ies

are

incr

easin

gly

reco

gnisi

ng t

he n

eed

to e

nact

pol

icie

s to

cr

eate

urb

an e

nviro

nmen

ts c

ondu

cive

to

phys

ical

act

ivity

.T

he Is

lam

ic R

epub

lic o

f Ira

n ha

s im

plem

ente

d a

pack

age

of a

ctiv

ities

to

prom

ote

phys

ical

ac

tivity

, incl

udin

g im

prov

emen

ts t

o pu

blic

ope

n sp

aces

, dev

elop

men

t of

cyc

le h

ire s

chem

es

in s

ome

citie

s an

d ex

pand

ing

cycl

e la

nes

(48)

.A

live

able

nei

ghbo

urho

ods

desig

n co

de w

as in

trod

uced

in t

he c

ity o

f Per

th, W

este

rn

Aus

tral

ia. A

stu

dy c

ompa

ring

impl

emen

tatio

n in

diff

eren

t ne

ighb

ourh

oods

foun

d th

at fo

r ev

ery

10%

incr

ease

in it

s im

plem

enta

tion,

the

odd

s of

wal

king

incr

ease

d by

50%

(51

).O

man

’s N

atio

nal N

utrit

ion

Stra

tegy

201

4–20

50 in

clud

es t

he a

im t

o cr

eate

urb

an g

reen

sp

aces

and

ped

estr

ian

tran

spor

t ro

utes

for

cycl

ing,

wal

king

and

jogg

ing

in a

ll ci

ties

that

are

pe

dest

rian-

frie

ndly

and

ope

n fo

r sa

fe e

xerc

ise a

nd t

rave

l day

and

nig

ht, in

clud

ing

“gre

en

tunn

els”

of t

rees

and

shr

ubs

to p

rovi

de s

hade

for

wal

king

(14

1).

3.6

Con

tinue

impl

emen

ting

thes

e m

easu

res,

scal

ing

up c

over

age

and

mon

itorin

g im

pact

.Su

stai

ned

effo

rts

are

requ

ired

to b

ring

abou

t th

e re

quire

d ch

ange

s in

urb

an a

nd r

ural

en

viro

nmen

ts a

nd v

ario

us s

ettin

gs a

nd fa

cilit

ate

grea

ter

part

icip

atio

n in

phy

sical

act

ivity

.Fi

nlan

d ha

s sh

own

com

mitm

ent

to in

crea

sing

phys

ical

act

ivity

sin

ce 1

980

thro

ugh

a va

riety

of

diff

eren

t ac

tions

, incl

udin

g le

gisla

tion,

gui

delin

e de

velo

pmen

t, re

com

men

datio

ns a

nd lo

cal

fund

ing

(46)

. It

has

succ

essf

ully

dev

elop

ed n

atio

nal p

rogr

amm

es fo

r ev

ery

phas

e of

the

life

-co

urse

(13

5).

68


Ann

ex 3

. Exa

mpl

es o

f cou

ntry

exp

erie

nce

wit

h im

plem

enta

tion

of t

he p

ropo

sed

stra

tegi

c in

terv

enti

ons

Pri

orit

y ar

ea fo

r ac

tion

Prop

osed

str

ateg

ic in

terv

enti

ons

Exam

ples

of c

ount

ry e

xper

ienc

e of

impl

emen

tati

on

Food

sup

ply

and

trad

e

4.1

Con

duct

a s

ituat

ion

anal

ysis

of t

he n

atio

nal a

nd/

or lo

cal f

ood

supp

ly, in

clud

ing

esta

blish

ing

the

prop

ortio

ns o

f fat

s/oi

ls an

d su

gar

used

in t

he

diet

tha

t ar

e de

rived

from

impo

rts

and

dom

estic

pr

oduc

tion,

alo

ng w

ith t

he e

xten

t of

food

m

anuf

actu

re a

nd p

roce

ssin

g w

ithin

the

cou

ntry

an

d th

e su

pply

of f

ruit,

veg

etab

les

and

who

le

grai

ns.

As

part

of d

evel

opm

ent

of a

nut

ritio

n st

rate

gy fo

r O

man

, a S

WO

T a

naly

sis w

as c

ondu

cted

, w

hich

iden

tified

a n

eed

to r

educ

e im

port

s of

hig

h-en

ergy

den

sity

food

pro

duct

s. T

he

nutr

ition

str

ateg

y in

clud

es t

he a

im o

f red

ucin

g im

port

atio

n of

hig

h-de

nsity

food

s to

< 3

0%

of a

ll in

take

s th

roug

h co

oper

ativ

e ag

reem

ents

with

reg

iona

l sup

plie

rs, in

crea

sed

regu

latio

n an

d im

port

tar

iffs

on u

nhea

lthy

food

s (1

41).

4.2

Faci

litat

e th

e de

velo

pmen

t of

loca

l foo

d po

licie

s an

d en

cour

age

city

aut

horit

ies

to s

ign

the

Mila

n U

rban

Foo

d Po

licy

Pact

and

impl

emen

t its

Fr

amew

ork

for A

ctio

n to

dev

elop

sus

tain

able

ur

ban

food

sys

tem

s.

By t

he e

nd o

f 201

6, 1

33 c

ities

glo

bally

, with

a t

otal

of m

ore

than

460

milli

on in

habi

tant

s, ha

d sig

ned

up t

o th

e M

ilan

Urb

an F

ood

Polic

y Pa

ct. I

n th

e Ea

ster

n M

edite

rran

ean,

a fe

w c

ities

, su

ch a

s Be

thle

hem

and

Heb

ron,

are

sig

nato

ries

(63)

.

4.3

Con

sider

intr

oduc

ing

stan

dard

s or

oth

er le

gal

inst

rum

ents

(e.

g. co

mpo

sitio

nal s

tand

ards

, tar

iffs,

impo

rt r

estr

ictio

ns, s

ales

ban

s, pl

anni

ng la

ws,

zoni

ng p

olic

ies)

to

redu

ce t

he v

olum

e an

d im

prov

e th

e qu

ality

of f

ats/

oils

and

redu

ce s

ugar

s in

the

nat

iona

l and

loca

l foo

d su

pply.

A n

umbe

r of

cou

ntrie

s ha

ve in

trod

uced

impo

rt d

utie

s on

pro

duct

s su

ch a

s so

ft dr

inks

, su

gar,

conf

ectio

nery

, ice

crea

m, f

atty

mea

ts a

nd s

peci

fic o

ils.

In r

espo

nse

to c

once

rns

abou

t hi

gh le

vels

of c

onsu

mpt

ion

of c

heap

mea

t pr

oduc

ts w

ith a

ve

ry h

igh

fat

cont

ent

– su

ch a

s tu

rkey

tai

ls –

, Sam

oa a

nd G

hana

, for

exa

mpl

e, in

trod

uced

le

gal m

easu

res

(a s

ales

ban

and

com

posit

iona

l sta

ndar

ds r

espe

ctiv

ely)

in o

rder

to

limit

avai

labi

lity

of t

hese

pro

duct

s (5

9,60

).T

he Is

lam

ic R

epub

lic o

f Ira

n in

trod

uced

mea

sure

s to

red

uce

impo

rts

of p

alm

oil,

with

the

ai

m o

f low

erin

g th

e sh

are

of p

alm

oil

in t

otal

veg

etab

le o

il co

nsum

ptio

n to

30%

(14

2).

Om

an’s

nutr

ition

str

ateg

y in

clud

es t

he a

im o

f red

ucin

g im

port

atio

n of

hig

h-de

nsity

food

s to

<30

% o

f all

inta

kes

thro

ugh

coop

erat

ive

agre

emen

ts w

ith r

egio

nal s

uppl

iers

, incr

ease

d re

gula

tion

and

impo

rt t

ariff

s on

unh

ealth

y fo

ods

(141

).

4.4

Con

sider

rem

ovin

g ag

ricul

tura

l sub

sidie

s fo

r pr

oduc

ers

of s

ugar

s an

d oi

ls (e

spec

ially

tho

se

oils

high

in s

atur

ated

fatt

y ac

ids)

, rep

laci

ng t

hem

, w

here

nec

essa

ry, w

ith o

ther

mec

hani

sms

to

supp

ort

farm

ers

and

grow

ers.

In E

aste

rn E

urop

ean

coun

trie

s, ch

ange

s to

nat

iona

l sub

sidie

s of

ani

mal

fats

afte

r th

e po

litic

al

chan

ges

of t

he e

arly

199

0s le

d to

muc

h hi

gher

con

sum

ptio

n of

veg

etab

le o

ils in

som

e co

untr

ies,

with

res

ulta

nt h

ealth

ben

efits

(14

3).

69

Annex 3

Ann

ex 3

. Exa

mpl

es o

f cou

ntry

exp

erie

nce

wit

h im

plem

enta

tion

of t

he p

ropo

sed

stra

tegi

c in

terv

enti

ons

Pri

orit

y ar

ea fo

r ac

tion

Prop

osed

str

ateg

ic in

terv

enti

ons

Exam

ples

of c

ount

ry e

xper

ienc

e of

impl

emen

tati

on

Ref

orm

ulat

ion

5.1

Coo

pera

te w

ith o

ther

Mem

ber

Stat

es t

o ad

opt

a re

gion

al a

ppro

ach

for

enga

ging

with

fo

od p

rodu

cers

to

driv

e fo

od r

efor

mul

atio

n to

el

imin

ate

tran

s fa

ts a

nd r

educ

e pr

ogre

ssiv

ely

tota

l and

sat

urat

ed fa

t, sa

lt, s

ugar

s, en

ergy

and

po

rtio

n siz

e in

a s

ubst

antia

l pro

port

ion

of

proc

esse

d fo

ods.

Mos

t of

the

exp

erie

nce

of r

efor

mul

atio

n to

dat

a ha

s fo

cuse

d on

red

ucin

g sa

lt le

vels

in

proc

esse

d fo

ods.

A 2

015

revi

ew fo

und

that

61

coun

trie

s in

clud

ed r

efor

mul

atio

n in

the

ir na

tiona

l sal

t re

duct

ion

stra

tegi

es, 1

9 co

untr

ies

repo

rt r

educ

tions

in t

he s

alt

cont

ent

of fo

ods

and

12 c

ount

ries

repo

rt a

fall

in p

opul

atio

n sa

lt in

take

(65

).

Kuw

ait

has

intr

oduc

ed a

vol

unta

ry fo

od r

efor

mul

atio

n pr

ogra

mm

e to

red

uce

salt

and

fat

leve

ls, w

ith a

n in

itial

focu

s on

red

ucin

g sa

lt th

e sa

lt co

nten

t of

bre

ad a

nd c

hees

es (

132)

.M

ore

than

11

coun

trie

s ha

ve in

trod

uced

law

s to

lim

it th

e tr

ans

fatt

y ac

id c

onte

nt o

f foo

ds,

incl

udin

g, fr

om t

he R

egio

n, t

he Is

lam

ic R

epub

lic o

f Ira

n (1

32).

A n

umbe

r of

cou

ntrie

s ha

ve m

oved

bey

ond

salt,

to

impl

emen

t re

form

ulat

ion

mea

sure

s to

re

duce

the

leve

ls of

oth

er n

utrie

nts

or in

gred

ient

s.T

he N

ethe

rland

s ha

s im

plem

ente

d a

prog

ram

me

to r

educ

e sa

lt, s

atur

ated

fat

and

calo

ries

in s

ugar

pro

duct

s; In

the

UK,

a p

rogr

amm

e to

red

uce

suga

r le

vels

by 2

0% b

y 20

20 w

ill fo

cus

initi

ally

on

nine

typ

es o

f pro

duct

tha

t m

ake

the

bigg

est

cont

ribut

ion

to c

hild

ren’

s su

gar

inta

ke [

brea

kfas

t ce

real

s, yo

ghur

ts, b

iscui

ts, c

akes

, con

fect

ione

ry, m

orni

ng g

oods

(fo

r ex

ampl

e, p

astr

ies)

, pud

ding

s, ic

e cr

eam

and

sw

eet

spre

ads]

(14

4).

5.2

Enga

ge w

ith p

rivat

e se

ctor

pro

vide

rs o

f foo

d in

cat

erin

g/fo

od s

ervi

ce o

utle

ts (

incl

udin

g ta

keaw

ays

and

stre

et fo

od t

rade

rs)

to e

stab

lish

a pr

ogra

mm

e to

elim

inat

e tr

ans

fats

and

red

uce

prog

ress

ivel

y to

tal a

nd s

atur

ated

fat,

salt,

sug

ars,

ener

gy a

nd p

ortio

n siz

e, w

ith d

efine

d qu

antifi

ed

redu

ctio

ns in

use

of t

hese

ingr

edie

nts.

Sing

apor

e’s

Hea

lthie

r H

awke

r pr

ogra

mm

e en

cour

ages

str

eet

food

ven

dors

to

use

heal

thie

r in

gred

ient

s an

d in

volv

es t

he g

over

nmen

t ab

sorb

ing

som

e of

the

cos

ts a

ssoc

iate

d w

ith t

he

use

of t

he h

ealth

ier

ingr

edie

nts

(145

).T

he U

K’s

suga

r re

duct

ion

prog

ram

me

– to

red

uce

suga

r co

nten

ts b

y at

leas

t 20

% b

y 20

20

– w

ill al

so a

pply

to

the

out-

of-h

ome

sect

or, in

clud

ing

rest

aura

nts,

take

away

s an

d ca

fés

(144

)

Mar

ketin

g

6.1

Wor

k w

ith o

ther

cou

ntrie

s in

the

Reg

ion

to

esta

blish

a c

oord

inat

ed a

ppro

ach,

incl

udin

g ap

prop

riate

lega

l adv

ice,

to

redu

ce t

he im

pact

of

cros

s-bo

rder

mar

ketin

g.

In t

he E

aste

rn M

edite

rran

ean

Reg

ion,

whe

re c

ross

-bor

der

mar

ketin

g is

so p

reva

lent

, a

regi

onal

app

roac

h w

ill be

fund

amen

tal.

In t

he E

urop

ean

Uni

on fo

od m

anuf

actu

rers

hav

e th

emse

lves

rec

ogni

zed

the

valu

e of

th

e le

vel p

layi

ng fi

eld

crea

ted

by a

har

mon

ized

regi

onal

app

roac

h an

d ha

ve in

trod

uced

a

volu

ntar

y pl

edge

(th

e EU

Ple

dge)

to

rest

rict

broa

dcas

t m

arke

ting

of fo

ods

high

in fa

t or

sal

t or

sug

ar t

o ch

ildre

n (1

46).

70


Ann

ex 3

. Exa

mpl

es o

f cou

ntry

exp

erie

nce

wit

h im

plem

enta

tion

of t

he p

ropo

sed

stra

tegi

c in

terv

enti

ons

Pri

orit

y ar

ea fo

r ac

tion

Prop

osed

str

ateg

ic in

terv

enti

ons

Exam

ples

of c

ount

ry e

xper

ienc

e of

impl

emen

tati

on

Mar

ketin

g

6.2

Impl

emen

t th

e W

HO

Set

of R

ecom

men

datio

ns

on M

arke

ting

of F

oods

and

Non

-alc

ohol

ic

Beve

rage

s to

Chi

ldre

n an

d co

nsid

er m

anda

tory

re

stric

tions

to

elim

inat

e al

l for

ms

of m

arke

ting

of fo

ods

high

in fa

t, su

gar

and

salt

to c

hild

ren

and

adol

esce

nts

(up

to a

ge 1

8) a

cros

s al

l med

ia,

acco

rdin

g to

the

Reg

iona

l Act

ion

Plan

to

Add

ress

U

nopp

osed

Mar

ketin

g of

Unh

ealth

y Fo

od a

nd

Beve

rage

s.

Six

year

s on

from

the

pub

licat

ion

of W

HO

’s Se

t of

Rec

omm

enda

tions

on

the

Mar

ketin

g of

Foo

ds a

nd N

on-A

lcoh

olic

Bev

erag

es t

o C

hild

ren,

aro

und

20%

of c

ount

ries

in t

he

East

ern

Med

iterr

anea

n (a

nd 2

8% o

f cou

ntrie

s gl

obal

ly)

have

intr

oduc

ed g

over

nmen

t le

gisla

tion

on t

his

issue

(14

7). A

lthou

gh n

o co

untr

y ha

s co

mpr

ehen

sivel

y im

plem

ente

d th

e R

ecom

men

datio

ns, t

here

are

ele

men

ts o

f goo

d pr

actic

e.R

estr

ictio

ns in

trod

uced

in S

outh

Kor

ea, I

rela

nd, B

razi

l and

Nor

way

con

cern

chi

ldre

n up

to

the

age

of 1

8 ye

ars

(132

). M

easu

res

in C

hile

and

Por

tuga

l inc

lude

aud

ienc

es w

ith 2

0% o

r m

ore

child

ren,

in c

ontr

ast

to

man

y sc

hem

es t

hat

only

cov

er a

udie

nces

com

prisi

ng a

t le

ast

35%

or

50%

chi

ldre

n (1

32).

Res

tric

tions

in P

eru

and

Braz

il ar

e ba

sed

on b

road

defi

nitio

ns o

f mar

ketin

g, co

verin

g di

ffere

nt m

edia

(e.

g. te

levi

sion,

rad

io, p

rint,

Inte

rnet

, app

s) a

nd m

arke

ting

met

hods

(13

2).

In t

he E

aste

rn M

edite

rran

ean

Reg

ion,

the

Isla

mic

Rep

ublic

of I

ran

has

intr

oduc

ed r

ules

to

rest

rict

radi

o an

d te

levi

sion

adve

rtisi

ng t

o ch

ildre

n an

d ad

oles

cent

s (u

p to

19

year

s of

age

) (u

npub

lishe

d re

port

).

6.3

Use

the

reg

iona

l nut

rient

pro

file

mod

el, w

hich

ca

tego

rizes

the

app

ropr

iate

leve

l of n

utrie

nts

in

food

s, to

iden

tify

food

s to

whi

ch t

he m

arke

ting

rest

rictio

ns s

houl

d ap

ply.

The

nut

rient

pro

file

mod

el d

evel

oped

for

the

Euro

pean

reg

ion

has

alre

ady

been

ado

pted

an

d ad

apte

d by

a n

umbe

r of

Eur

opea

n co

untr

ies

(e.g

. Slo

veni

a, Ire

land

) fo

r us

e in

res

tric

ting

mar

ketin

g to

chi

ldre

n.

6.4

Con

duct

an

asse

ssm

ent

(pre

fera

bly

as p

art

of a

reg

iona

l col

labo

ratio

n) o

f the

impa

ct o

f m

arke

ting

of fo

ods

high

in fa

t, su

gar

or s

alt

to

adul

ts.

Polic

y at

tent

ion,

to

date

, has

focu

sed

pred

omin

antly

on

mar

ketin

g to

chi

ldre

n an

d th

is is

an

unde

r-res

earc

hed

area

.

6.5

Con

sider

ext

endi

ng m

anda

tory

res

tric

tions

on

mar

ketin

g of

unh

ealth

y fo

ods

to w

hole

po

pula

tion.

Som

e co

untr

ies

have

tak

en s

teps

to

limit

the

effe

cts

of m

arke

ting

of fo

ods

high

in fa

t or

sal

t or

sug

ar t

o th

e w

hole

pop

ulat

ion.

The

Isla

mic

Rep

ublic

of I

ran

has

proh

ibite

d br

oadc

ast

adve

rtisi

ng o

f sof

t dr

inks

sin

ce 2

004

and,

in 2

014,

furt

her

rest

rictio

ns w

ere

prop

osed

on

an a

dditi

onal

24

food

item

s (1

32).

Irela

nd li

mits

bro

adca

st a

dver

tisin

g of

HFS

S fo

ods

to n

o m

ore

than

25%

of s

old

adve

rtisi

ng

time

(132

).

6.6

Legi

slate

to

allo

w r

etai

l pro

mot

ions

onl

y on

he

alth

y fo

ods.

Som

e U

K-ba

sed

supe

rmar

ket

chai

ns h

ave

volu

ntar

ily a

gree

d to

lim

it th

e pr

opor

tion

of

pric

e pr

omot

ions

on

HFS

S fo

ods

(148

).

Labe

lling

7.1

Impl

emen

t a

man

dato

ry fr

ont-

of-p

ack

labe

lling

sche

me

with

ele

men

ts t

o en

able

con

sum

ers

to

inte

rpre

t in

form

atio

n ea

sily

(e.g

. col

our

codi

ng o

r th

e us

e of

ter

ms

such

as “

high

” “m

ediu

m”,

“low

”).

Man

dato

ry fr

ont-

of-p

ack

nutr

ition

labe

lling

has

been

intr

oduc

ed in

, for

exa

mpl

e, E

cuad

or

and

Mex

ico

(132

), an

d tr

affic

-ligh

t la

bellin

g ha

s be

en in

trod

uced

in t

he Is

lam

ic R

epub

lic o

f Ira

n (1

33).

Gov

ernm

ent-

defin

ed v

olun

tary

tra

ffic-

light

sch

emes

are

in p

lace

in a

num

ber

of

othe

r co

untr

ies

such

as

Sout

h Ko

rea

and

the

UK

(132

).

7.2

Enfo

rce

the

labe

lling

sche

me

and

mon

itor

its

impa

ct.

It is

impo

rtan

t th

at t

he in

trod

uctio

n of

the

labe

lling

sche

me

is pr

oper

ly e

nfor

ced

and

mon

itore

d, p

artic

ular

ly t

o as

sess

the

impa

ct a

cros

s al

l soc

ioec

onom

ic g

roup

s.

71

Annex 3

Ann

ex 3

. Exa

mpl

es o

f cou

ntry

exp

erie

nce

wit

h im

plem

enta

tion

of t

he p

ropo

sed

stra

tegi

c in

terv

enti

ons

Pri

orit

y ar

ea fo

r ac

tion

Prop

osed

str

ateg

ic in

terv

enti

ons

Exam

ples

of c

ount

ry e

xper

ienc

e of

impl

emen

tati

on

Brea

stfe

edin

g

8.1

Prom

ote

brea

stfe

edin

g th

roug

h m

anda

tory

ba

by-fr

iend

ly h

ealth

sys

tem

s an

d ef

fect

ive

com

mun

ity-b

ased

str

ateg

ies.

Cam

bodi

a in

crea

sed

brea

stfe

edin

g fr

om 1

1% in

200

0 to

74%

by

2010

thr

ough

vig

orou

s pr

omot

ion

of b

reas

tfeed

ing,

regu

latin

g th

e m

arke

ting

of b

reas

t-m

ilk s

ubst

itute

s an

d ba

by

food

s an

d a

wid

e-ra

ngin

g ba

by-fr

iend

ly in

itiat

ive

(114

).

8.2

Fully

impl

emen

t of

the

Inte

rnat

iona

l Cod

e of

M

arke

ting

of B

reas

t-m

ilk S

ubst

itute

s an

d th

e W

HO

Gui

danc

e on

end

ing

inap

prop

riate

pr

omot

ion

of fo

ods

for

infa

nts

and

youn

g ch

ildre

n.

In t

he R

egio

n, 8

5% o

f cou

ntrie

s ha

ve e

nact

ed le

gisla

tion

to im

plem

ent

the

Cod

e bu

t on

ly

30%

hav

e la

ws

with

all

or m

any

of t

he C

ode

prov

ision

s (1

13).

Keny

a an

d So

uth

Afr

ica

have

ado

pted

com

preh

ensiv

e C

ode-

rela

ted

legi

slatio

n, in

clud

ing

wid

e-ra

ngin

g pr

ohib

ition

s on

pro

mot

iona

l act

iviti

es a

nd m

easu

res

to e

nsur

e ef

fect

ive

enfo

rcem

ent

(113

). Ku

wai

t’s 2

014

Cod

e-im

plem

entin

g le

gisla

tion

feat

ures

a b

road

sco

pe, a

wid

e ra

nge

of

proh

ibiti

ons

and

deta

iled

requ

irem

ents

for

info

rmat

ion

and

educ

atio

n m

ater

ials

and

labe

lling

(113

).

8.3

Empo

wer

wom

en t

o ex

clus

ivel

y br

east

feed

by

enac

ting

prog

ress

ivel

y in

crea

sing

rem

uner

ated

tim

e of

f wor

k up

to

a go

al o

f 6 m

onth

s’ m

anda

tory

pai

d m

ater

nity

leav

e, a

s w

ell a

s po

licie

s th

at e

ncou

rage

wom

en t

o br

east

feed

in

the

wor

kpla

ce, in

clud

ing

brea

stfe

edin

g br

eaks

an

d pr

ovisi

on o

f sui

tabl

e fa

cilit

ies.

Glo

bally

, 32

coun

trie

s ha

ve r

atifi

ed t

he In

tern

atio

nal L

abou

r O

rgan

izat

ion

Mat

erni

ty

Prot

ectio

n C

onve

ntio

n (C

onve

ntio

n N

o. 1

83)

(149

). In

the

Eas

tern

Med

iterr

anea

n R

egio

n, M

oroc

co r

atifi

ed t

he C

onve

ntio

n in

201

1, p

rovi

ding

14

wee

ks o

f mat

erni

ty le

ave

(149

).

Mas

s m

edia

9.1

Impl

emen

t ap

prop

riate

soc

ial m

arke

ting

cam

paig

ns, le

d by

the

pub

lic s

ecto

r, on

hea

lthy

diet

and

phy

sical

act

ivity

in o

rder

to

build

co

nsen

sus,

com

plem

ent

the

othe

r in

terv

entio

ns

in t

he p

acka

ge a

nd e

ncou

rage

beh

avio

ur c

hang

e.

Man

y co

untr

ies

have

impl

emen

ted

publ

ic a

war

enes

s, m

ass

med

ia a

nd in

form

atio

nal

cam

paig

ns a

nd s

ocia

l mar

ketin

g on

hea

lthy

eatin

g. T

here

are

also

exa

mpl

es o

f cou

ntrie

s us

ing

mas

s m

edia

cam

paig

ns t

o re

info

rce

othe

r ac

tions

.M

exic

o la

unch

ed a

med

ia c

ampa

ign

aim

ed a

t ra

ising

aw

aren

ess

of o

besit

y at

the

sam

e tim

e as

intr

oduc

ing

the

suga

ry d

rink

tax

and

new

fron

t-of

-pac

k la

bellin

g re

quire

men

ts, a

s w

ell a

s an

initi

ativ

e on

food

in s

choo

ls an

d in

crea

sing

acce

ss t

o dr

inki

ng w

ater

(25

).T

he P

ourin

g on

the

Pou

nds

publ

ic in

form

atio

n ca

mpa

ign

in N

ew Yo

rk C

ity r

an a

t th

e sa

me

time

as t

he e

xcise

tax

was

intr

oduc

ed o

n su

gary

drin

ks. A

35%

and

27%

dro

p in

the

nu

mbe

r of

adu

lts a

nd p

ublic

hig

h sc

hool

stu

dent

s re

spec

tivel

y ha

ving

one

of m

ore

suga

ry

drin

ks a

day

was

rep

orte

d (2

6).

9.2

Ensu

re s

usta

ined

impl

emen

tatio

n of

cam

paig

ns

and

mon

itor

thei

r im

pact

.C

ampa

igns

nee

d to

be

sust

aine

d in

ord

er t

o ha

ve a

long

-ter

m im

pact

.

Hea

lth s

ecto

r10

.1 E

nsur

e pr

ovisi

on o

f die

tary

cou

nsel

ling

on n

utrit

ion,

phy

sical

act

ivity

and

hea

lthy

wei

ght

gain

bef

ore

and

durin

g pr

egna

ncy

for

pros

pect

ive

mot

hers

and

fath

ers.

Seve

ral c

ount

ries

prov

ide

nutr

ition

al c

ouns

ellin

g to

pre

gnan

t w

omen

. T

hese

incl

ude,

for

exam

ple,

Fin

land

, whe

re n

utrit

ion

guid

ance

is p

rovi

ded

by p

ublic

hea

lth

nurs

es a

s pa

rt o

f ant

enat

al a

nd p

ostn

atal

car

e, a

nd M

exic

o, w

here

indi

vidu

al c

ouns

ellin

g is

prov

ided

to

preg

nant

wom

en a

nd m

othe

rs o

f chi

ldre

n un

der

five

year

s (1

32).

72


Ann

ex 3

. Exa

mpl

es o

f cou

ntry

exp

erie

nce

wit

h im

plem

enta

tion

of t

he p

ropo

sed

stra

tegi

c in

terv

enti

ons

Pri

orit

y ar

ea fo

r ac

tion

Prop

osed

str

ateg

ic in

terv

enti

ons

Exam

ples

of c

ount

ry e

xper

ienc

e of

impl

emen

tati

on

Hea

lth s

ecto

r

10.2

inte

grat

e sc

reen

ing

for

over

wei

ght

and

othe

r di

abet

es r

isk fa

ctor

s in

to p

rimar

y he

alth

car

e an

d pr

ovid

e pr

imar

y-ca

re b

ased

cou

nsel

ling

for

high

-risk

indi

vidu

als.

Cou

ntrie

s th

at h

ave

inte

grat

ed s

cree

ning

and

/or

coun

sellin

g fo

r hi

gh-r

isk in

divi

dual

s in

to

prim

ary

care

incl

ude

Braz

il, Fi

ji, So

uth

Afr

ica

and

Mal

aysia

(13

2).

Und

er B

razi

l’s U

nifie

d H

ealth

Sys

tem

hea

lth t

eam

s pr

omot

e he

alth

y ea

ting,

eval

uate

fo

od in

take

and

ant

hrop

omet

ry o

f ind

ivid

uals

and

prov

ide

nutr

ition

al c

ouns

ellin

g. T

he

gove

rnm

ent

prov

ides

man

uals

and

teac

hing

mat

eria

ls fo

r he

alth

pro

fess

iona

ls, a

s w

ell a

s pr

ovid

ing

fund

s fo

r th

is w

ork

(132

).U

nder

Qat

ar’s

natio

nal n

utrit

ion

and

phys

ical

act

ivity

act

ion

plan

, reg

ular

scr

eeni

ng o

f th

e po

pula

tion

in p

rimar

y he

alth

car

e ce

ntre

s w

as in

trod

uced

, alo

ng w

ith p

rovi

sion

of

coun

sellin

g fo

r hi

gh-r

isk g

roup

s (1

50).

10.3

Est

ablis

h or

str

engt

hen,

as

appr

opria

te, a

hi

gh-le

vel m

ultis

ecto

ral m

echa

nism

to

defin

e an

d ov

erse

e th

e im

plem

enta

tion

of fo

od a

nd

phys

ical

act

ivity

pol

icie

s fo

r th

e pr

even

tion

of

obes

ity a

nd d

iabe

tes.

Man

y co

untr

ies

have

est

ablis

hed

som

e ki

nd o

f cro

ss-g

over

nmen

t co

ordi

natio

n m

echa

nism

fo

r nu

triti

on a

nd/o

r no

ncom

mun

icab

le d

iseas

es (

NC

D)

prev

entio

n. L

eade

rshi

p at

the

hi

ghes

t le

vel i

s im

port

ant

to c

reat

e th

e ne

cess

ary

polit

ical

will.

In t

he P

acifi

c isl

and

stat

es, t

he P

acifi

c N

CD

Par

tner

ship

, whi

ch w

as s

et u

p to

enc

oura

ge a

m

ultis

ecto

ral a

ppro

ach,

has

hig

h le

vel p

oliti

cal p

artic

ipat

ion

with

the

invo

lvem

ent

of P

acifi

c Isl

and

Foru

m L

eade

rs a

nd M

inist

ers

of H

ealth

(13

2). B

razi

l’s N

atio

nal C

ounc

il of

Foo

d an

d N

utrit

ion

Secu

rity

(CO

NSE

A)

repo

rts

to t

he o

ffice

of t

he c

ount

ry’s

Pres

iden

t (1

32).

10.4

Est

ablis

h na

tiona

l tar

gets

for

obes

ity a

nd

diab

etes

, alo

ng w

ith S

MA

RT c

omm

itmen

ts

for

actio

n, a

nd w

ork

with

WH

O t

o de

velo

p an

d im

plem

ent

a m

onito

ring

fram

ewor

k fo

r re

port

ing

on p

rogr

ess.

The

Tun

isian

str

ateg

y fo

r pr

even

ting

and

tack

ling

obes

ity 2

013-

2017

set

s ou

t fiv

e pr

iorit

y ar

eas

and

88 s

peci

fic a

ctio

ns a

re d

etai

led.

For

eac

h ac

tion

the

body

res

pons

ible

(an

d pa

rtne

rs),

timet

able

, sou

rces

of i

nfor

mat

ion

and

mon

itorin

g in

dica

tors

are

defi

ned

(151

).

10.5

Impl

emen

t ev

iden

ce-b

ased

com

mun

ity-b

ased

in

terv

entio

ns, a

ddre

ssin

g bo

th h

ealth

y ea

ting

and

phys

ical

act

ivity

, com

prisi

ng d

iffer

ent

activ

ities

and

tar

getin

g hi

gh-r

isk g

roup

s, to

pr

omot

e an

d fa

cilit

ate

beha

viou

r ch

ange

and

pr

even

t ob

esity

and

dia

bete

s.

Som

e of

the

mos

t w

ell-k

now

n w

ork

in t

his

area

has

tak

en p

lace

in F

inla

nd, w

here

, fam

ously

, th

e N

orth

Kar

elia

pro

ject

red

uced

car

diov

ascu

lar

deat

hs. P

rogr

amm

es t

arge

ting

mid

dle-

aged

ove

rwei

ght

men

and

wom

en a

t hi

gher

risk

of d

iabe

tes

(ove

rwei

ght

with

impa

ired

gluc

ose

tole

ranc

e) p

rovi

ded

indi

vidu

al c

ouns

ellin

g an

d re

duce

d th

e ris

k of

dia

bete

s by

mor

e th

an 5

0% (

152)

.

73

Ann

ex 4

. Fe

asib

ility

con

side

rati

ons

for

impl

emen

ting

str

ateg

ic i

nter

vent

ions

in

10

prio

rity

are

as fo

r ac

tion

to

prev

ent

obes

ity

and

diab

etes

in t

he E

aste

rn

Med

iter

rane

an R

egio

n Pr

iori

ty a

rea

for

acti

onR

each

(ca

paci

ty t

o de

liver

an

inte

rven

tion

to

the

targ

et

popu

lati

on)

Tech

nica

l com

plex

ity

(e.g

. tec

hnol

ogie

s or

exp

erti

se n

eede

d)A

fford

abili

ty c

onsi

dera

tion

sC

ultu

ral a

ccep

tabi

lity

(soc

ial n

orm

s,

belie

fs)

Fisc

al m

easu

res:

Car

eful

us

e of

tax

es a

nd s

ubsid

ies

to p

rom

ote

heal

thie

r di

ets

Who

le p

opul

atio

n be

nefit

s fr

om a

ppro

pria

te fi

scal

pol

icie

s, w

ith a

gra

ded

soci

oeco

nom

ic

effe

ct (

bigg

er im

pact

on

poor

er

grou

ps).

Sele

ctiv

e ap

plic

atio

n of

fisc

al m

easu

res

to

help

the

poo

r re

quire

spe

cific

exp

ertis

e fr

om in

tern

atio

nal a

genc

ies,

e.g.

the

regi

onal

de

velo

pmen

t ba

nks.

Tech

nica

l sup

port

from

Reg

iona

l Offi

ce t

o he

lp c

ount

ries

impl

emen

t ta

xes.

For

taxe

s on

hig

h fa

t an

d/or

sug

ar fo

ods,

idea

lly c

ondu

ct m

odel

ling

exer

cise

s to

ca

refu

lly d

esig

n ap

prop

riate

tax

es t

o av

oid

unin

tend

ed e

ffect

s (e

.g. in

crea

sed

salt

inta

kes)

. Car

eful

ana

lyse

s ha

ve s

ugge

sted

a

simpl

er a

ppro

ach

is to

use

a c

omm

odity

ap

proa

ch, i.

e. o

n th

e ve

geta

ble

oils

and

fats

or

tot

al fr

ee s

ugar

inpu

t to

the

indu

stry

, ra

ther

tha

n a

reta

il pr

oduc

t ba

sis w

hich

is

mor

e co

mpl

icat

ed in

cou

ntrie

s w

ithou

t ex

istin

g sa

les

taxe

s.Te

chni

cal s

uppo

rt fr

om t

he R

egio

nal O

ffice

to

ada

pt t

he n

utrie

nt p

rofil

e m

odel

to

use

for

taxe

s.

App

ropr

iate

tax

es c

an g

ener

ate

reve

nue

and

prov

ide

grea

ter

flexi

bilit

y fo

r ot

her

gove

rnm

ent

spen

ding

.R

emov

ing

exist

ing

subs

idie

s on

fats

/oi

ls an

d su

gars

can

rem

ove

a m

ajor

bu

rden

on

natio

nal fi

nanc

es. S

ome

of t

he fi

nanc

ial g

ain

to g

over

nmen

t fin

ance

s ca

n be

sel

ectiv

ely

used

for

targ

etin

g th

roug

h ca

sh t

rans

fers

an

d ot

her

sche

mes

, e.g

. vou

cher

s fo

r po

orer

sec

tions

of t

he

com

mun

ity a

s al

read

y pr

opos

ed

by d

evel

opm

ent

bank

ana

lyse

s fo

r so

me

coun

trie

s in

the

Reg

ion.

Polit

ical

and

soc

ial a

ccep

tanc

e ca

n be

incr

ease

d by

pub

lic c

omm

itmen

t to

allo

cate

som

e of

the

tax

rev

enue

to

sup

port

hea

lth p

rom

otio

n/he

alth

se

rvic

es.

The

con

cept

of t

axat

ion

for

heal

th

purp

oses

is a

lread

y w

ell a

ccep

ted.

Som

e ta

xes

on s

ugar

-sw

eete

ned

beve

rage

ar

e al

read

y in

pla

ce, b

ut a

t lo

w le

vels.

C

onsid

er in

crea

sing

taxe

s pr

ogre

ssiv

ely

as

with

tob

acco

tax

.R

emov

al o

f foo

d su

bsid

ies

need

s ca

refu

l han

dlin

g po

litic

ally.

Pha

sed

impl

emen

tatio

n m

ay b

e ne

eded

and

m

easu

res

to m

itiga

te t

he im

pact

on

low

er

soci

oeco

nom

ic g

roup

s by

rep

laci

ng w

ith

appr

opria

te c

ash

tran

sfer

s.

Annex 4

74


Ann

ex 4

. Fe

asib

ility

con

side

rati

ons

for

impl

emen

ting

str

ateg

ic i

nter

vent

ions

in

10

prio

rity

are

as fo

r ac

tion

to

prev

ent

obes

ity

and

diab

etes

in t

he E

aste

rn

Med

iter

rane

an R

egio

n Pr

iori

ty a

rea

for

acti

onR

each

(ca

paci

ty t

o de

liver

an

inte

rven

tion

to

the

targ

et

popu

lati

on)

Tech

nica

l com

plex

ity

(e.g

. tec

hnol

ogie

s or

exp

erti

se n

eede

d)A

fford

abili

ty c

onsi

dera

tion

sC

ultu

ral a

ccep

tabi

lity

(soc

ial n

orm

s,

belie

fs)

Publ

ic p

rocu

rem

ent:

Proc

urem

ent

and

prov

ision

of h

ealth

y fo

od

in p

ublic

inst

itutio

ns (

e.g.

sc

hool

s, un

iver

sitie

s, ho

spita

ls, m

ilitar

y, pr

isons

, ot

her

gove

rnm

ent

inst

itutio

ns)

Rea

ch is

con

sider

able

, but

will

depe

nd o

n pr

opor

tion

of m

eals

eate

n in

pub

lic s

ecto

r fa

cilit

ies.

Will

requ

ire c

apac

ity b

uild

ing

of t

hose

in

volv

ed in

pro

cure

men

t an

d ca

terin

g.

Ass

essm

ents

of b

udge

t im

plic

atio

ns w

ill be

req

uire

d, a

long

with

adv

ice

on t

he

prep

arat

ion

of n

utrit

iona

lly a

ppro

pria

te

mea

ls w

ithou

t su

bsta

ntia

l cos

t in

crea

ses.

The

re h

ave

been

con

cern

s th

at im

plem

entin

g he

alth

y fo

od

proc

urem

ent

or n

utrit

ion

stan

dard

s m

ight

incr

ease

the

cos

ts o

f pub

lic

sect

or fo

od, w

heth

er b

ecau

se

of h

ighe

r co

sts

of fr

esh

and/

or

who

le fo

ods

or a

nee

d fo

r m

ore

equi

pmen

t an

d/or

mor

e sk

illed

staf

f. Ef

fect

ive

stra

tegi

es t

o m

inim

ize

the

inve

stm

ent

need

ed in

clud

e (a

) co

llabo

ratio

n w

ith fo

od

who

lesa

lers

, man

ufac

ture

rs a

nd

cate

rers

to

impr

ove

the

nutr

ition

al

qual

ity o

f pro

duct

s, (b

) pa

rtne

rshi

ps

betw

een

publ

ic in

stitu

tions

to

harn

ess

thei

r co

llect

ive

barg

aini

ng

pow

er a

nd (

c) r

igor

ous

over

sight

of

con

trac

t ca

tere

rs’ c

harg

es

(42,

46,4

7).

Emph

asis

on r

educ

ing

the

use

of o

ils a

nd s

ugar

s (in

add

ition

to

switc

hing

typ

es o

f oil

used

) sh

ould

le

ad t

o co

st s

avin

gs.

The

se m

easu

res

will

crea

te n

ew

dem

and

for

heal

thy

food

s an

d w

ill,

with

the

ir in

crea

sed

scal

e, o

ften

resu

lt in

pric

e re

duct

ions

.

Dra

mat

ic c

hang

es in

soc

ieta

l foo

d pa

tter

ns h

ave

occu

rred

thr

ough

out

the

Reg

ion

over

the

pas

t 10

–20

year

s. Ye

t re

sista

nce

to t

hese

pro

pose

d ch

ange

s is

likel

y un

less

acc

ompa

nied

by

a cl

ear

publ

ic a

war

enes

s ca

mpa

ign

to e

xpla

in

the

impo

rtan

ce o

f the

se m

easu

res

for

redu

cing

the

risk

of d

iabe

tes

and

obes

ity.

The

re is

pot

entia

l for

coh

eren

ce w

ith

sust

aina

bilit

y an

d ec

onom

ic o

bjec

tives

. T

his

will

depe

nd o

n th

e pa

rtic

ular

food

en

viro

nmen

t/co

ntex

t.Pu

blic

-fund

ed fo

od is

ofte

n a

sour

ce o

f pr

ofit

for

cate

ring

cont

ract

ors,

who

may

sh

ow r

esist

ance

to

chan

ge e

spec

ially

if

ther

e is

a pe

rcei

ved

thre

at t

o pr

ofit

mar

gins

. How

ever

, alte

rnat

ive

cate

ring

sour

ces

shou

ld b

e co

nsid

ered

as

wel

l as

, in s

ome

coun

trie

s, th

e po

ssib

ility

of s

ettin

g up

sel

ectiv

e in

itiat

ives

to

purc

hase

food

s fr

om lo

cal f

arm

ers.

The

re

is su

bsta

ntia

l int

erna

tiona

l exp

erie

nce

that

thi

s ca

n be

ver

y ef

fect

ive

and

lead

to

com

mun

ity e

ngag

emen

t, w

ith

loca

l far

mer

s pr

ofitin

g fr

om t

hese

de

velo

pmen

ts.

75

Annex 4

Ann

ex 4

. Fe

asib

ility

con

side

rati

ons

for

impl

emen

ting

str

ateg

ic i

nter

vent

ions

in

10

prio

rity

are

as fo

r ac

tion

to

prev

ent

obes

ity

and

diab

etes

in t

he E

aste

rn

Med

iter

rane

an R

egio

n Pr

iori

ty a

rea

for

acti

onR

each

(ca

paci

ty t

o de

liver

an

inte

rven

tion

to

the

targ

et

popu

lati

on)

Tech

nica

l com

plex

ity

(e.g

. tec

hnol

ogie

s or

exp

erti

se n

eede

d)A

fford

abili

ty c

onsi

dera

tion

sC

ultu

ral a

ccep

tabi

lity

(soc

ial n

orm

s,

belie

fs)

Phys

ical

act

ivity

: Im

plem

ent

polic

ies,

legi

slatio

n an

d in

terv

entio

ns t

o pr

omot

e an

d fa

cilit

ate

heal

th

enha

ncin

g ph

ysic

al a

ctiv

ity

The

re is

pot

entia

l to

reac

h th

e w

hole

pop

ulat

ion,

par

ticul

arly

th

roug

h in

terv

entio

ns o

n ur

ban

plan

ning

and

impr

ovin

g ac

cess

to

phys

ical

act

ivity

opp

ortu

nitie

s.

Polic

y ex

pert

ise in

diff

eren

t ar

eas

will

be

need

ed, s

uch

as e

duca

tion,

urb

an p

lann

ing,

co

mm

unity

org

aniz

atio

n an

d sp

ort.

Som

e of

the

inte

rven

tions

m

ay r

equi

re c

apita

l inv

estm

ent

(par

ticul

arly

in r

elat

ion

to t

rans

port

an

d ur

ban

plan

ning

) an

d w

ill ta

ke

time

to e

nact

, but

the

res

ultin

g im

pact

sho

uld

be s

usta

inab

le

and

the

bene

fits

long

-last

ing.

In

addi

tion,

the

ben

efits

are

like

ly t

o ex

tend

wel

l bey

ond

obes

ity a

nd

diab

etes

pre

vent

ion.

Tra

nspo

rt a

nd

plan

ning

pol

icie

s m

ay g

ener

ate

envi

ronm

enta

l ben

efits

, incl

udin

g im

prov

ing

heal

th o

utco

mes

thr

ough

cl

eane

r ai

r. Ph

ysic

al e

duca

tion

and

scho

ol-b

ased

inte

rven

tions

may

re

ap b

road

er s

ocia

l and

aca

dem

ic

rew

ards

(50

).

Car

eful

des

ign

of in

terv

entio

ns is

nee

ded

to e

nsur

e th

at t

hey

faci

litat

e in

crea

sed

phys

ical

act

ivity

for

all. S

pace

s an

d fa

cilit

ies

that

are

saf

e an

d ap

prop

riate

for

wom

en

are

esse

ntia

l. Fac

ilitie

s an

d pr

ogra

mm

es

shou

ld a

lso a

ddre

ss t

he s

peci

fic n

eeds

of

peop

le w

ith d

isabi

litie

s.T

he p

oten

tial s

yner

gies

with

en

viro

nmen

tal a

nd s

usta

inab

ility

obje

ctiv

es s

houl

d be

em

phas

ised

in o

rder

to

bui

ld p

ublic

sup

port

.

76


Ann

ex 4

. Fe

asib

ility

con

side

rati

ons

for

impl

emen

ting

str

ateg

ic i

nter

vent

ions

in

10

prio

rity

are

as fo

r ac

tion

to

prev

ent

obes

ity

and

diab

etes

in t

he E

aste

rn

Med

iter

rane

an R

egio

n Pr

iori

ty a

rea

for

acti

onR

each

(ca

paci

ty t

o de

liver

an

inte

rven

tion

to

the

targ

et

popu

lati

on)

Tech

nica

l com

plex

ity

(e.g

. tec

hnol

ogie

s or

exp

erti

se n

eede

d)A

fford

abili

ty c

onsi

dera

tion

sC

ultu

ral a

ccep

tabi

lity

(soc

ial n

orm

s,

belie

fs)

Food

sup

ply

and

trad

e:

Use

food

sta

ndar

ds, le

gal

inst

rum

ents

and

oth

er

appr

oach

es t

o im

prov

e th

e na

tiona

l and

/or

loca

l fo

od s

uppl

y in

thi

s R

egio

n of

net

food

-impo

rtin

g co

untr

ies

Any

tra

de m

easu

res

have

po

tent

ial f

or u

nive

rsal

rea

ch

if im

port

ed fo

ods

mak

e up

a

subs

tant

ial p

ropo

rtio

n of

the

na

tiona

l foo

d su

pply.

City

- or

mun

icip

ality

-bas

ed

inte

rven

tions

cou

ld r

each

a

subs

tant

ial p

ropo

rtio

n of

the

po

pula

tion

in t

hese

loca

litie

s.

Inte

rnat

iona

l tra

de a

nd le

gal e

xper

tise

is re

quire

d to

des

ign

appr

opria

te t

ools,

w

ithin

the

con

stra

ints

of c

urre

nt W

orld

Tr

ade

Org

aniz

atio

n (W

TO)

and

othe

r tr

ade

agre

emen

ts, t

o re

duce

the

vol

ume

of im

port

s of

fats

and

sug

ars.

The

det

aile

d ca

se o

f the

mag

nitu

de o

f the

obe

sity

and

diab

etes

pro

blem

in t

he R

egio

n m

ay n

eed

to b

e m

ade

for

a pu

blic

hea

lth e

xem

ptio

n to

just

ify t

hese

mea

sure

s w

ithin

WTO

rul

es

(invo

king

the

SPS

sub

-cla

uses

). H

owev

er if

re

stric

tions

are

not

disc

rimin

ator

y be

caus

e do

mes

tic s

uppl

y an

d im

port

s ar

e bo

th

rest

ricte

d, t

hen

appl

ying

con

siste

ncy

to

dom

estic

food

sup

ply

as w

ell a

s im

port

s is

legi

timat

e an

d m

inim

izes

disp

utes

with

in a

W

TO c

onte

xt.

As

part

of a

pac

kage

with

ref

orm

ulat

ion

effo

rts,

tech

nica

l exp

ertis

e w

ill be

pro

vide

d to

the

food

indu

stry

to

cut

the

leve

ls of

fa

ts/s

ugar

s an

d/or

rep

lace

with

hea

lthie

r in

gred

ient

s (f

ruit

and

vege

tabl

es, p

ulse

s, co

mpl

ex c

arbo

hydr

ates

).

Thi

s w

ill de

pend

on

the

prec

ise

inst

rum

ents

use

d. Im

port

dut

ies

will

gene

rate

pub

lic r

even

ue, w

hile

tr

ade

rest

rictio

ns w

ill no

t.

Phas

ed r

educ

tions

, sup

port

ed w

ith

advo

cacy

, will

help

with

pub

lic a

ccep

tanc

e an

d in

dust

rial a

dapt

atio

n. L

ocal

food

in

itiat

ives

can

com

bine

hea

lth, e

cono

mic

an

d su

stai

nabi

lity

obje

ctiv

es, w

hich

ca

n he

lp t

o ge

nera

te a

bro

ad b

ase

of

supp

ort.

Ref

orm

ulat

ion:

Impl

emen

t a

gove

rnm

ent-

led

prog

ram

me

of p

rogr

essiv

e re

form

ulat

ion,

ada

pted

to

the

nat

iona

l con

text

, to

elim

inat

e tr

ans

fats

an

d re

duce

pro

gres

sivel

y to

tal a

nd s

atur

ated

fat,

salt,

sug

ars,

ener

gy a

nd

port

ion

size.

Rea

ch d

epen

ds o

n th

e sp

ecifi

cs

of t

he n

atio

nal f

ood

supp

ly, i.

e.

how

and

whe

re t

he in

gred

ient

s/nu

trie

nts

ente

r fo

od (

impo

rts,

loca

l pro

duct

ion

or in

the

ho

me)

.

Tech

nica

l sup

port

/exp

ertis

e w

ill be

nee

ded

to c

ondu

ct in

itial

ana

lyse

s to

des

ign

a re

form

ulat

ion

prog

ram

me

appr

opria

te t

o th

e na

tiona

l foo

d en

viro

nmen

t. A

det

aile

d un

ders

tand

ing

of t

he n

atio

nal f

ood

chai

n is

requ

ired

to d

esig

n an

effe

ctiv

e pr

ogra

mm

e.Fo

od p

rodu

cers

/pro

vide

rs w

ill re

quire

te

chni

cal s

uppo

rt t

o m

ake

the

chan

ges.

Phas

ed a

nd p

rogr

essiv

e nu

trie

nt/

ingr

edie

nt c

hang

es a

re w

ell t

oler

ated

, pr

ovid

ed t

hat

they

are

uni

vers

ally

app

lied

acro

ss fo

od c

ateg

orie

s. N

on-

com

plia

nt

com

pani

es c

an li

mit

the

effe

ctiv

enes

s of

na

tiona

l mea

sure

s. T

hese

des

ired

chan

ges

are

ther

efor

e be

st m

anda

ted

as s

tand

ards

th

at a

re c

hang

ed e

very

1–2

yea

rs a

s th

e lim

its o

n th

e un

desir

able

nut

rient

s/in

gred

ient

s ar

e re

duce

d pr

ogre

ssiv

ely.

77

Annex 4

Ann

ex 4

. Fe

asib

ility

con

side

rati

ons

for

impl

emen

ting

str

ateg

ic i

nter

vent

ions

in

10

prio

rity

are

as fo

r ac

tion

to

prev

ent

obes

ity

and

diab

etes

in t

he E

aste

rn

Med

iter

rane

an R

egio

n Pr

iori

ty a

rea

for

acti

onR

each

(ca

paci

ty t

o de

liver

an

inte

rven

tion

to

the

targ

et

popu

lati

on)

Tech

nica

l com

plex

ity

(e.g

. tec

hnol

ogie

s or

exp

erti

se n

eede

d)A

fford

abili

ty c

onsi

dera

tion

sC

ultu

ral a

ccep

tabi

lity

(soc

ial n

orm

s,

belie

fs)

Mar

ketin

g: Im

plem

ent

appr

opria

te r

estr

ictio

ns

on m

arke

ting

(incl

udin

g pr

ice

prom

otio

ns)

of

food

s hi

gh in

fat,

suga

r an

d sa

lt.

A c

ompr

ehen

sive

appr

oach

(m

edia

, aud

ienc

e, t

ype

of

mar

ketin

g) is

req

uire

d to

hav

e su

bsta

ntia

l im

pact

.T

here

is p

oten

tial t

o re

ach

a la

rge

prop

ortio

n of

the

reg

iona

l po

pula

tion

give

n th

e do

min

ance

of

cro

ss-b

orde

r m

edia

.T

here

is p

oten

tial f

or t

otal

co

vera

ge if

res

tric

tions

are

ex

tend

ed t

o m

arke

ting

to t

he

who

le p

opul

atio

n (a

s is

curr

ently

do

ne in

one

cou

ntry

in t

he

Reg

ion)

. In

view

of t

he R

egio

n’s

youn

g po

pula

tion

and

the

maj

or

heal

th a

nd s

ocie

tal c

osts

of

obes

ity, d

iabe

tes

and

the

othe

r N

CD

s in

adu

lts, t

here

is m

erit

in r

estr

ictin

g m

arke

ting

of fo

ods

high

in fa

t or

sal

t or

sug

ar fo

r th

e w

hole

of s

ocie

ty.

Ado

ptio

n of

the

reg

iona

l nu

trie

nt p

rofil

e m

odel

ens

ures

w

ides

prea

d ap

plic

atio

n of

re

stric

tions

to

unhe

alth

y fo

ods.

Onl

y re

gula

tory

mea

sure

s to

re

stric

t pr

ice

prom

otio

ns o

n hi

gh fa

t/su

gar

food

s w

ill pe

rmit

com

plet

e co

vera

ge, p

artic

ular

ly

in p

oore

r ar

eas.

Mea

sure

s fo

r m

onito

ring

and

enfo

rcem

ent

are

an im

port

ant

chal

leng

e fo

r th

e R

egio

n.

Spec

ialis

t le

gal a

nd m

edia

exp

ertis

e is

requ

ired

from

the

beg

inni

ng o

f the

le

gisla

tive

proc

ess.

Giv

en t

he c

onsis

tent

Reg

ion-

wid

e co

nseq

uenc

es o

f the

se is

sues

, a h

uman

rig

hts-

base

d ap

proa

ch t

o re

gula

tion

in

this

area

sho

uld

be t

aken

, suc

h th

at a

ctio

n is

unde

rsto

od a

s ne

cess

ary

to p

rom

ote,

re

spec

t an

d fu

lfil t

he r

ight

to

heal

th in

the

R

egio

n, e

spec

ially

the

chi

ld’s

right

to

heal

th.

The

lega

l bas

is is

the

com

mon

obl

igat

ions

of

tho

se c

ount

ries

in t

he R

egio

n th

at a

re

stat

e pa

rtie

s to

the

Inte

rnat

iona

l Cov

enan

t on

Eco

nom

ic, S

ocia

l and

Cul

tura

l Rig

hts.

On

this

hum

an r

ight

s un

ders

tand

ing,

the

UN

Gui

ding

Prin

cipl

es o

n Bu

sines

s an

d H

uman

Rig

hts,

and

the

Maa

stric

ht P

rinci

ples

on

the

Ext

rate

rrito

rial O

blig

atio

ns o

f St

ates

in t

he A

rea

of E

cono

mic

, Soc

ial a

nd

Cul

tura

l Rig

hts

prov

ide

guid

elin

es o

n ho

w

to d

eal w

ith t

he c

ompl

ex c

ross

-bor

der

issue

s in

volv

ed in

suc

cess

fully

res

tric

ting

inap

prop

riate

mar

ketin

g ac

ross

the

Reg

ion.

Cou

ntry

-spe

cific

ana

lyse

s on

the

de

mog

raph

ic p

rofil

e an

d m

arke

ting

expo

sure

of c

hild

ren

and

adol

esce

nts

are

need

ed.

Tech

nica

l sup

port

from

the

Reg

iona

l Offi

ce

may

be

need

ed t

o im

plem

ent

the

nutr

ient

pr

ofile

mod

el a

nd t

o ad

apt

it fo

r va

rious

us

es.

Prim

ary

cost

s fo

r go

vern

men

t im

plem

enta

tion

are

mod

est.

The

re a

re m

ajor

impl

icat

ions

for

med

ia

and

othe

r or

gani

zatio

ns d

epen

dent

on

the

curr

ent

inte

nsiv

e m

arke

ting

of fo

ods

high

in fa

t or

sal

t or

sug

ar; t

his

requ

ires

maj

or h

igh-

leve

l pol

itica

l com

mitm

ent

and

sust

aine

d ad

voca

cy.

A p

relim

inar

y st

udy

to d

ocum

ent

the

exte

nt a

nd n

atur

e of

pric

e pr

omot

ions

in

the

Reg

ion

wou

ld b

e he

lpfu

l to

build

po

litic

al a

ccep

tabi

lity.

Prio

r aw

aren

ess-

raisi

ng c

ampa

igns

to

enh

ance

pub

lic u

nder

stan

ding

of

the

harm

ful e

ffect

s of

cur

rent

pric

e pr

omot

ions

on

food

s hi

gh in

fat

or s

alt

or

suga

r w

ill pr

obab

ly b

e ne

eded

to

impr

ove

the

publ

ic a

nd p

oliti

cal a

ccep

tabi

lity

of

thes

e ch

ange

s.

78


Ann

ex 4

. Fe

asib

ility

con

side

rati

ons

for

impl

emen

ting

str

ateg

ic i

nter

vent

ions

in

10

prio

rity

are

as fo

r ac

tion

to

prev

ent

obes

ity

and

diab

etes

in t

he E

aste

rn

Med

iter

rane

an R

egio

n Pr

iori

ty a

rea

for

acti

onR

each

(ca

paci

ty t

o de

liver

an

inte

rven

tion

to

the

targ

et

popu

lati

on)

Tech

nica

l com

plex

ity

(e.g

. tec

hnol

ogie

s or

exp

erti

se n

eede

d)A

fford

abili

ty c

onsi

dera

tion

sC

ultu

ral a

ccep

tabi

lity

(soc

ial n

orm

s,

belie

fs)

Labe

lling:

Impl

emen

t or

rev

ise s

tand

ards

for

nutr

ition

labe

lling

to

incl

ude

fron

t-of

-pac

k la

bellin

g fo

r al

l pre

-pa

ckag

ed fo

ods

The

rea

ch o

f the

pro

gram

me

will

be v

ery

depe

nden

t on

the

pr

opor

tion

of n

atio

nal d

iet

deriv

ed fr

om p

re-p

acka

ged

food

.

The

food

indu

stry

will

requ

ire t

echn

ical

su

ppor

t to

impl

emen

t th

e st

anda

rds.

Phas

ed im

plem

enta

tion

(e.g

. ove

r a

two-

year

per

iod)

to

min

imize

the

co

sts

to in

dust

ry w

ill be

impo

rtan

t.In

vest

men

t in

tra

inin

g of

sta

ff in

volv

ed in

reg

ulat

ion

and

insp

ectio

n of

food

s w

ill be

nee

ded.

The

gro

win

g ac

cept

ance

of h

ealth

m

essa

ges

and

rapi

d ex

pans

ion

of a

cces

s to

diff

eren

t fo

rms

of m

edia

pre

sent

an

oppo

rtun

ity t

o co

mm

unic

ate

mes

sage

s to

ac

com

pany

and

exp

lain

labe

lling.

Brea

stfe

edin

g: Im

plem

ent

a pa

ckag

e of

pol

icie

s an

d in

terv

entio

ns t

o pr

omot

e,

prot

ect

and

supp

ort

brea

stfe

edin

g

Full

capa

city

can

be

reac

hed

in

polit

ical

ly s

tabl

e co

ntex

ts.

(All

effo

rts

to p

rom

ote

prot

ect

and

supp

ort

brea

stfe

edin

g sh

ould

also

be

mad

e in

con

flict

sit

uatio

ns.)

Lega

l exp

ertis

e is

need

ed t

o im

plem

ent

the

Inte

rnat

iona

l Cod

e, t

he G

uida

nce

and

mat

erni

ty le

gisla

tion.

Cap

acity

to

mon

itor

and

enfo

rce

legi

slatio

n is

cruc

ial.

Publ

ic a

nd p

rivat

e se

ctor

(em

ploy

er)

enga

gem

ent

is re

quire

d to

intr

oduc

e m

ater

nity

pro

tect

ion

for

wom

en.

Subs

tant

ial i

nves

tmen

t is

requ

ired

part

icul

arly

for

mat

erni

ty

prot

ectio

n, d

epen

ding

on

the

prop

ortio

n of

wom

en w

orki

ng in

th

e fo

rmal

sec

tor.

Neg

ativ

e at

titud

es t

o br

east

feed

ing

amon

g yo

ung

wom

en, e

spec

ially

in

high

-inco

me

coun

trie

s, ne

ed t

o be

tr

ansf

orm

ed.

The

re is

gro

win

g cu

ltura

l acc

epta

nce

of t

he n

eed

for

paid

mat

erni

ty le

ave

alre

ady

in e

vide

nce

in t

he R

egio

n an

d on

e co

untr

y (M

oroc

co)

has

ratifi

ed t

he

rele

vant

ILO

Con

vent

ion

(ILO

Mat

erni

ty

Prot

ectio

n C

onve

ntio

n 20

00, N

o 18

3).

Mas

s M

edia

Cam

paig

n:

Mas

s m

edia

cam

paig

ns o

n he

alth

y di

et a

nd p

hysic

al

activ

ity.

The

ext

ent

of r

each

dep

ends

on

the

desig

n of

cam

paig

ns, w

hich

ne

ed t

o be

tar

gete

d an

d ad

apte

d fo

r di

ffere

nt a

udie

nces

.

Expe

rt u

nder

stan

ding

of s

ocie

tal a

ttitu

des

and

com

mun

icat

ion

tech

niqu

es is

req

uire

d.D

etai

led

eval

uatio

n an

d m

essa

ge a

dapt

atio

n ar

e fr

eque

ntly

req

uire

d to

sus

tain

cam

paig

ns

Maj

or r

epea

ted

annu

al

com

mitm

ent

is ne

cess

ary

to

coun

ter

perv

asiv

e in

dust

rial

mar

ketin

g in

the

Reg

ion.

Cam

paig

ns m

ust

be c

ultu

rally

app

ropr

iate

in

ord

er t

o be

effe

ctiv

e.

Hea

lth S

ecto

r Act

ion:

H

arne

ss t

he h

ealth

sec

tor

to e

nabl

e ch

ange

and

to

pro

vide

lead

ersh

ip

on g

over

nanc

e an

d ac

coun

tabi

lity

The

re is

pot

entia

l to

reac

h fu

ture

ge

nera

tions

thr

ough

cou

nsel

ling

to p

rosp

ectiv

e pa

rent

s; pr

imar

y-ca

re b

ased

cou

nsel

ling

and

com

mun

ity-b

ased

inte

rven

tions

w

ould

be

mor

e ta

rget

ed a

t hi

gh-

risk

grou

ps.

The

effe

ctiv

enes

s an

d th

e co

st–e

ffect

iven

ess

of t

he h

ealth

-ser

vice

bas

ed in

terv

entio

ns

(ant

enat

al c

ouns

ellin

g, pr

imar

y-ca

re b

ased

co

unse

lling

and

scre

enin

g) w

ill de

pend

on

exte

nt a

nd e

ase

of a

cces

s to

prim

ary

care

. Sp

ecifi

c tr

aini

ng o

f hea

lth p

rofe

ssio

nals

will

also

be

requ

ired.

The

affo

rdab

ility

of t

he h

ealth

-se

rvic

e re

late

d in

terv

entio

ns is

al

so r

elat

ed t

o th

e cu

rren

t st

ate

of

prim

ary

care

pro

visio

n an

d he

alth

sy

stem

fina

ncin

g.

Mul

tisec

tora

l coo

rdin

atio

n an

d ac

coun

tabi

lity

are

heav

ily d

epen

dent

on

succ

essf

ully

con

vinc

ing

polic

y-m

aker

s ou

tsid

e th

e he

alth

dom

ain

that

the

ir po

licy

area

s ar

e im

port

ant

for

heal

th a

nd

that

thi

s w

ill tr

ansla

te t

o br

oade

r so

cial

an

d ec

onom

ic g

ains

.

There is an alarming and escalating burden of overweight, obesity and diabetes in the Eastern Mediterranean Region, closely linked to changing dietary patterns. Obesity and the most common type of diabetes are largely preventable and urgent action is needed to reduce exposure to their causal factors, such as unhealthy diet and physical inactivity. This document takes into account the recommendations of several recent initiatives on the prevention of obesity and diabetes and identifies priorities for an approach to reduce exposure to unhealthy dietary risk factors. It presents an initial proposal for 10 priority areas for action, which cover 37 strategic interventions to help prevent overweight, obesity and diabetes in the whole population, including children, adolescents and adults.