As the WHO South-East Asia Region enters the era of the Sustainable Development Goals with remarkable Strategic Action Plan to reduce the social and economic development in all Member States, the nutrition status of the population, however, double burden of has not kept pace with development in other sectors. Large segments of the population continue to suffer from malnutrition. An ongoing transition is reshaping malnutrition the nutrition profile across all countries where undernutrition predominated previously. While in the South-East Asia Region undernutrition rates, including micronutrient malnutrition, are declining, albeit slowly, a significant rise in overweight and obesity – the double burden– is 2016–2025 seen across many age groups. There is also an associated rapid upsurge in noncommunicable diseases. The key challenge in the Region is to ensure that interventions for undernutrition remain in focus and are scaled up, while addressing overweight and obesity.
The Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016–2025 aims to provide guidance to Member States on comprehensive approaches to prevent malnutrition. This plan will serve Member States as an advocacy and reference tool to ensure that interventions covering all forms of malnutrition are addressed comprehensively in country policies, strategies and actions.
ISBN 978-92-9022-543-0
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Strategic Action Plan to reduce the double burden of malnutrition in the South-East Asia Region 2016–2025 WHO Library Cataloguing-in-Publication data
World Health Organization, Regional Office for South-East Asia.
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region 2016-2025.
1. Malnutrition - statistics and numerical data. 2. Social Planning. 3. Health Promotion.
ISBN 978-92-9022-543-0 (NLM classification: QU 145)
© World Health Organization 2016 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications – wheth- er for sale or for noncommercial distribution – can be obtained from Publishing and Sales, World Health Organization, Regional Office for South- East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concern- ing the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the infor- mation contained in this publication. However, the published material is being distributed with- out warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in India Contents
Abbreviations...... v
Foreword...... vii
Executive summary...... ix
1. Introduction...... 1 1.1 The double burden of malnutrition...... 1 1.2 Suboptimal diets and energy imbalance...... 2 1.3 Consequences of malnutrition...... 2 1.4 Addressing determinants of the double burden of malnutrition...... 3 1.5 Nutrition challenges to overcome...... 4
2. Profile of nutritional status in the WHO South-East Asia Region...... 5 2.1 Nutritional status of children aged 0–5 years,...... 6 2.2 Nutritional status of adolescents...... 9 2.3 Nutritional status of adults...... 9 2.4 Nutrition in older persons ...... 10 2.5 Micronutrient deficiencies in the South-East Asia Region...... 11 2.6 Diets in South-East Asia...... 12
3. The Strategic Framework and Action Plan ...... 15 3.1 Goal...... 15 3.2 Objectives...... 15 3.3 Scope and purpose...... 15 3.4 Global nutrition targets and diet-related NCD targets...... 16 3.5 Policy context...... 18
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 iii 3.6 Time frame...... 18 3.7 Monitoring and evaluation...... 18 3.8 Guiding principles...... 18 3.9 Role of WHO...... 18
4. The Action Plan ...... 21
5. References...... 27
Annexes
1. Evidence-based interventions to reduce the double burden of malnutrition...... 29
2. Supporting global and regional resolutions/mandates and content analysis of technical areas covered...... 35
3. Regional monitoring framework for policy, capacity and legislative indicators (to be assessed in 2016 (baseline), 2021 (mid-term) and 2025 (end term))...... 39
4. Mapping of strategic directions and policy actions and linkages to the global nutrition and diet-related NCD targets (where specified, indicators from the WHO Global Monitoring Framework have been used)...... 41
5. Examples of sector(s) key policies and interventions...... 63
6. Resolution of the WHO Regional Committee for South-East Asia...... 65 Abbreviations
BMI body mass index BMS Breast milk substitutes CIP Comprehensive Implementation Plan DHS Demographic and Health Survey eLENA Electronic Library of Evidence for Nutrition Actions FAO Food and Agriculture Organization GDP gross domestic product GHI Global Hunger Index GNP gross national product HDI Human Development Index ICN 2 Second International Conference on Nutrition IDD iodine deficiency disorder USI universal salt iodization IYCF infant and young child feeding practices IMR infant mortality rate LBW low birth weight MICS Multiple Indicator Cluster Survey MDG Millennium Development Goal NCD noncommunicable diseases REACH renewed efforts against child hunger and undernutrition SAM severe acute malnutrition SD standard deviation SEAR South-East Asia Region SUN scaling up nutrition SDG Sustainable Development Goal
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 v U5MR under-five mortality rate UNICEF United Nations Children’s Fund WASH water, sanitation and hygiene WHA World Health Assembly WHO World Health Organization WIFS weekly iron and folate supplementation IDA iron deficiency anaemia IEC information, education and communication IFA iron folic acid IYCF infant and young children feeding LMICs low and middle-income countries
vi Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Foreword
The past two decades have seen Member States of the WHO South-East Asia Region make impressive gains in public health. Maternal and child morbidity and mortality rates in the Region have shown remarkable improvement. Hunger and food insecurity have declined and most countries are averaging high economic growth rates. However, malnutrition continues to persist across countries. Undernutrition rates have been slow to reduce while overweight and obesity rates continue to rise rapidly, increasing the burden of noncommunicable diseases and preventing people from reaching their full potential.
For a region that has focused on maternal and child undernutrition in the past three decades or more, the transition in the epidemiology of nutrition and the emergence of a double burden of malnutrition is challenging. Our health systems are geared towards fighting persistent undernutrition, but will now need to curb the rising rates of overweight and obesity if they are to reduce noncommunicable diseases (NCDs).
In 2015, all 11 WHO SEAR Member States, along with 183 Member States across the world, adopted the 2030 Agenda for Sustainable Development. Nutrition is an enabler for many of the Sustainable Development Goals, including those on health, education, water and sanitation, poverty and women’s empowerment. In order to support the Region’s commitments to improving nutrition, the WHO South- East Asia Region has developed the Strategic Action Plan to reduce the double burden of malnutrition, 2016–2025. The plan is timely, comes at the start of the United Nations Decade of Action on Nutrition, and advocates Member States to simultaneously focus on actions to reduce both undernutrition and overweight and obesity.
Interventions to prevent malnutrition need to start from the prenatal period and a special focus is needed towards children and adolescents to achieve positive and sustainable changes. Policy-makers also need to act decisively to counter the current obesogenic environment which perpetuates unhealthy dietary practices and a sedentary lifestyle. For such interventions to be successful, the policy setting around nutrition needs to be enhanced and this action plan provides the necessary guidance to do so.
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 vii The WHO Regional Committee for South-East Asia, at its Sixty–ninth Session in Colombo in September 2016, endorsed and adopted Resolution SEA/RC69/R5 on the Strategic Action Plan to reduce the double burden of malnutrition in the South-East Asia Region 2016–2025. I urge Member States to use this action plan to formulate/revise their policies and plans in order to implement evidence-based interventions to tackle both undernutrition and the rising burden of obesity. The complexity of the problem is challenging, but early, sustained and focused investments in nutrition will yield positive results.
Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia Region Executive summary
Economic growth and investments in education, social development and health have resulted in significant improvements to the nutritional status of the population in the WHO South-East Asia Region. Yet, many women, children and adolescents do not have access to healthy and nutritious diets. Persistent undernutrition including micronutrient deficiencies, and rapidly rising rates of overweight and obesity characterize the Region’s nutrition transition. Latest estimates show 60 million children stunted, 45 million underweight and 8.8 million overweight in the age group 0–5 years in the Region. Anaemia affects approximately 96 million young children and 202 million women. Malnutrition bears a high health and socioeconomic cost. Undernutrition contributes to about 45% of preventable deaths of young children annually. Increased overweight and obesity underpin the high Noncommunicable Disease rates and consequent premature mortality. In total, the economic cost of malnutrition in countries is estimated to range from 2 to 3 per cent of their gross domestic products.
The Strategic Action Plan to reduce the double burden of malnutrition in the South-East Asia Region 2016–2025 was developed through an extensive consultative process and builds on the efforts of the previous regional strategy. It brings together guidance from global and regional policy platforms for integrated approaches to reduce all forms of malnutrition. The overarching objective of the Action Plan is to promote and establish an enabling environment within health and other sectors for effective implementation of nutrition interventions. School-aged children and adolescents join women and young children as key target groups. The Action Plan aims to support Member States to achieve eight nutrition targets, the six global nutrition targets, and two diet-related NCD targets.
This Action Plan recognizes the complexity of governance and multisectoral organization needed to reduce the double burden of malnutrition. It emphasizes the need to remain committed to reducing undernutrition while simultaneously preventing overweight and obesity, through integrated programmes that incorporate prevention of infection, and promote healthy high-quality diets and physical activity. The plan promotes adoption of global guidance and relevant legislative frameworks, improving health sector resources and capacity for nutrition, community empowerment and cultivating strategic partnerships to ensure sustainable solutions for nutrition issues. These are articulated through four strategic directions.
Evidence-based interventions in this plan address inadequate diets and poor care practices, inequities in health and nutrition services, knowledge enhancement on healthy diets and access to safe water and sanitation as well as poverty, food insecurity and education. Prioritization of direct and indirect nutrition interventions provided in this document should be based on country context and needs, within an enabling environment created by implementing policy actions of each strategic direction. Approaches to mitigate the obesogenic environment should accompany life-course interventions.
This strategic action plan is an advocacy and reference tool for policy-makers in Member States to reduce the double burden of malnutrition. It also provides direction to the WHO Regional Office and country offices on key areas of support for Member States.
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 ix © P. Lanerolle and C. Arambepola © P. Lanerolle and C. Arambepola 1
Introduction
1.1 The double burden of malnutrition Malnutritiona in all its forms threatens human health and development. The WHO South-East Asia Region (SEAR) has historically carried a high burden of child undernutrition, due to socioeconomic disadvantages and other biological and social determinants. The picture is now changing with a parallel rise in both child and adult overweight and obesity. Today, most countries face a double burden of malnutrition characterized by persistent undernutrition (stunting, wasting, micronutrient deficiencies) and coexisting overweight and obesity across the life-course.1 The emergence of obesity and lifestyle- related noncommunicable diseases (NCDs)b such as cardiovascular disease, diabetes mellitus and cancer is threatening already stretched and under-resourced health systems.2 The SEA Region exceeds the global average annual mortality rate for maternal, perinatal and nutritional conditions (334 versus 230 per 100 000); and noncommunicable diseases (676 versus 573 per 100 000).c
Constrained growth early in life is linked to increased risk of overweight and obesity in a later environment of food availability, especially where unhealthy food is plentiful and sedentary behaviours dominate.3 The biological responses of a child to the dietary environment is shaped partly by nutrition in utero, placing it on the pathway to stunting if faced with inadequate diets or obesity when faced with an unhealthy diet (Figure 1), as often seen in today’s transitioning societies.4 For stunted children in South-East Asia, the risks of mismatch between genetic programming (preparing for a resource-poor environment after birth) and the unhealthy dietary environment after birth that promotes rapid weight gain and greatly increase NCD risk, making investments in nutrition a strong economic and social case5,6.
a Malnutrition is defined as nutritional excesses of macronutrients and micronutrients as well as deficiencies (WHO 1995). b World Health Organization. Noncommunicable diseases. http://www.who.int/mediacentre/factsheets/fs355/en/ accessed 1 August 2016. c World Health Organization. World Health Statistics: Age-standardized mortality rates for CDs, NCDs and injuries in SEAR countries compared with averages for the world and high-income countries. 2011, accessed 1 August 2016.
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 1 Figure 1: The double burden of malnutrition across the life-course
Source: Global Nutrition Targets 2025, Childhood Overweight Policy Brief, WHO 2014.
1.2 Suboptimal diets and energy imbalance The predominant dietary patterns in South-East Asia are plant-based, low in diversity and often inadequate in energy, proteins and micronutrients, giving rise to stunting, wasting and anaemia.7 Food insecurity, poor knowledge and practices are contributory factors.8 However, particularly in urban areas, changing lifestyles and increased availability of low-cost, micronutrient-poor, energy-dense convenience foods are changing dietary patterns.
Intrauterine life, infancy and childhoodd are critical periods where long-term regulation of energy balance is programmed. Therefore, promoting a healthy diet with an adequate balance of nutrients from early childhood is vital in preventing malnutrition. A life-course perspective with continued emphasis on reducing undernutrition, along with measures to promote healthy eating has the greatest potential to reduce all forms of malnutrition. Healthy diets where adequate energy should be obtained mostly from unrefined carbohydrates, protein from plant and animal sources, shifting away from saturated to unsaturated fats, and elimination of trans fatty acids, limiting intake of free sugars and increasing fruits, legumes, whole grains and nuts in the diet have to be advocated and made accessible. Simultaneous efforts to reduce the obesogenic environment are essential.4,9
1.3 Consequences of malnutrition Worldwide, more than one third of child deaths and a fifth of the total disease burden are attributed to maternal and child undernutrition.10 Some of the key risk factors contributing to disease burden (measured in DALYs) in the South-East Asia Region are underweight (7.8%), iron deficiency (1.0%), unsafe water, sanitation and hygiene (4.6%), high blood pressure (3.0%), overweight and obesity (2.3%), low fruit and vegetable intake (1.0%) and suboptimal breastfeeding (2.9%).11 Stunting during the prenatal period and infancy impairs cognitive development, resulting in reduced school performance. Adult work performance
d Children aged between 6 and 19 years.
2 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 and earning capacity is reduced, along with the increased risk of noncommunicable diseases.10,12 Loss of attainment of height causes an annual loss of two to three per cent of GDP, undermining efforts to eradicate poverty.13 Micronutrient deficiencies add to the social and economic burden, compromising immunity, diminishing cognitive functions and intellect, causing anaemia and other illnesses.1 Of a total 13.7 million deaths in SEA Region countries during 2012, 6.8 million were due to NCDs, with many being premature deaths.14 Together, both undernutrition and NCDs represent a significant economic and social cost to countries, estimated to be more than US$ 30 trillion globally over the next 20 years.15
1.4 Addressing determinants of the double burden of malnutrition Figure 2 provides a conceptual framework of the determinants of the double burden of malnutrition (adopted from the 1997 UNICEF Framework).16 Unhealthy diets, physical inactivity and infections are the immediate causes of malnutrition. Lack of access to nutritious foods, care, poor feeding practices, unhygienic overcrowded living conditions and poor access to safe water and sanitation facilities are underlying causes. Food environments characterized by easy availability and promotion of low-cost, energy-dense micronutrient poor foods underpin overweight and obesity. Social environments that support sedentary practices also increase obesity, which in turn are influenced by the built environment. At a basic level, many system-level factors such as economic status, education and food systems act as directional forces for underlying and immediate causes of malnutrition. These multiple layers have to be addressed comprehensively through multisectoral mechanisms to achieve sustainable development.
Figure 2: Conceptual framework of the double burden of malnutrition
Outcomes of malnutrition and basic, underlying and immediate causes are included in this figure, ASEAN/UNICEF/WHO (2016) Regional Report on Nutrition Security in ASEAN, Volume 2, Bangkok, UNICEF.
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 3 1.5 Nutrition challenges to overcome Governance Although widespread progress in nutrition is evident across the Region, governance, a major driver of the responses to all forms of malnutrition is inadequate. The positioning of nutrition as central to development, enacting legislation to promote healthy diets, improved capacity for service delivery, ability to coordinate across multiple sectors, regulating and incentivizing industry and empowerment of population regarding healthy dietary choices provide a supportive environment to enable reduction of malnutrition. Since the NCD prevention agenda dominates public policy, a clear understanding of the drivers of NCDs and improved nutrition governance mechanisms will also prevent neglect of the undernutrition agenda.
Obesogenic environment The abundance of low-cost, high-energy foods available today come from two sources, one being the informal food sector, which has a predominant role in providing low-cost, high-energy convenience foods, specially in urban settings. The other is increased availability and access to ultra-processed pre-packaged foods. The solutions lie in empowering communities through increased knowledge and awareness to demand healthier diets, engaging and educating the informal food sector, regulatory changes that can positively affect the food environment and tactical engagement with industry.
Inadequate local evidence Much of the evidence for interventions that aim to prevent overweight and obesity are from high-income countries. These often do not take into account cultural complexities and other factors such as the high prevalence of undernutrition in low and middle-income countries. Therefore, local evidence generation is vital, for adaptation of interventions to suit the South-East Asian context.
Ageing The percentage of elderly is growing rapidly worldwide, with a projected estimated increase from 524 million (2010) to nearly 1500 million in 2050 globally.e Undernutrition among the elderly is a significant and neglected public health problem. Older people are vulnerable to malnutrition due to physiological and functional changes that occur with age, lack of financial support and inadequate access to food. Nutritional interventions for the elderly could play a role in preventing degenerative conditions and improve quality of life.
Climate change The South-East Asia Region is highly vulnerable to climate change which increases the incidence and severity of extreme weather events and magnifies the risk of disasters.f These affect both rural and urban livelihoods and accelerate population displacement, posing a major threat to agriculture and food security through effects on food availability, accessibility, and utilization, thereby exacerbating current states of malnutrition. It is the poorest and least resilient groups such as young children and women that would be most affected. e National Institute on Aging, National Institutes of Health. Global Health and Ageing. United States: NIH Publication, 2011. f United Nations. United Nations conference on climate change: Copenhagen, 7-18 December 2009 – SCN statement. http:// www.unscn.org/files/Statements/SCN_statement_climate_change_final.pdf -accessed 1 August 2016.
4 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 2
Profile of nutritional status in the WHO South-East Asia Region
The WHO South-East Asia Region represents a diverse range of 11 low- and Member States: middle-income countries, with wide variations in geography, culture, social development and nutrition transition. Over the past two to three decades, Bangladesh the Region has seen significant social, economic and demographic changes Bhutan that have greatly influenced the nature of nutrition issues currently faced by Democratic People’s countries. A quarter of the world’s population lives in the South-East Asia Republic of Korea Region, with more than 90% of the regional population being in Bangladesh, India and Indonesia.17 India Indonesia The rate of urbanization in Asia (1.5% per annum) is the highest in Maldives the world.18 Apart from Indonesia and Thailand, where the rural-urban population ratio is almost equal, in all other Member States, the majority of Myanmar the population is rural.19 The Region has the largest working age population Nepal in the world, representing an enormous human resource potential. Sri Lanka Literacy rates, especially among women, are rising consistently, Thailand contributing to human and social capital. In Thailand, Sri Lanka, Indonesia Timor-Leste and Myanmar, literacy is more than 90%. Around three-fourths of the adult population in India and more than 55% in Bangladesh, Nepal and Timor-Leste are literate.19
Robust economic growth, accompanied by intensive efforts for social development have resulted in declining poverty and improvements in the Human Development Index (HDI). A review of the HDI over a 5-year period shows positive changes in rank for most Member States.20 Under-five mortality in South-East Asia has declined significantly from 34 deaths per 1000 live births in 2000 to an estimated 26 deaths in 2015.g Significant progress has been made in reducing undernutrition. Bangladesh reported a 35%–40% decline in child stunting and underweight between 2004 and 2014.21 Similarly, a 60% reduction in stunting prevalence and 70% reduction in underweight among under-five children was reported from Bhutan between 2000 and 2015.22 Available data for selected states from the India National Family Health Survey (2015) also show a reduction in stunting and underweight in children under five yearsh and an increase in exclusive breastfeeding rates.23 However, while undernutrition is declining, micronutrient deficiencies, particularly anaemia, persist, and prevalence of child, adolescent and adult overweight and obesity is increasing. g World Health Organisation. Global Health Observatory data, Geneva http://www.who.int/gho/child_health/mortality/mortality_under_five/en/index1.html- accessed 1 August 2016. h International Institute for Population Sciences. National Family Health Survey, India. http://rchiips.org/NFHS/factsheet_NFHS-4. shtml – accessed 1 August 2016.
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 5 2.1 Nutritional status of children aged 0–5 yearsi,j 2.1.1 Stunting and overweight in children < 5 years Stuntingk is the cumulative result of chronic malnutrition and deprivations from the prenatal period and childhood. Overweight may or may not be superimposed on stunting. Figure 3 indicates the prevalence of both stunting as well as overweight in young children.l The double burden of malnutrition varies across countries with over 10% of children in under-five age group estimated to be overweight in Indonesia and Thailand and less than 3% in Bangladesh, Myanmar, Nepal and Sri Lanka. The regional prevalence of overweight in children was 3.3% in 2005 and 4.9% in 2014.m
Though prevalence of stunting is declining across all countries, the overall annual average rate of reduction of 1 percentage point per year is much slower than the estimated 3.9% needed to meet the global nutrition targets. Although the overall prevalence of stunting in SEAR countries has reduced from 59% in 1990 to 32.9% in 2013, it translates into 60.8 million stunted children.24
Figure 3: Prevalence of stunted children (-2SD height-for-age Z scores) and overweight children (+2SD weight-for-age Z scores) aged <5 years in SEARn ) 60 (% Stunting Overweight 50.2 50 38.7 37.4 40 36.1 36.4 35.1 33.6 32.9 27.9 30 20.3 20 14.7 16.3 11.5 10.9 7.6 10 6.5 5.1 1.4 2.6 2.1 0.6 1.5 0 Percentage of under-five children l r a a a e ia re nk Indi SEAR Ko La Nepa r-Lest Bhutan i Thailand Maldives Sr Myanma Indones mo DPR Bangladesh Ti
Source: WHO/UNICEF/World Bank joint monitoring estimates 2015. Data updated by March 2016. Data are from surveys included in the WHO/UNICEF/World Bank joint monitoring estimates 2015. WHO cut-offs for public health significance: [stunting: >40% very high prevalence; 30–39% high prevalence, (red); 20–29% moderate prevalence; <20% low prevalence (green)]. Thailand notes that prevalence of stunting is 10.5% and prevalence of overweight is 8.2% in children aged < 5 years.o
i Nutritional status is most commonly measured by anthropometry in comparison with WHO growth standards; for example, stunting (height-for-age), wasting (weight-for-height), underweight (weight-for-age) for infants and children, and body mass index (BMI) for adults. j For the purpose of uniformity, the data for nutrition profiles of children have been taken from WHO/UNICEF/World Bank joint monitoring estimates 2015. However, any recent data available from Member States’ recent surveys are given in the footnote. k Defined as height –for-age that is more than two standard deviations below the World Health Organization Child Growth Standards median (birth to < 5 years). l Defined as weight- for- age more than 2 standard deviations above the WHO growth standards median (birth to < 5 years). m WHO/UNICEF/World Bank joint monitoring estimates 2015. http://www.wssinfo.org/ - accessed 1 August 2016. n National Nutrition Survey 2015 of Bhutan reports a stunting prevalence of 21.2% in children < 5 years of age. o UNICEF, MICS. Multiple Indicator Cluster Survey (MICS) 2015/16: Thailand. http://mics.unicef.org/surveys - accessed 1 August 2016.
6 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 2.1.2 Wasting in children < 5 years of agep Wasting is the result of recurrent acute deprivations of nutrition. In 2014, in the SEAR, 14.5% of children were wasted (25.9 million children wasted and 8.1 million severely wasted) as indicated in Figure 4.24
Figure 4: Prevalence of wasting in children aged <5 years (-2SD Weight-for-height Z scores) in SEARq
) 25 21.4 20
14.3 15.1 15 13.5 11.3 10.2 11 10 7.9 5.9 6.7 5 4
Precentage of children under five (% 0 l ) ) a a a a e 2) 2) sh si re nk 013) 012) 014) 01 Indi Ko La Nepa (2 (2014) (201 (2 (2 (2010) (2 (2013) (2009) r-Lest Bhutan i 013/14 Thailand Maldives Sr Myanmar Indone (2009/10 (2 mo DPR Banglade Ti
Data updated by March 2016. The specific year when the data was obtained in each country is given in parenthesis. National data is from various household surveys included in the WHO/UNICEF/World Bank joint monitoring estimates 2015. WHO cut-offs for public health significance: [wasting: medium (5-9%, yellow), high severity (10-14%, red)]. Thailand notes that prevalence of wasting is 5.4 % in children aged < 5 years15.
p Defined as more than two standard deviations (-2SD) below the median weight-for-height of the WHO Child Growth Standards median. Those below minus three standard deviations (-3 SD) are considered to be severely wasted. q National Nutrition Survey (NNS) 2015,Bhutan reported a prevalence of 4.4% wasting and 9% underweight among children < 5 years
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 7 2.1.3 Underweight in children <5 years Most countries show a significant decline in prevalence of underweight (Figure 5). Despite this, in 2014, 46 million children in the Region were estimated to have low weight-for-age.24
Figure 5: Prevalence of underweight (-2SD weight-for-age Z scores) in children <5 years in SEARr
40 37.7 ) 35 32.6 29.4 30.1 30 26.3 25 22.6 19.9 20 17.8 15.2 15 12.8 9.2 10
5
Precentage of children under five (% 0 l ) a a a e ia 2) 4) sh re 12) nk 012) 013) 014) Indi Ko La Nepa (2010) (2 (2014) (201 (20 (2 (2 (2013) (2009) r-Lest Bhutan i 013/1 Thailand Maldives Sr Myanmar Indones (2009/10 (2 mo DPR Banglade Ti
Data updated by March 2016. The specific year when data were obtained in each country is given in parenthesis. National data are from various household surveys included in the WHO/UNICEF/World Bank joint monitoring estimates 2015. WHO cut-offs for public health significance: [underweight: > 30% (very high severity, red), >20% (high severity, yellow); <10 % (low severity, green)].
2.1.4 Low birth weight (LBW) A birth weight <2500 g is associated with higher morbidity and mortality, especially in the neonatal period. The prevalence of LBW is highest in India, followed by Bangladesh, Nepal and Sri Lanka (Figure 6). However, birth weight figures are likely to be under-reported because of home deliveries.
Figure 6: Prevalence of low birth weight children in SEAR
30 28
25 22 )
20 18 17
15 11 11 12 10 9 9 10 6 weight <2500g (% 5 rcentage of children born with Pe 0 l r a a a a 7 6 0 sh si 09 03 09 07 ste re nk –0 Indi Le 2011 2010 2007 2009 20 20 20 201 20 Ko La Nepa r- i Bhutan Thailand Maldives 2006–0 2005 Sr Myanma Indone mo DPR Banglade Ti
Source: State of World’s Children 2015: Reimagine the Future (UNICEF 2015).
r Defined as weight-for-age less than 2 standard deviations _-2SD) below the WHO growth standards median (< 5 years of age).
8 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 2.2 Nutritional status of adolescents Stunting: Approximately one-tenth of adolescents in South-East Asian countries, except in Timor-Leste where more than 20% are stunted, fall below the cut-off point (145 cm of height) for stunting. (Figure 7)
Thinness: DHS data from six countries of the Region show that thinness (BMI < 18.5kg/m2) among adolescent girls is in the range of 24%–47%, indicating significant energy deficits in the diet.
Overweight and obesity: Often seen side by side with thinness and stunting in the same community, increasing prevalence of overweight and obesity (BMI-for-age > 1 SD and 2 SD above the WHO growth reference median respectively) is being reported (Figure 7).
Figure 7: Proportion of stunted, underweight and overweight/obese female adolescents aged 15–19 years in selected countries of SEAR
50 47 45 BMI ≥ 25kg/m2
) BMI <18.5kg/m2 40 40 Height <145 cm 35 33
30 26 25 24 24 25 22 20 15 15 13 12 11 10 rcentage of adolescents (% 10 8 8 7 Pe 5 2 3 0 Bangladesh IndiaMaldivesNepal Sri LankaTimor-Leste
Source: Bangladesh DHS 2011; India NFHS3 2005-06; Maldives DHS 2009; Nepal DHS 2011; Sri Lanka DHS 2006; Timor-Leste DHS 2009-10. Overweight: BMI > 25 kg/m2, obese: BMI > 30 kg/m2. Data updated by March 2016.
2.3 Nutritional status of adults More than a fifth of adults are overweight, with greater prevalence among women (Figure 8). The burden is highest in Maldives and Thailand followed by Bhutan, Indonesia and Sri Lanka. In SEAR, female body mass index (BMI) increase ranged from 0.3 kg/m2/decade in India and 1.3 kg/m2/decade in Maldives between 1980 and 2008.25
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 9 Figure 8: Trends in prevalence of overweight (mean BMI ≥25 kg/m2) in adults (both sexes) in 2010 and 2014 in SEAR
40 2010 2014
) 30 30 30 27 27 27 24 25 25 20 22 22 22 20 21 20 18 19 18 20 18 16 15 16 15 13
10 Percentage of adults (%
0 l r a a a ia sh ste re nk Indi Le SEAR Ko La Nepa r- Bhutan i Thailand Maldives Sr Myanma Indones mo DPR Banglade Ti
Source: Global Health Observatory Data Repository, WHO 2013. http://www.who.int/gho/en
2.4 Nutrition in older persons Figure 9 provides population projection estimates of older persons in the SEAR. By 2030, the proportion of older persons could be as high as 21% to 27% in Sri Lanka and Thailand, posing significant challenges to health and nutrition.26
Figure 9: Proportion of older persons (aged 60 years and over) in SEAR
40
) 2015 2030
30 26.9
21.0 19.4 20 15.7 12.4 12.4 13.0 13.0 11.5 12.0 12.0 11.0 9.0 10.6 10 8.0 8.0 7.07.0 6.0 7.0 6.7 4.4 Percentage of older persons (% 0 l a a a a si ste re nk Le Indi Ko La Nepa r- Bhutan i Thailand Maldives Sr Myanmar Indone mo DPR Bangladesh Ti
Source: United Nations Department of Economic and Social Affairs. Profiles of Aging 2015. http://esa.un.org/unpd/popdev/ Profilesofageing2015/index.html,- accessed 1 August 2016.
10 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 2.5 Micronutrient deficiencies in the South-East Asia Region
Vitamins and mineral deficiencies, particularly iron, folic acid, vitamin B12, vitamin A and iodine, affect a sizable proportion of the population, especially women and children in the Region.27
2.5.1 Anaemia Anaemia is mainly nutritional in nature and primarily attributed to iron deficiency and partly to folic acid and vitamin B12 deficiencies. Other causes inlcude infections such as Malaria and haemoglobinopathies. Iron deficiency, the most prevalent micronutrient deficiency across all age groups affects physical, cognitive and social health.28 Children, adolescents and pregnant women are at risk of developing iron deficiency due to increased iron requirements for growth and deficient diets.
Recent DHS data from Bangladesh (49%), India (56%), Nepal (39%) and Timor-Leste (22%) indicate that adolescent anaemia is a moderate to severe public health problem in many countries. Figure 10 indicates the high prevalence of anaemia among women and young children in the Region.29 Anaemia is a severe public health problem in Bangladesh, Bhutan, India, Myanmar, Nepal and Timor-Leste as indicated in Table 1.
Figure 10: Prevalence of anaemia among children aged < 5 years and non-pregnant women in SEAR
100 Children <5 years 90 Non-pregnant women
) 80 Severe public health problem 70 Moderate public health problem 59 56 55 60 51 48 50 43 44 45 40 37 40 34 32 36 36 25 30 30 26 29 30 22 24 22 non-pregnant women(% rcentage of children an and 20 Pe 10 0 l a a a a si ste re nk Indi Le Ko La Nepa r- Bhutan i Thailand Maldives Sr Myanmar Indone mo DPR Bangladesh Ti
Data are based on WHO’s modelled estimates (from 1995 to 2011) in national estimates of anaemia for the year 2011, Percentage of children and pregnant women with haemoglobin concentration <110 g/L and <120 g/L for non-pregnant women. To ensure comparability, the most recent data for certain countries are not presented in this figure. Thailand noted that the prevalence of anaemia in child-bearing age women (15-49 years old) has declined to 22.7% NHES5 (2014-15).s Bhutan reports that prevalence of anaemia is 44%.22
s National Health Exam Survey, Thailand.
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 11 Table 1: Level of public health burden caused by anaemia among children, non-pregnant women, and pregnant women
Women 15–49 years Women 15–49 years Children aged 6–59 months (non-pregnant) (pregnant) Anaemic Public health Anaemic non- Public health Anaemic Public health Country childrent significance pregnantt significance pregnantt significance Bangladesh 56% Severe 43% Severe 48% Severe Bhutan 55% Severe 44% Severe 46% Severe DPR Korea 34% Moderate 25% Moderate 27% Moderate India 59% Severe 48% Severe 54% Severe Indonesia 32% Moderate 22% Moderate 30% Moderate Maldives 30% Moderate 37% Moderate 39% Moderate Myanmar 40% Severe 30% Moderate 33% Moderate Nepal 51% Severe 36% Moderate 44% Severe Sri Lanka 36% Moderate 26% Moderate 25% Moderate Thailand 29% Moderate 24% Moderate 30% Moderate
Timor-Leste 45% Severe 22% Moderate 24% Moderate
2.5.2 Status of other micronutrient deficiencies Vitamin A: Among young children <5 years the estimated prevalence of night blindness in South-East Asia is 0.5% and among pregnant women, it is 9.9%.30
Iodine: Iodine deficiency disorders are the most common causes of mental impairment.31 Fortification of iodine through salt iodization has been successful in the Region. Most Member States are classified as having adequate iodine status.32 Household consumption of iodized salt varies from 65 to 90% in Bangladesh, Bhutan, India, Nepal and Sri Lanka.32
2.6 Diets in South-East Asia
2.6.1 Consumption of minimum acceptable diets by young children Breastfeeding and complementary feeding practices determine the nutritional status of young children. Figure 11 indicates the percentage of 6–23 month-old breastfed children consuming minimum acceptable diets, a composite indicator of dietary diversity (consuming foods from three or more food groups) and meal frequency. Only one fifth to one third of children in Bangladesh, India, Indonesia and Nepal consume minimum acceptable diets.33
t Adapted from National estimates of anaemia for 2011, WHO. The global prevalence of anaemia in 2011. Geneva: World Health Organization; 2015. WHO classifies countries by degree of public health significance of the problem, based on blood haemoglobin concentration: <5% = no public health problem; 5–19.9% mild public health problem; 20–39.9% moderate public health problem; ≥40% severe public health problem (red).
12 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Figure 11: Consumption of minimum acceptable diets by 6–23-month-old childrenu in selected countries in the South-East Asia Region
100 90 83 old 80 70 63 ) 60 50 41 40 34
children (% 25 30 21 22 20 10 Percentage of 6-23 month 0 a * 6 7 0 ia a st e nk Le 20 12 20 09 Indi La –200 –201 20 11 –200 r- i Maldives Sr Indones mo Bangladesh 20 06 20 09 2005 Ti Nepal 2011
*Children consuming foods from 4+ food groups. Source: Country Demographic and Health surveys.
2.6.2 Dietary risk factors for noncommunicable disease risk
Dietary salt intake Reduction in dietary salt intake is considered one of the most cost-effective strategies to reduce risk of NCDs, especially cardiovascular disease.34 Figure 12 provides age standardized estimates of sodium intake in adults in SEAR.
Figure 12: Dietary risk factors: Age standardized estimated sodium intake (g/d) in 2010, persons aged 20 years and over, both sexes in the South- East Asia Region35
8 7 5.31 intake 6 4.49 4.47 5 3.79 3.89 3.87 ) 3.54 3.64 3.72 3.36 3.31 4 (g/d sodium 3 2 1
Estimated 0 l a a a e ia re nk Indi Ko La Nepa r-Lest Bhutan i Thailand Maldives Sr Myanmar Indones mo Bangladesh DPR Ti
All data have been obtained from Powles et al.35 For comparability reasons, data from the most recent surveys for each country have not been included.
u Source: World Health Organization. Indicators for assessing infant and young child feeding practices. Geneva: WHO, 2010. http://apps.who.int/iris/bitstream/10665/43895/1/9789241596664_eng.pdf - accessed 1 August 2016.
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 13 2.6.3 Fruit and vegetable consumption Fruits and vegetables are important components of a healthy diet, and their sufficient daily consumption could help prevent noncommunicable diseases. STEPwise approach to noncommunicable disease risk factor surveillance (STEPS) surveys across the Region indicates grossly inadequate consumption of fruits and vegetables (Figure 13).
Figure 13: Percentage of adults who ate less than 5 servings of fruits and vegetables per day
98 99 99 94 93 95 100 88 90 ) 90 83 84 85 80 70 73 72 71 70 65 60 50 40 30 20
Percentage of adults (% 10 0 l a a 0 4 6 4 1 4 3 3 sh si ste nk –1 Le 201 200 201 201 201 200 La Nepa r- i Maldives 2012 Sr Myanmar Indone mo Banglade Ti Bhutan 201 Men Women
Source: STEPs country fact sheets, http://www.who.int/chp/steps/reports/en/
14 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 3
The Strategic Framework and Action Plan
A healthy well-nourished population is essential to development, ending poverty and achieving SDG 2, end hunger, achieve food security and improved nutrition, and promote sustainable agriculture.36 Nutrition is also an enabler for many other SDGs including the health goal. In recognition of this, the Strategic Action Plan sets out a goal, guiding principles, three objectives and eight targets, in line with current global initiatives.
3.1 Goal Improve nutrition status of populations in the South-East Asia Region.
3.2 Objectives §§ To promote and develop an enabling environment for the effective implementation of nutrition interventions. §§ To support implementation and scaling up of evidence-based direct and indirect nutrition interventions through the life course. §§ To promote healthy diets to reduce the double burden of malnutrition.
3.3 Scope and purpose The Strategic Action Plan to reduce the double burden of malnutrition in the South-East Asia Region is an advocacy and reference tool for policy makers in Member States. The plan provides guidance to create an enabling environment for the successful implementation of interventions to reduce both undernutrition and overweight and obesity through four strategic directions and relevant policy instruments. Evidence- based interventions are listed in Annex 1. The plan does not focus on physical activity, an integral component of a healthy lifestyle, since it is addressed in other documents. §§ Strategic direction 1: Improve nutrition governance through enhanced political commitment and evidence informed context-specific sectoral policies and actions. §§ Strategic direction 2: Develop or adopt relevant guidelines, legislation and regulatory frameworks needed to implement evidence-based interventions. §§ Strategic direction 3: Strengthen health systems to address the double burden of malnutrition with adequate resources, capacity strengthening and comprehensive monitoring and evaluation. §§ Strategic direction 4: Empower communities, support and strengthen academia and civil society to promote healthy diets, and form strategic alliances with stakeholders.
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 15 3.4 Global nutrition targets and diet-related NCD targets The voluntary global nutrition targets in the Comprehensive Implementation Plan on Maternal, Infant and Young Child nutrition37, and the diet-related NCD targets of the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases38 are given in Figure 14. Member States are encouraged to set time-bound targets based on their country context and needs. The SDG targets include the global nutrition targets to be achieved by 2025. The outcomes of the action plan are set out in a theory of change process in Figure 15.
Figure 14: Global nutrition and diet-related noncommunicable disease targets and indicators
Global nutrition targets 2025 Indicatorv,w 40% reduction in the number of children under five Prevalence of low height-for-age in children who are stunted under five years of age
50% reduction of anaemia in women of reproductive Prevalence of haemoglobin<11 g/dL in pregnant age women
30% reduction in low birth weight Prevalence of infants born <2500 g
No increase in childhood over weight Prevalence of weight-for-height >2 SD in children under five years of age
Increase the rate of exclusive breastfeeding in the first Prevalence of exclusive breastfeeding in infants 6 months up to at least 50% aged six months or less
Reduce and maintain childhood wasting to less than Prevalence of weight-for-height <2 SD in 5% children under five years of age
Nutrition-related targets from the WHO Global Action Plan for the Prevention and Control of NCDsx A 30 % relative reduction in mean population intake Age standardized mean population intake of salt of salt/sodium (sodium chloride) per day in grams in persons aged 18+ years
Halt the rise in diabetes and obesity Overweight women The prevalence of overweight in women of reproductive age
v Source: World Health Organization. Indicators for assessing infant and young child feeding practices. Geneva: WHO, 2010. http://apps.who.int/iris/bitstream/10665/43895/1/9789241596664_eng.pdf - accessed 1 August 2016. w Indicator definitions are provided in Annex4. x World Health Organization. Noncommunicable diseases global monitoring framework: indicator definitions and specifications. Geneva: WHO, 2014. http://www.who.int/nmh/ncd-tools/indicators/GMF_Indicator_Definitions_Version_NOV2014.pdf - accessed 1 August 2016.
16 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Impact Double burden of malnutrition reduced Outcomes* Country level targets are met * Contextual influences/assumptions agenda Political Economic situation and competing priorities conflict, emergencies. Outputs Functioning multisectoral Functioning mechanisms are implemented and policy coherence achieved across relevant sectors. and regulatory Policy frameworks are adopted and legislation enacted. Health system capacity strengthened to deliver nutrition interventions Community and civil society are empowered and strategic partnerships are created to promote healthy diets Evidence- based interventions are implemented and/or scaled up. Activities The outcomes of the action plan are set out in following theory change Figure 15: Figure Establish multisectoral coordination mechanisms and promote policy coherence within health and across other sectors.* Identify national targets and indicators for nutrition and diet-related NCD risk factors that address country priorities. Develop/adopt guidelines regulatory frameworks, and enact legislations. Strengthen health systems with adequate resources, capacity and monitoring frameworks.** Empower communities, support civil society and academia and create strategic partnerships with stakeholders to promote healthy diets.*** *Implement indirect nutrition interventions. **Implement direct nutrition interventions ***Implement interventions to reduce the obesogenic environment Inputs Advocacy, Advocacy, planning, policy dialogue and resource mobilization. Global and regional frameworks, guidance and tools. Evidence-informed nutrition interventions are provided in Annex 1. Strategic directions and policy actions linkages to the global nutrition diet related NCD targets have been mapped ( Annex 4)
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 17 3.5 Policy context This action plan is guided by the global commitments and World Health Assembly Resolutions related to nutrition, maternal and child health and NCDs, (Annex 2) and the goals of policy platforms such as the Second International Conference on Nutrition (ICN2), the Scaling Up Nutrition (SUN) Movement and the UN Secretary-General’s Zero Hunger Challenge.
3.6 Time frame A ten year timeline (2016–2025) aligns the action plan with the Global Nutrition and NCD targets, and the Decade of Action for Nutrition 2016–2025.
3.7 Monitoring and evaluation The Regional office will track progress in implementing the strategic action plan in the medium (2021) and long term (2025) through monitoring of selected process indicators. (Annex 3). Progress will be reported in 2022 and 2026. The plan will be reviewed in 2021 and revised as necessary.
3.8 Guiding principles A life course approach, with a special focus on the “window of opportunity,” from conception to two years (first 1000 days); supporting improved nutrition of the school-aged child and adolescent; ensuring human rights and the right to food; facilitating the accountability of governments, civil society and other stakeholders on commitments to improve nutrition; promoting sustainable solutions that build self- reliance and empowerment; multisectorality, gender equality and ensuring equity are key principles that guide this action plan.
3.9 Role of WHO The Regional and country offices will work with Member States in a variety of roles to support, facilitate and strengthen nutrition actions.
Policy advocacy and planning §§ Advocate for nutrition to be prioritized and repositioned as central to development and support Member States to set nutrition targets and develop/revise national policies, strategies and action plans to reduce the double burden of malnutrition. §§ Promote and support adequate resource allocation for nutrition, establishment of partnerships and coordination mechanisms within health and other sectors to promote nutrition security. §§ Develop strategic collaboration and coordination with development partners and other stakeholders, through platforms such as the SUN, UNDAF and partnerships with technical institutions/ academia and other actors.
18 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Technical guidance and policy support to §§ access normative products and tools. §§ translate global guidance to region and country specific interventions. §§ monitor nutrition outcomes and implement national action plans. §§ strengthen human resource capacity in countries for effective and sustainable implementation of relevant interventions. §§ build additional capacity including in legislation, standards and specifications for promoting healthy diets, food labelling and fortification of foods.
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 19
4
The Action Plan
The framework for implementing the four strategic directions is given below. Selected evidence -based interventions are given in Annex 1. Particular interventions to be prioritized and implemented or scaled up depend on each country’s nutrition profile, development priorities and health system capacities. Annex 4 provides a mapping of policy actions, evidence based interventions, relevant indicators and the global nutrition and diet-related NCD targets.
Strategic direction 1 Improve nutrition governance through enhanced political commitment and evidence informed, context-specific sectoral policies and actions Good governance is contingent upon strong leadership, political commitment and administrative will. Nutrition has to be prioritized and repositioned as central to the development agenda of countries. Policy development has to take into account the country context and comprehensively address all forms of malnutrition. Emerging issues such as global warming and climate change, urbanization, the nutrition transition and migration are significant challenges to nutrition security in the Region and requisite sectoral actions should be promoted. Implementing direct nutrition interventions are essential to preventing malnutrition and needs cooperation among health sector (health promotion, school health, NCD and Nutrition). It is also critical that other sectors such as agriculture, education, and social welfare implement indirect nutrition interventions to address the underlying determinants of malnutrition. Indirect nutrition intervention programmes could incorporate nutrition actions, increase food security, access to health services, ensure hygienic conditions and support reduction of the obesogenic environment. A truly multisectoral approach with policy coherence between health and other sectors will achieve optimal nutrition outcomes (Annex 5).
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 21 Policy actions Policy indicators
Establish a high-level coordination mechanism High-level coordination mechanism established with specific terms of to guide multisectoral nutrition actions reference
Advocate and ensure adequate financing Adequate resources (as identified by costing analysis) are earmarked and for nutrition; prepare budget and cost for available for implementation of nutrition action plans implementing key interventions to reduce the double burden
Develop/update national policies and plans National nutrition and/or related health policies and plans have in nutrition and related sectors to reflect the addressed the double burden of malnutrition double burden of malnutrition and ensure nutrition security Multisectoral nutrition action plans with operational mechanisms are updated with identified budget lines, implemented and monitored
At least three key non-health policies address the double burden of malnutritiony
Policy actions developed in cooperation with the agricultural sector to reinforce measures directed at food growers, processors, retailers, to provide greater opportunities for utilization of healthy and nutritious agricultural products and foods.
Identify national targets and indicators for Time bound national nutrition targets and diet-related NCD targets nutrition and diet-related NCD risk factors that are set and indicators based on the global monitoring framework are address country priorities included in monitoring mechanisms
Ensure policy actions to insulate nutrition Frameworks to protect nutrition policies and dietary guidance from policy-making from conflict of interest to conflict of interest are developed and implemented safeguard public good
Build on existing WHO policy frameworks and Nutrition is addressed in policies, strategies and plans on healthy ageing plans on healthy ageing to include nutrition
Ensure that policies on emerging challenges Health emergency /disaster preparedness plans explicitly address the such as climate change and natural disasters double burden of malnutrition address nutrition
Strategic direction 2 Develop or adopt relevant guidelines, legislation and regulatory frameworks needed to implement evidence-based interventions. Development and adaptation of guidelines, legislation and regulatory frameworks are essential instruments to reduce the double burden of malnutrition. Evidence-based guidance is available at the global level and should be adopted by countries, based on country context.
y Education, social protection, sports (or relevant policies) identified as relevant to each country context.
22 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Policy actions Policy indicators
Ensure availability and operationalization National food-based dietary guidelines that promote nutritious diets of legislation and guidelines to promote which emphasize on diversity, high intake of fiber, and low in fat, sugar healthy diets to reduce the double burden of and salt are developed and utilized malnutrition and minimize diet-related risk of NCDs Strategies and roadmaps for population reduction of salt, sugar and fat intake are developed and implemented
National policies that limit saturated fatty acids and virtually eliminate partially hydrogenated vegetable oils in the food supply are implemented
National nutrition plans include linkages with WASH (Water, Sanitation, and Hygiene (WASH)
Promote fiscal policies to reduce unhealthy diets Fiscal policies are developed and implemented for food products that and enhance accessibility of healthy foods (e.g. are high in sugar, fat and salt targeted subsidies for fruits and vegetables) Policies for subsidizing local fruits and vegetables are implemented
Ensure that regulations and guidelines are Micronutrient (supplementation) guidelines within the country are in place for micronutrient supplementation updated regularly and fortification of products as suitable to the country context Food fortification legislation for iodization of salt and other relevant micronutrients are developed and implemented
Enact legislation on provision of appropriate Legislation enacted to ensure mandatory nutrient content labelling nutritional information for packaged food based on codex guidance and interpretative labelling of food products products (front of pack)
A watchdog mechanism is established to ensure that health and nutrition claims are based on codex guidelines and adequate scientific evidence
Promote healthy and safe foods in the informal Healthy and safe food guidelines are developed for informal food food sector to enable a healthy dietary sector, disseminated and their utilization monitored environment
Review, develop and disseminate national National guidelines developed and in use for relevant diseases/ guidelines on prevention and treatment of conditions including obesity nutritional care in the management of common diseases
Review, develop and disseminate guidelines Nutrition Guidelines for disaster preparedness or emergencies are for disaster preparedness, response and developed and disseminated management of nutrition emergencies
Promote, protect and support breastfeeding International Code of Marketing of Breast milk Substitutes (the and complementary feeding practices through Code) and subsequent relevant WHA resolutions are legislated and comprehensive legislation and monitoring implemented mechanisms Maternity protection measures enacted and aligned with ILO Convention 183
Institutions where deliveries take place have successfully implemented the 10 steps to breastfeeding
Infant and Young Child Feeding Guidelines are updated with information on promoting a nutritious diet low in salt, sugar and fat
Measures to prevent inappropriate promotion of foods for infants and young children are in place
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 23 Policy actions Policy indicators
Enact legislation/regulations and implement Legislation enacted to implement WHO’s Recommendations on actions to promote nutritious foods to reduce Marketing of unhealthy foods and beverages to children undernutrition and overweight and obesity in women and children School guidelines and standards ensuring a healthy food environment are developed and implemented
Develop guidelines for supplementary food Guidance on appropriate food supplementation for pregnant and assistance to vulnerable groups for improving lactating women and young children health and nutritional status
Strategic direction 3 Strengthen health systems to address the double burden of malnutrition with adequate resources, capacity strengthening and comprehensive monitoring and evaluation. Equitable access to nutrition services are critical to achieving the global nutrition and diet related NCD targets. A comprehensive, human resource capacity development process that will integrate latest research, learning tools and technology to enhance leadership and workforce capacity needs to be implemented. Other critical areas for investments include infrastructure, equipment, and nutrition information systems.
Policy actions Policy indicators Ensure health systems incorporate Maternal and Child Health systems have defined an essential package of nutrition Health and Nutrition interventions in primary health-care interventions reflecting the double burden of malnutrition packages Ensure adequate financing for nutrition through identified Adequate resources are earmarked and available for budget lines for nutrition-related activities implementation of nutrition interventions. Ensure qualified personnel with skills and competencies Existing curricula/programmes for health and nutrition workers to develop, deliver and evaluate population-based have been evaluated and revised to include the double nutrition services burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population Promote nutrition services in clinical conditions and Proportion of health-care facilities that offer prevention/ settings for prevention and treatment of severe acute treatment counselling and other nutrition services for malnutrition, obesity and other nutrition-related undernutrition and overweight and obesity conditions Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition-related conditions Establish/upgrade health infrastructure to facilitate the Food laboratories are upgraded to ensure food safety and implementation of policy and legal directions to ensure support implementation of healthy diet legislation food safety and promote healthy diets Management of safe water and accessibility of sanitation facilities is supported Initiate actions to develop and operationalize Efficient and effective nutrition surveillance actions suitable for comprehensive nutrition surveillance systems and identify tracking the double burden of malnutrition established relevant indicators to inform, monitor and evaluate Disaggregated data on nutritional status (reflecting the double policies and programmes to track data on double burden burden) available and utilized of malnutrition
24 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Strategic direction 4 Empower communities, support and strengthen academia and civil society to promote healthy diets and form strategic alliances with stakeholders. Promoting effective community engagement and empowerment through strengthening civil society organizations, is essential to address socio cultural determinants of malnutrition. Support for academia to encourage country-based research would an improved prioritization and implementation of actions based on country context.
Forming strategic partnerships with the other stakeholders including the food sector is also important in promoting healthy diets and reducing the obesogenic environment. However, countries need to ensure that such alliances do not inform public health policy, are free of conflict of interest and ensure public good.
Policy actions Policy indicators
Recognize the importance of professional and civil Relevant professional and civil society organizations have formed society organizations to promote and support healthy networks and action groups to support nutrition-promoting diets programmes and behavior change communication campaigns
Engage academic institutions to address knowledge Academia are engaged in locally relevant nutrition research, and evidence gaps in promoting and creating healthy monitoring, evaluation and surveillance to reduce the double dietary and physical activity promoting environments burden of malnutrition
Create a demand for healthy lifestyles (diversified Community advocacy plan developed and implemented to diets and physical activity) in communities to reduce promote healthy, diversified diets all forms of malnutrition Health promoting activities carried out to improve knowledge and behaviours on healthy diets
Evidence-informed public campaigns and social marketing initiatives conducted to inform and encourage consumers about healthy dietary practice
Require childcare settings, pre-schools, schools, Teacher training and guidance are available to support children’s and youth sports facilities and events to participative, skills-based nutrition education in schools create healthy food environments
Engage with stakeholders including private sector to Relevant stakeholders including private sector are appropriately reduce the obesogenic environment, while instituting engaged to implement actions, aimed at reducing overweight, essential checks and balances to prevent undue obesity and dietary risk of NCDs with necessary checks and influence on policymaking balances in place.
Promote healthy diets and lifestyle at the workplace Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 25
5
References
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28 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Annex 1
Evidence-based interventions to reduce the double burden of malnutrition
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 29 Sources and criteria for selection of interventionsa: §§ Nutrition interventions in eLENA that address undernutrition and overweight and obesityb. All interventions are from eLENA unless stated otherwise. §§ WHA Global Nutrition Targets 2025 Policy brief series.c §§ Interventions stated in the Action plan for the prevention and control of noncommunicable diseases in South-East Asia, 2013–2020. §§ Interventions in the Report of the Commission on Ending Childhood Obesityd. §§ Indirect nutrition interventions from Lancet series on Maternal and Child Nutrition 2013e. This list of interventions are a dynamic resource that should be adapted to different country contexts. It will be updated online on the SEARO website when new evidence is available.
Infants and young children
Breastfeeding •• Continued breastfeeding •• Education for increased breastfeeding duration •• Early initiation of breastfeeding •• Exclusive breastfeeding •• Implementation of the Baby-friendly Hospital Initiative •• Regulation of marketing breast-milk substitutes Complementary •• Supplementary feeding in community settings for promoting child growth feeding •• Deworming to combat the health and nutritional impact of helminth infections •• Reviewing supplementary feeding programmes that encourage rapid weight gain without linear growth in infants and young children Growth monitoring •• Improved identification, measurement and understanding of stunting and scale up coverage of and promotionc stunting-prevention activities •• Incorporating linear growth assessment into routine child health services, to provide critical, real time information for target setting and progress monitoring. •• Integrating nutrition in health-promotion strategies and strengthen service-delivery capacity in primary health systems and community-based care for prevention of stunting and acute malnutrition, supported by social protection programmes where feasible. Anaemia/iron •• Optimal timing of cord clamping for the prevention of iron deficiency anaemia in infants deficiency •• Iron supplementation in children 6-23 months of age •• Multiple micronutrient powders for home fortification of foods consumed by children 6–23 months of age •• Iron: intermittent supplementation in preschool and school-age children •• Iron: intermittent supplementation in children in malaria-endemic areas
a Other health sector interventions are not provided in this document b World Health Organisation. e Library of Evidence for Nutrition Actions (eLENA). http://www.who.int/elena/en/ c World Health Organisation. Global nutrition targets 2025 to improve maternal, infant and young child nutrition. http://www. who.int/nutrition/global-target-2025/en/ d Report of the Commission on Ending Childhood Obesity 2016. http://www.who.int/end-childhood-obesity/publications/echo- report/en/ e Maternal and child nutrition. Lancet. 2013 (http://www.thelancet.com/ series/maternal-and-child-nutrition,
30 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Micronutrients •• Vitamin A supplementation in infants 1–5 months of age •• Vitamin A supplementation in infants and children 6–59 months of age •• Vitamin A supplementation in neonates •• Vitamin D supplementation in children with respiratory infections •• Vitamin D supplementation in infants •• Vitamin E supplementation for the prevention of morbidity and mortality in preterm infants •• Zinc supplementation and growth in children •• Zinc supplementation in children with respiratory infections •• Zinc supplementation in the management of diarrhoea Low birth weight •• Breastfeeding of low-birth-weight infants •• Cup-feeding for low-birth-weight infants unable to fully breastfeed •• Demand feeding for low-birth-weight infants •• Donor human milk for low-birth-weight infants •• Feeding of very-low-birth-weight infants •• Kangaroo mother care to reduce morbidity and mortality in low-birth-weight infants •• Micronutrient supplementation in low-birth-weight and very-low-birth-weight infants •• Mother’s milk for low-birth-weight infants •• Standard formula for low-birth-weight infants following hospital discharge Wasting •• Identification, measurement and understanding of wasting and scaling up coverage of services for the identification and treatment of wasting. Moderate Acute Malnutrition: Supplementary foods for the management of moderate acute malnutrition in children Severe Acute Malnutrition •• Identification of severe acute malnutrition in children 6–59 months of age •• Identification of severe acute malnutrition requiring inpatient care in children 6–59 months of age •• Management of infants under 6 months of age with severe acute malnutrition •• Management of severe acute malnutrition in children 6–59 months of age with oedema •• Micronutrient intake in children with severe acute malnutrition Childhood •• Exclusive breastfeeding to reduce the risk of childhood overweight and obesity overweight and •• Implementing WHO Recommendations on marketing of foods and nonalcoholic beverages to obesity (in addition children to micronutrient •• Limiting portion sizes to reduce the risk of childhood and adolescent overweight and obesity. supplementation if warranted)c,d •• Reducing consumption of sugar-sweetened beverages to reduce the risk of childhood overweight and obesity •• Implement an effective tax on sugar-sweetened beverages •• Establish cooperation between Member States to reduce the impact of cross-border marketing of unhealthy foods and beverages •• Require settings such as schools, child-care settings, children’s sports facilities and events to create healthy food environments •• Provide clear guidance and support to caregivers to encourage the consumption of a wide variety of healthy foods for children •• Develop appropriate and context-specific nutrition information and guidelines for children and disseminate in a simple, understandable and accessible manner to all groups in society •• Ensuring planning and regulations to limit the availability of fast-food outlets near preschools, nurseries and schools
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 31 School aged children and adolescents
Micronutrients •• Iron: intermittent supplementation in preschool and school-age children •• Deworming to combat the health and nutritional impact of helminth infections* •• Iron: intermittent supplementation in children in malaria-endemic areas Healthy weight gainc,d •• Ensure data collection on BMI-for-age of children – including for ages not currently monitored •• Establish standards for meals provided in schools, or foods and beverages sold in schools and other child-care settings meet healthy nutrition guidelines •• Implementing WHO Recommendations on marketing of foods and nonalcoholic beverages to children •• Limiting portion sizes to reduce the risk of childhood and adolescent overweight and obesity •• Reducing consumption of sugar-sweetened beverages to reduce the risk of childhood overweight and obesity •• Providing outlets for fresh drinking water, wherever children and others gather (i.e. in preschools, nurseries and schools, play areas, parks, leisure facilities, primary health-care centers and hospitals). •• Removing incentives to unhealthy impulse purchases of foods high in saturated fats, trans- fats, free sugars or salt/sodium (i.e. snacks, confectionery) at shop checkouts, and investing in promotion of fresh fruits and vegetables (and in accessible locations) •• Ensuring planning and regulations to limit the availability of fast-food outlets near preschools, nurseries and schools Noncommunicable •• Increasing fruit and vegetable consumption to reduce the risk of noncommunicable diseases diseases •• Potassium: increasing intake to control blood pressure in children •• Sodium: reducing sodium intake to control blood pressure in children •• Taxation on sugar-sweetened beverages. •• Inclusion of nutrition and health education within the core curriculum of schools •• Improving nutrition literacy and skills of parents and caregivers. •• Establish multicomponent weight management services for children and adolescents who are overweight or obese as part of universal health coverage
32 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Pregnancy and women of reproductive age
Undernutrition •• Balanced energy and protein supplementation during pregnancy •• Monitor and manage appropriate gestational weight gain. •• Periconceptional folic acid supplementation to prevent neural tube defects •• Anaemia: insecticide-treated nets to reduce the risk of malaria in pregnant women •• Calcium supplementation during pregnancy for the prevention of pre-eclampsia •• Folic acid: peri-conceptional supplementation to prevent neural tube defects •• Iodine supplementation in pregnant and lactating women •• Iron and folic acid: daily supplementation during pregnancy •• Iron and folic acid: daily supplementation during pregnancy in malaria-endemic areas •• Iron and folic acid supplementation to prevent anaemia in postpartum women •• Multiple micronutrient powders for home fortification of foods consumed by pregnant women •• Multiple micronutrient supplementation during pregnancy •• Nutrition counselling during pregnancy •• Vitamin A supplementation during pregnancy •• Vitamin D supplementation during pregnancy for the prevention of pre-eclampsia •• Zinc supplementation during pregnancy •• Vitamin A supplementation in postpartum women •• Intermittent iron and folic acid supplementation in menstruating women •• Intermittent iron and folic acid supplementation in menstruating women in malaria-endemic areas Noncommunicable •• Reducing sodium intake to reduce blood pressure and risk of cardiovascular diseases in adults diseases •• Increasing potassium intake to reduce blood pressure and risk of cardiovascular diseases in adults •• Reducing consumption of sugar-sweetened beverages to reduce the risk of unhealthy weight gain in adults
Adults and older adults
Noncommunicable •• Develop and disseminate appropriate and context-specific nutrition information and diseases guidelines for adults and disseminate in a simple, understandable and accessible manner to all groups in society. •• Implement interpretive front-of-pack labelling, with public education for nutrition literacy*. •• Reducing sodium intake to reduce blood pressure and risk of cardiovascular diseases in adults. •• Increasing potassium intake to reduce blood pressure and risk of cardiovascular diseases in adults. •• Reducing consumption of sugar-sweetened beverages to reduce the risk of unhealthy weight gain in adults. Tuberculosis •• Management of moderate undernutrition in individuals with active tuberculosis •• Management of severe acute malnutrition in individuals with active tuberculosis •• Micronutrient supplementation in individuals with active tuberculosis •• Nutrition assessment and counselling in individuals with active tuberculosis
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 33 Indirect nutrition interventionsf
• Supporting women's empowerment and changes to intra household food allocation. • Promoting agriculture and nutrition friendly healthy food systems. • Early Childhood development interventions • Classroom education for girls • Social protection and safety nets including cash transfers • Water and sanitation initiatives • Targeted subsidies for nutritious foods or provision of foods for disadvantaged, vulnerable women: during pre- pregnancy and the pregnancy period, as required mothers with infants (0–6 months) and young children 6-23 months of age. • Infrastructure, income generation actions
f Ruel MT & Alderman H. the Maternal and Child Nutrition Study Group. Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Lancet. 2013, Aug;382 (9891): 536–51.
34 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Annex 2
Supporting global and regional resolutions/mandates and content analysis of technical areas covered
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 35 Targets Technical areas Maternal child Infant + Young Children + adolescent General population (adult) NCDs (salt/sweet/fat) Breastfeeding Overweight and Obesity Undernutrition (stunting, wasting and underweight) Micro nutrient Healthy systems
Global WHA55.25 Global Strategy on infant and + + + + + young child feeding 2003 www.who.int/nutrition/publications/ infantfeeding/9241562218/en/- accessed 1 August 2016
WHA57.17 Global Strategy on Diet, Physical + + + + Activity and Health 2004 www.who.int/dietphysicalactivity/strategy/ eb11344/strategy_english_web.pdf- accessed 1 August 2016 WHA65.6 Comprehensive Implementation + + + + + + + + Plan on Maternal Infant and Young Child Nutrition (WHO, 2014) and 2025 Global Nutrition targets www.who.int/nutrition/publications/CIP_ document/en/- accessed 1 August 2016 WHA68.19 Rome Declaration and 2nd + + + + + + + + + + International Conference on Nutrition and the framework for actions 2014, www.fao.org/resources/infographics/ infographics-details/en/c/266118- accessed 1 August 2016 Report of the Commission on ending (+) + + + + + + Childhood Obesity 2016 www.who.int/end- childhood-obesity/en/- accessed 1 August 2016 WHA66.10 Global Action Plan for prevention + + + + and control of NCD’s 2013–2020 www.who. int/nmh/events/ncd_action_plan/en/- accessed 1 August 2016 Sustainable Development Goal 2 targets at + + + (+) + 2025, 2030a WHA69.8 and UNGA A/70/L.42 UN Decade + + + + + + + + of Action on Nutrition. 2016–2025
a United Nations Environment Program. Final list of proposed Sustainable Development Goal Indicators. E/CN.3/2016/2/Rev.1. 41/67. 15-22439 www.unep.org/.../EARS_WG3_INF3_Final%20List%20proposed%20SDG%20indicat.. -accessed 4 August 2016
36 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Targets Technical areas Maternal child Infant + Young Children + adolescent General population (adult) NCDs (salt/sweet/fat) Breastfeeding Overweight and Obesity Undernutrition (stunting, wasting and underweight) Micro nutrient Healthy systems
Regional SEA/RC64/R4 Regional Nutrition Strategy; + + + + + Addressing malnutrition and micronutrient deficiencies 2011–2015 www.searo.who.int/entity/nutrition/documents/ sea_nut_181/en- accessed 1 August 2016 Action plan for the prevention and control + + + + of noncommunicable diseases in South-East Asia 2013–2020 www.searo.who.int/entity/ noncommunicable_diseases/documents/sea_ ncd_89/en- accessed 1 August 2016 South-East Asia Regional Strategic Framework + + + + + for Improving Neonatal and Child Health and Development 2012 www.searo.who.int/entity/ child_adolescent/documents/child_publication/ en/- accessed 1 August 2016
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 37
Annex 3
Regional monitoring framework for policy, capacity and legislative indicators (to be assessed in 2016 (baseline), 2021 (mid-term) and 2025 (end term))
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 39 Policy and progress indicators for Indicator definitions monitoring by WHO SEARO 1 National nutrition policies, strategies or National nutrition policies, strategies or action plans with explicit action plans with explicit reference to both reference to implementing actions to reduce undernutrition and undernutrition and overweight and obesity overweight and obesity are available.a Yes=2, in process= 1, are available No=0 2 Government has a functioning a multi- A multi-stakeholder coordination mechanism for nutrition is stakeholder coordination process for established and functionalb nutrition Yes=2 in process=1, No=0 3 Countries have identified time-bound Country has identified time-bound nutrition targets and diet- nutrition targets based on global nutrition related NCD targets in public policy documents. targets and diet related noncommunicable Yes=2, in process= 1, No=0 diseases (NCD) targets. 4 Appropriately skilled personnel with No. of appropriately skilled personnel with competencies to competencies to deliver nutrition services deliver nutrition services /public health nutritionists/100 000 are available populationa 5. Countries have conducted regular national Country has conducted a Demographic and Health Survey/ level nutrition surveys Multiple Indicator Cluster Survey/comparable national nutrition survey in the past three years? Yes (=1) if the survey was dated three years prior to baseline, mid- term or end term. No (=0) if no new surveys undertakena 6 Country food-based dietary guidelines that Country has food-based dietary guidelines that promote healthy promote healthy diets are developed and diets are developed and used for nutrition promotion. used for nutrition promotion Yes=2, in process= 1, No=0 7 Government has adopted legislation for Country has a comprehensive legislation for effective effective national implementation and implementation of the International Code of Marketing of Breast monitoring of the International Code of milk Substitutes (the Code) and subsequent relevant WHA Marketing of Breast milk Substitutes (ICBMS) resolutionsa and subsequent relevant WHA resolutions Yes=2, in process= 1, No=0 8 Legislation or regulations enacted to Country has legislation enacted to implement WHO’s implement WHO’s Recommendations on Recommendations on Marketing of unhealthy foods and non- Marketing of unhealthy foods and non- alcoholic beverages to childrena alcoholic beverages to children. Yes=2, in process= 1, No=0 9 Country has developed and implemented a Country has developed and implemented a mechanism for mechanism for promoting health diets in the promoting healthy diets for the informal food sector. informal food sector Yes=2, in process= 1, No=0 10 Countries have developed and implemented Country has developed/implemented the followingc processes to promote healthy dietary Meals provided in schools adhere to minimum nutrition standards environments in schools to reduce the based on national or regional dietary guidelines double burden of malnutrition (Yes =1, in process= 1, No=0,) Guidance set for food sold in vending machines and school snack bars (Yes =1, in process= 1, No=0,)
a World Health Organization. Indicators for the global monitoring framework on maternal, infant and young child nutrition. Geneva, 2014. http://www.who.int/nutrition/topics/proposed_indicators_framework/en/ - accessed 1 August 2016. b HANCI: Hunger and Nutrition Commitment Index. http://www.hancindex.org/explore-the-data/understanding-the-indicators/ - accessed 1 August 2016. c World Health Organization. School policy framework: implementation of the WHO global strategy on diet, physical activity and health. Geneva: WHO, 2008. http://www.who.int/dietphysicalactivity/SPF-en-2008.pdf - accessed 1 August 2016.
40 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Annex 4
Mapping of strategic directions and policy actions and linkages to the global nutrition and diet-related NCD targets (where specified, indicators from the WHO Global Monitoring Framework have been used)
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 41 Strategic Strategic Strategic Strategic direction 1 direction 2 direction 3 direction 4
Each policy action and policy indicator of Strategic Direction 1 presumably contributes to creating an enabling environment to achieving every nutrition target * Applied only for stunting target. The given asterisk is solely to deviating indicators between stunting and wasting target. a Indicators for the Global Monitoring Framework on Maternal, Infant and Young Child Nutrition 2014. b South East Asia Regional Strategic Framework for Improving Neonatal & Child Health and Development c Global NCDs monitoring framework and Action Plan for the Prevention and Control of Noncommunicable diseases in South-East Asia 2013-2020 d Report of the Commission on Ending Childhood Obesity-WHO
Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes IMPLEMENT RELEVANT EVIDENCE BASED INTERVENTIONS Proportion of Proportion of High level coordination Establish a high-level women aged children aged 6-23 mechanism established with coordination mechanism 15-49 years with months receiving specific terms of reference to guide multisectoral low body mass a minimum nutrition actions index (<18.5 kg/ acceptable dieta 40% reduction 2 a m ) Adequate resources (as identified Advocate and ensure in the number Percentage of by costing analysis) are earmarked adequate financing of children Number of births births in baby a and available for implementation for nutrition; prepare under five who during a given friendly facilities reference period of nutrition action plans budget and cost for are stunted Proportion of to women aged mothers of implementing key The change in 15-19 years children 0-23 interventions to reduce the number of /1000 females months receiving the double burden height-for-age aged 15-19 a counselling, National nutrition and/or related Develop/update national < (-)2 SD in years* support or health policies and plans have policies and plans in children under Prevalence messages addressed the double burden of nutrition and related five years of age of diarrhea in on optimal malnutrition sectors to reflect the between 2010 children under 5 breastfeeding at a double burden of and 2025 years of age least once in the Multisectoral nutrition action a last year plans with operational malnutrition and ensure Proportion of nutrition security stunted women Proportion women mechanisms are updated of reproductive aged 15-49 with identified budget lines, age (15-49 years receiving implemented and monitored years)a counselling / At least three key nonhealth Reduce and treatment on policies address the double maintain appropriate weight burden of malnutrition childhood gain wasting to less Proportion of Policy actions developed than 5% population using in cooperation with the a safely managed agricultural sector to reinforce The prevalence a drinking service measures directed at food of weight-for- growers, processors, retailers, height <(-)2 Proportion of population using to provide greater opportunities SD in children a safely managed for utilization of healthy and under five years sanitation servicea nutritious agricultural products of age between and foods. 2010 and 2025 Proportion of children with Time bound national nutrition Identify national targets severe acute malnutrition targets and diet-related NCD and indicators for having access targets are set and indicators nutrition and diet-related to appropriate based on the global monitoring NCD risk factors that treatment including framework are included in address country priorities therapeutic foods monitoring mechanism and nutrition counsellinga
42 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes Proportion of Frameworks to protect nutrition Ensure policy actions to children aged policies and dietary guidance from insulate nutrition policy- 12-59 months conflict of interest are developed making from conflict receiving at and implemented of interest to safeguard least one dose public good of deworming medicationa Health emergency /disaster Ensure that emerging preparedness plans explicitly challenges such as Percentage of address the double burden of climate change and pregnant women malnutrition natural disasters address aged 15-49 nutrition years receiving 1+ ANC visit National food based dietary Ensure availability and (including nutrition guidelines that promote nutritious operationalization counselling)b diets which emphasize on of legislation and diversity, high intake of fiber, guidelines to promote Percentage of and low fat, sugar and salt are healthy diversified diets pregnant women developed and utilized to reduce the double aged 15-49 burden of malnutrition years receiving National nutrition plans include and minimize diet 4+ ANC visit linkages with WASH (Water, related risk of NCDs (including nutrition Sanitation, and Hygiene (WASH) counselling)b Micronutrient (supplementation) Ensure that regulations Proportion of guidelines regularly updated and guidelines are in place for children under Food fortification legislation supplementation and five years old for iodization of salt and other fortification of products with diarrhea (in identified micronutrients are last two weeks) as suitable to the country developed and implemented receiving oral context dehydration salts (ORS packets or National guidelines developed Review, develop and pre-packaged ORS and in use for relevant diseases/ disseminate national fluids)a conditions including obesity guidelines on prevention and treatment of nutritional care in the management of common diseases Nutrition Guidelines for disaster Review, develop and preparedness or emergencies are disseminate guidelines developed and disseminated for disaster preparedness, response and management of nutrition emergencies International Code of Marketing of Promote protect and Breast milk Substitutes (the Code) support breastfeeding and subsequent relevant WHA and complementary resolutions are legislated and feeding practices implemented through comprehensive legislation and Maternity protection measures monitoring mechanisms enacted and aligned with ILO Convention 183 Institutions where deliveries take place successfully implemented the 10 steps to breastfeeding
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 43 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes Infant and Young Child Feeding Guidelines are updated with information on promoting a nutritious diet low in salt, sugar, and fat Measures to prevent inappropriate promotion of foods for infants and young children are in place Guidance provided on Develop guidelines for appropriate food supplementation supplementary food for pregnant and lactating women assistance to vulnerable and young children groups for improving health and nutritional status Health systems have defined an Ensure health systems essential package of nutrition incorporate Maternal interventions reflecting the double and Child Health and burden of malnutrition Nutrition interventions in primary health-care packages Adequate resources are earmarked Ensure adequate and available for implementation financing for nutrition of nutrition interventions through identified budget lines for nutrition related activities Existing curricula/programmes Ensure qualified for health and nutrition workers personnel with skills have been evaluated and revised and competencies to to include the double burden of develop, deliver and malnutrition evaluate population based nutrition services Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population Proportion of health-care facilities Promote nutrition that offer prevention/treatment services in clinical counselling and other nutrition conditions and settings services for undernutrition and for prevention and overweight and obesity treatment of severe acute malnutrition, obesity, and Defined, systematic bidirectional other nutrition related pathway developed and conditions implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded Establish/upgrade health to ensure food safety and support Infrastructure to facilitate implementation of healthy diet the implementation legislation of policy and legal directions to ensure Management of safe water and food safety and promote accessibility of sanitation facilities healthy diets is supported
44 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes Efficient and effective nutrition Initiate actions to develop surveillance actions suitable for and operationalize tracking the double burden of comprehensive nutrition malnutrition established surveillance systems and identify relevant Disaggregated data on nutritional indicators to inform, status (reflecting the double monitor and evaluate burden) available and utilized policies and programmes to track data on double burden of malnutrition Relevant professional and civil Recognize the society organizations have formed importance of networks and action groups to professional and civil support nutrition-promoting society organizations to programmes and behavior change promote and support communication campaigns healthy diets Academia are engaged in locally Engage academic relevant nutrition research, institutions to address monitoring, evaluation and knowledge and evidence surveillance to reduce the double gaps in promoting and burden of malnutrition creating healthy dietary and physical activity promoting environments Community advocacy plan Create a demand developed and implemented to for healthy lifestyles promote healthy, diversified diets (diversified diets and physical activity) in Evidence-informed public communities to reduce campaigns and social marketing all forms of malnutrition initiatives conducted to inform and encourage consumers about healthy dietary practice Teacher training and guidance are Require child-care available to support participative, settings, pre-schools, skills-based nutrition education in schools, children’s and schools youth sports facilities and events to create healthy food environments
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 45 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes IMPLEMENT RELEVANT EVIDENCE BASED INTERVENTIONS Proportion of Proportion of --Strategic direction 1-- --Strategic direction 1-- women aged pregnant women National food based dietary Ensure availability and 15-49 years with aged 15-49 years guidelines that promote nutritious operationalization low body mass receiving weekly diets which emphasize on of legislation and index (<18.5 kg/ iron-folic acid 50% reduction diversity, high intake of fiber, guidelin3es to promote m2)a supplementationa of anaemia and low fat, sugar and salt are healthy diversified diets in women of Number of Proportion of developed and utilized to reduce the double reproductive age births during a nonpregnant burden of malnutrition given reference women aged and minimize diet related The change National nutrition plan includes period to women 15-49 years risk of NCDs in number linkages to WASH (Water, aged 15-19 receiving weekly of pregnant Sanitation, and Hygiene (WASH) women aged years/1000 iron-folic acid a 15-49 years with females aged 15- supplementation a haemoglobin 19 years Proportion women <11 g/dL in aged 15-49 Micronutrient (supplementation) Ensure that regulations between (period years receiving guidelines within the country are and guidelines of 1993-2005) counselling/ updated regularly are in place for and 2025 treatment on supplementation and Food fortification legislation appropriate weight fortification of products The change for iodization of salt and gain as suitable to the country in number of other identified identified context nonpregnant Proportion of micronutrients are developed and women aged population using implemented 15-49 years with a safely managed haemoglobin drinking servicea National guidelines developed Review, develop and <12 g/dL in and in use for relevant diseases/ disseminate national Proportion of between (period conditions including obesity guidelines on prevention population using of 1993-2005) and treatment of a safely managed and 2025 nutritional care in the sanitation servicea management of common Percentage of diseases pregnant women Nutrition Guidelines for disaster Review, develop and aged 15-49 preparedness or emergencies are disseminate guidelines years receiving developed and disseminated for disaster preparedness, 1+ ANC visit response and (including nutrition management of nutrition counselling)b emergencies Percentage of School guidelines and standards Enact legislation/ pregnant women ensuring a healthy food regulations and aged 15-49 environment are developed and implement actions to years receiving implemented promote nutritious foods 4+ ANC visit to reduce undernutrition (including nutrition and overweight and b counselling) obesity in women and children Guidance provided on Develop guidelines for appropriate food supplementation supplementary food for pregnant and lactating women assistance to vulnerable and young children groups for improving health and nutritional status
46 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes Health systems have defined an Ensure health systems essential package of nutrition incorporate Maternal interventions reflecting the double and Child Health and burden of malnutrition Nutrition in essential primary health-care packages Adequate resources are Ensure adequate earmarked and available for financing for nutrition implementation of nutrition through identified budget interventions lines for nutrition related activities Existing curricula/programmes Ensure qualified for health and nutrition workers personnel with skills have been evaluated and revised and competencies to to include the double burden of develop, deliver and malnutrition evaluate population based nutrition services Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population Proportion of health-care facilities Promote nutrition that offer prevention/treatment services in clinical counselling and other nutrition conditions and settings services for undernutrition and for prevention and overweight and obesity treatment of severe acute malnutrition, obesity, and Defined, systematic bidirectional other nutrition related pathway developed and conditions implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded Establish/upgrade health to ensure food safety and support Infrastructure to facilitate implementation of healthy diet the implementation legislation of policy and legal directions to ensure Management of safe water and food safety and promote accessibility of sanitation facilities healthy diets is supported Efficient and effective nutrition Initiate actions to develop surveillance actions suitable for and operationalize tracking the double burden of comprehensive nutrition malnutrition established surveillance systems and identify relevant Disaggregated data on nutritional indicators to inform, status (reflecting the double monitor and evaluate burden) available and utilized policies and programmes to track data on double burden of malnutrition Relevant professional and civil Recognize the society organizations have formed importance of networks and action groups to professional and civil support nutrition-promoting society organizations to programmes and behavior change promote and support communication campaigns healthy diets
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 47 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes Academia engaged in locally Engage academic relevant nutrition research, institutions to address monitoring, evaluation and knowledge and evidence surveillance to reduce the double gaps in promoting and burden of malnutrition creating healthy dietary and physical activity promoting environments Community advocacy plan Create a demand developed and implemented to for healthy lifestyles promote healthy, diversified diets (diversified diets and physical activity) in Evidence-informed public communities to reduce campaigns and social marketing all forms of malnutrition initiatives conducted to inform and encourage consumers about healthy dietary practice Teacher training and guidance Require child-care are available to participative, settings, pre-schools, skills-based nutrition education schools, children’s and in schools youth sports facilities and events to create healthy food environments Healthy diets and lifestyle Promote healthy diets legislation and guidance are and lifestyle at the developed and implemented in workplaces workplaces
Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes IMPLEMENT RELEVANT EVIDENCE BASED INTERVENTIONS Proportion of Proportion of - -Strategic direction 1-- --Strategic direction 1-- women aged pregnant women National food based dietary Ensure availability and 15-49 years with aged 15-49 years guidelines that promote operationalization of low body mass receiving weekly nutritious diets which emphasize legislation and guidelines index (<18.5 kg/ iron and folic acid 30% reduction on diversity, high intake of fiber, to promote healthy diets m2)a supplementsa in low birth and low fat, sugar and salt are to reduce the double weight Percentage of developed and utilized burden of malnutrition and The change births in baby minimize diet related risk a in number of friendly facilities of NCDs infants born Proportion women Policies for subsidizing local fruit Promote fiscal policies to <2500 g aged 15-49 and vegetable are enacted reduce unhealthy diets between (period years receiving and enhance accessibility of 2006-2010) counselling/ of healthy foods such as and 2025 treatment on targeted subsidies for fruit appropriate weight and vegetables gain Micronutrient (supplementation) Ensure that regulations Percentage of guidelines are updated regularly and guidelines are in place pregnant women for supplementation and Food fortification legislation aged 15-49 fortification of products for iodization of salt and other years receiving as suitable for the country identified micronutrients are 1+ ANC visit context developed and implemented (including nutrition counselling)b Healthy and safe food guidelines Promote healthy and safe are developed for informal food foods in the informal food sector, disseminated and their sector to enable a healthy utilization monitored dietary environment
48 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes
Percentage of National guidelines developed Review, develop and pregnant women and in use for relevant diseases/ disseminate national aged 15-49 conditions including obesity guidelines on prevention years receiving and treatment of 4+ ANC visit nutritional care in the (including nutrition management of common counselling)b diseases Proportion of Nutrition Guidelines for disaster Review, develop and population using preparedness or emergencies disseminate guidelines a safely managed are developed and disseminated for disaster preparedness, drinking servicea response and management Proportion of of nutrition emergencies population using Maternity protection measures Promote protect and a safely managed enacted and aligned with ILO support breastfeeding sanitation servicea Convention 183 and complementary feeding practices through comprehensive legislation and monitoring mechanisms School guidelines and standards Enact legislation/regulations ensuring a healthy food and implement actions to environment are developed and promote nutritious foods to implemented reduce undernutrition and overweight and obesity in women and children Guidance provided Develop guidelines for on appropriate food supplementary food supplementation for pregnant assistance to vulnerable and lactating women and young groups for improving children health and nutritional status Health systems have defined Ensure health systems an essential package of nutrition incorporate Maternal and interventions reflecting the Child Health and Nutrition double burden of malnutrition in essential primary health- care packages Adequate resources are Ensure adequate financing earmarked and available for for nutrition through implementation of nutrition identified budget line for interventions nutrition related activities Existing curricula/programmes Ensure qualified for health and nutrition workers personnel with skills and have been evaluated and revised competencies to develop, to include the double burden of deliver and evaluate malnutrition population based nutrition services Number of appropriately skilled personnel with competencies to deliver nutrition services/public health nutritionists/100 000 population
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 49 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes
Proportion of health-care Promote nutrition services facilities that offer prevention/ in clinical conditions and treatment counselling and settings for prevention and other nutrition services for treatment of severe acute undernutrition and overweight malnutrition, obesity, and and obesity other nutrition related conditions Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Management of safe water Establish/upgrade health and accessibility of sanitation Infrastructure to facilitate facilities is supported the implementation of policy and legal directions to ensure food safety and promote healthy diets Efficient and effective nutrition Initiate actions to develop surveillance actions suitable for and operationalize tracking the double burden of comprehensive nutrition malnutrition established surveillance systems and identify relevant indicators Disaggregated data on to inform, monitor and nutritional status (reflecting the evaluate policies and double burden) available and programmes to track data utilized on double burden of malnutrition Relevant professional and civil Recognize the importance society organizations have of professional and civil formed networks and action society organizations to groups to support nutrition- promote and support promoting programmes and healthy diets behavior change communication campaigns Academia engaged in locally Engage academic relevant nutrition research, institutions to address monitoring, evaluation and knowledge and evidence surveillance to reduce the gaps in promoting and double burden of malnutrition creating healthy dietary and physical activity promoting environments Community advocacy plan Create a demand developed and implemented for healthy lifestyles to promote healthy, diversified (diversified diets and diets physical activity) in communities to reduce all Evidence-informed public forms of malnutrition campaigns and social marketing initiatives conducted to inform and encourage consumers about healthy dietary practice Teacher training and guidance Require child-care settings, are available to support pre-schools, schools, participative, skills-based children’s and youth nutrition education in schools sports facilities and events to create healthy food environments
50 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes IMPLEMENT RELEVANT EVIDENCE BASED INTERVENTIONS Proportion of Proportion of --Strategic direction 1-- --Strategic direction 1-- overweight and children 6-23 National food based dietary Ensure availability and obese women months of guidelines that promote operationalization of 18-49 years of age receiving nutritious diets which legislation and guidelines age (body mass a minimum No increase emphasize on diversity, high to promote healthy diets index ≥25 kg/ acceptable dieta in childhood intake of fiber, and low fat, to reduce the double m2)a overweight Percentage of sugar and salt are developed burden of malnutrition and The change Proportion of births in baby and utilized minimize diet related risk overweight in friendly facilitiesa of NCDs of prevalence National policies that limit school- age in weight-for- Proportion of saturated fatty acids and children and height >2 SD in mothers of virtually eliminate partially adolescents 5-18 children under children 0-23 hydrogenated vegetable years (BMI-for- five years of age months receiving oils in the food supply are age >+1 SD)a between 2010 counselling, implemented and 2025 support or Strategies and roadmaps messages for population reduction of on optimal salt, sugar and fat intake are breastfeeding at developed and implemented least once in the last yeara Fiscal-policies are developed Promote fiscal policies to and implemented for food reduce unhealthy diets and Proportion women products that high in sugar, fat, enhance accessibility of who received and salt healthy foods (e.g. targeted counselling/ subsidies for fruit and treatment of Fiscal policies for subsidizing vegetables) appropriate body local fruit and vegetable are weight implemented Proportion of Legislation enacted to ensure Enact legislation on children and mandatory nutrient content provision of appropriate adolescent labelling based on codex nutritional information for diagnosed as guidance and interpretative packaged food products overweight labelling of food products ( front or obese of pack) who received A watchdog mechanism is appropriate weight established to ensure that management health and nutrition claims are d service based on codex guidelines and All relevant adequate scientific evidence government Healthy and safe food guidelines Promote healthy and safe units have codes are developed for informal food foods in the informal food of guidance on sector, disseminated and their sector to enable a healthy identifying and utilization monitored dietary environment countering industry influences National guidelines developed Review, develop and and in use for relevant diseases/ disseminate national Guidance on conditions including obesity guidelines on prevention healthy idets to and treatment of nutritional prevent childhood care in management of overweight common diseases and obesity are updated. Nutrition Guidelines for disaster Review, develop and preparedness or emergencies disseminate guidelines Mandatory are developed and disseminated for disaster preparedness, nutrition labelling response and management is enacted of nutrition emergencies
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 51 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes International Code of Marketing Promote protect and of Breast milk Substitutes (the support breastfeeding Code) and subsequent relevant and complementary WHA resolutions are legislated feeding practices and implemented through comprehensive legislation and monitoring Maternity protection measures mechanisms enacted and aligned with ILO Convention 183 Institutions where deliveries take place successfully implemented the 10 steps to breastfeeding Infant and Young Child Feeding Guidelines are updated with information on promoting a nutritious diet low in salt, sugar, and fat Measures to prevent inappropriate promotion of foods for infants and young children are in place Legislation enacted Enact legislation/regulations to implement WHO’s and implement actions to Recommendations on Marketing promote nutritious foods to of unhealthy foods and reduce undernutrition and beverages to children overweight and obesity in women and children School guidelines and standards ensuring a healthy food environment are developed and implemented (include pre -schools) Health systems have defined an Ensure health systems essential package of nutrition incorporate Maternal and interventions reflecting the Child Health and Nutrition double burden of malnutrition in essential primary health- care packages Adequate resources are Ensure adequate financing earmarked and available for for nutrition through implementation of nutrition identified budget line for interventions nutrition related activities Existing curricula/programmes Ensure qualified for health and nutrition workers personnel with skills and have been evaluated and competencies to develop, revised to include the double deliver and evaluate burden of malnutrition population based nutrition services Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population
52 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes Proportion of health-care Promote nutrition services facilities that offer prevention/ in clinical conditions and treatment counselling and settings for prevention and other nutrition services for treatment of severe acute undernutrition and overweight malnutrition, obesity, and and obesity other nutrition related conditions Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded Establish/upgrade health to ensure food safety and Infrastructure to facilitate support implementation of the implementation of healthy diet legislation policy and legal directions to ensure food safety and promote healthy diets Efficient and effective nutrition Initiate actions to develop surveillance actions suitable for and operationalize tracking the double burden of comprehensive nutrition malnutrition established surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil Recognize the importance society organizations have of professional and civil formed networks and action society organizations to groups to support nutrition- promote and support promoting programmes and healthy diets education campaigns Academia engaged in locally Engage academic relevant nutrition research, institutions to address monitoring, evaluation and knowledge and evidence surveillance to reduce the gaps in promoting and double burden of malnutrition creating healthy dietary and physical activity promoting environments Community advocacy plan Create a demand for developed and implemented healthy lifestyles (diversified to promote healthy, diversified diets and physical activity) diets in communities to reduce all forms of malnutrition Evidence-informed public campaigns and social marketing initiatives conducted to inform and encourage consumers about healthy dietary practice
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 53 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes Teacher training and guidance Require child-care settings, are available to support pre-schools, schools, participative, skills-based children’s and youth nutrition education in schools sports facilities and events to create healthy food environments Relevant stakeholders including Engage with stakeholders private sector are appropriately including private sector engaged to implement actions, to reduce the obesogenic aimed at reducing overweight, environment, while obesity and dietary risk of NCDs instituting essential checks with necessary checks and and balances to prevent balances in place. undue influences on policymaking Healthy diets and lifestyle Promote healthy diets and legislation and guidance are lifestyle at the workplaces developed and implemented in workplaces
Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes IMPLEMENT RELEVANT EVIDENCE BASED INTERVENTIONS Proportion of Percentage of --Strategic direction 1-- --Strategic direction 1-- children born births in baby National food based dietary Ensure availability and in the last 24 friendly facilitiesa guidelines that promote operationalization of months who Proportion of nutritious diets which emphasize legislation and guidelines to were put to the Increase the mothers of on diversity, high intake of fiber, promote healthy diversified breast within one rate of exclusive children 0-23 and low fat, sugar and salt are diets to reduce the double hour of birtha breastfeeding months receiving developed and utilized burden of malnutrition and in the first 6 Number of births counselling, minimize diet related risk months up to at during a given support or of NCD’s least 50% reference period messages Nutrition Guidelines for disaster Review, develop and to women on optimal The prevalence preparedness or emergencies disseminate guidelines aged 15-19 breastfeeding at of infants aged are developed and disseminated for disaster preparedness, 0-5 months years/1000 least once in the a response and management received only females aged 15- last year a of nutrition emergencies breast milk 19 years during the International Code of Marketing Promote protect and previous day of Breast milk Substitutes (the support breastfeeding between (period Code) and subsequent relevant and complementary of 2006-2010) WHA resolutions are legislated feeding practices and 2025 and implemented through comprehensive legislation and monitoring Maternity protection measures mechanisms enacted and aligned with ILO Convention 183 Institutions where deliveries take place successfully implemented the 10 steps to breastfeeding Infant and Young Child Feeding Guidelines are updated with information on promoting a nutritious diet low in salt, sugar, and fat Measures to prevent inappropriate promotion of foods for infants and young children are in place
54 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes Guidance provided Develop guidelines for on appropriate food supplementary food supplementation for pregnant assistance to vulnerable and lactating women and young groups for improving health children and nutritional status Health systems have defined an Ensure health systems essential package of nutrition incorporate Maternal and interventions reflecting the Child Health and Nutrition double burden of malnutrition in essential primary health- care packages Adequate resources are Ensure adequate financing earmarked and available for for nutrition through implementation of nutrition identified budget line for interventions nutrition related activities Existing curricula/programmes Ensure qualified for health and nutrition workers personnel with skills and have been evaluated and revised competencies to develop, to include the double burden of deliver and evaluate malnutrition population based nutrition services Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population Proportion of health-care Promote nutrition services facilities that offer prevention/ in clinical conditions and treatment counselling and settings for prevention and other nutrition services for treatment of severe acute undernutrition and overweight malnutrition, obesity, and and obesity other nutrition related conditions Efficient and effective nutrition Initiate actions to develop surveillance actions suitable for and operationalize tracking the double burden of comprehensive nutrition malnutrition established surveillance systems and identify relevant indicators Disaggregated data on to inform, monitor and nutritional status (reflecting the evaluate policies and double burden) available and programmes to track data utilized on double burden of malnutrition Relevant professional and civil Recognize the importance society organizations have of professional and civil formed networks and action society organizations to groups to support nutrition- promote and support promoting programmes and healthy diets education campaigns Academia are engaged in locally Engage academic relevant nutrition research, institutions to address monitoring, evaluation and knowledge and evidence surveillance to reduce the gaps in promoting and double burden of malnutrition creating healthy dietary and physical activity promoting environments
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 55 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes Community advocacy plan Create a demand developed and implemented for healthy lifestyles to promote healthy, diversified (diversified diets and diets physical activity) in communities to reduce all Evidence-informed public forms of malnutrition campaigns and social marketing initiatives conducted to inform and encourage consumers about healthy dietary practice Healthy diets and lifestyle Promote healthy diets and legislation and guidance are lifestyle at the workplaces developed and implemented in workplaces
Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes IMPLEMENT RELEVANT EVIDENCE BASED INTERVENTIONS Age-standardized --Strategic direction 1-- --Strategic direction 1-- mean population National food based dietary Ensure availability and intake of salt guidelines that promote operationalization of (sodium Chloride) nutritious diets which legislation and guidelines to per day in grams in A 30% relative emphasize on diversity, high promote healthy diversified persons aged 18+ reduction intake of fiber, and low fat, diets to reduce the double yearsc in mean sugar and salt are developed burden of malnutrition and population Percentage of and utilized minimize diet related risk households that of NCDs intake of salt/ Strategies and roadmaps for have adequately sodium promoting healthy diets and iodized salt (>15 The change of population reduction of salt, ppm)a age-standardized sugar, and fat are developed mean population Mandatory and implemented nutrition labelling intake of Fiscal-policies are developed Promote fiscal policies to is encated salt (sodium and implemented for food reduce unhealthy diets and Chloride) per products that high in sugar, fat, enhance accessibility of day in grams in and salt healthy foods (e.g. targeted persons aged subsidies for fruit and Fiscal policies for subsidizing 18+ years vegetables) between 2010 local fruit and vegetable are and 2025 enacted Micronutrient (supplementation) Ensure that regulations guidelines are regularly updated and guidelines are in place for supplementation and Food fortification legislation fortification of products for iodization of salt and other as suitable to the country identified micronutrients are context developed and implemented Legislation enacted to ensure Enact legislation on mandatory nutrient content provision of appropriate labelling based on codex nutritional information for guidance and interpretative packaged food products labelling of food products ( front of pack) A watchdog mechanism is established to ensure that health and nutrition claims are based on codex guidelines and adequate scientific evidence
56 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes Healthy and safe food guidelines Promote healthy and safe are developed for informal food foods in the informal food sector, disseminated and their sector to enable a healthy utilization monitored dietary environment National guidelines developed Review, develop and and in use for relevant diseases/ disseminate national conditions including obesity guidelines on prevention and treatment of nutritional care in the management of common diseases Nutrition Guidelines for disaster Review, develop and preparedness or emergencies disseminate guidelines are developed and disseminated for disaster preparedness, response and management of nutrition emergencies Legislation enacted Enact legislation/regulation to implement WHO’s and mechanisms to Recommendations on Marketing promote healthy foods of unhealthy foods and for children to reduce beverages to children undernutrition and overweight and obesity and School guidelines and standards diet related risks of NCDs ensuring a healthy food environment are developed and implemented Guidance provided Develop guidelines for onappropriate food supplementary food supplementation for pregnant assistance to vulnerable and lactating women and young groups for improving health children and nutritional status Adequate resources are Ensure adequate financing earmarked and available for for nutrition through implementation of nutrition identified budget lines for interventions nutrition related activities Existing curricula/programmes Ensure qualified for health and nutrition workers personnel with skills and have been evaluated and competencies to develop, revised to include the double deliver and evaluate burden of malnutrition population based nutrition services Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population Proportion of health-care Promote nutrition services facilities that offer prevention/ in clinical conditions and treatment counselling and settings for prevention and other nutrition services for treatment of severe acute undernutrition and overweight malnutrition, obesity, and and obesity other nutrition related conditions
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 57 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes Food laboratories are upgraded Establish/upgrade health to ensure food safety and Infrastructure to facilitate support implementation of the implementation of healthy diet legislation policy and legal directions to ensure food safety and promote healthy diets Efficient and effective nutrition Initiate actions to develop surveillance actions suitable for and operationalize tracking the double burden of comprehensive nutrition malnutrition established surveillance systems and identify relevant indicators Disaggregated data on to inform, monitor and nutritional status (reflecting the evaluate policies and double burden) available and programmes to track data utilized on double burden of malnutrition Relevant professional and civil Recognize the importance society organizations have of professional and civil formed networks and action society organizations to groups to support nutrition- promote and support promoting programmes and healthy diets education campaigns Academia are engaged in locally Engage academic relevant nutrition research, institutions to address monitoring, evaluation and knowledge and evidence surveillance to reduce the gaps in promoting and double burden of malnutrition creating healthy dietary and physical activity promoting environments Community advocacy plan Create a demand developed and implemented for healthy lifestyles to promote healthy, diversified (diversified diets and diets physical activity) in communities to reduce all Evidence-informed public forms of malnutrition campaigns and social marketing initiatives conducted to inform and encourage consumers about healthy dietary practice Teacher training and guidance Require child-care settings, are available to support pre-schools, schools, participative, skills-based children’s and youth nutrition education in schools sports facilities and events to create healthy food environments Relevant stakeholders including Engage with stakeholders private sector are appropriately including private sector engaged to implement actions, to reduce the obesogenic aimed at reducing overweight, environment, while obesity and dietary risk of NCDs instituting essential checks with necessary checks and and balances to prevent balances in place. undue influences on policymaking Healthy diets and lifestyle Promote healthy diets and legislation and guidance are lifestyle at the workplaces developed and implemented in workplaces
58 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes IMPLEMENT RELEVANT EVIDENCE BASED INTERVENTIONS Increased intake Age-standardized --Strategic direction 1-- --Strategic direction 1-- of fruits and prevalence of National food based dietary Ensure availability and vegetables persons (aged 18+ guidelines that promote operationalization of years) consuming Reduced nutritious diets which legislation and guidelines to less than five total Halt the rise in consumption of emphasize on diversity, high promote healthy diversified servings (400 diabetes and saturated fats/ intake of fiber, and low fat, diets to reduce the double grams) of fruit and obesity trans fats, sugar sugar and salt are developed burden of malnutrition and vegetables per dayc and salt and utilized minimize diet related risk The change Age-standardized of NCDs in prevalence Reduced cardio- National policies that limit mean proportion of of overweight metabolic risk saturated fatty acids and total energy intake and obesity in in persons aged virtually eliminate partially from saturated fatty adolescents 18+ years hydrogenated vegetable acids in persons (defined oils in the food supply are aged 18+ yearsc implemented according to the Age-standardized WHO growth Strategies and roadmaps mean proportion of reference for for population reduction of persons aged 18+ school-aged salt, sugar and fat intake are years receiving developed and implemented children and counselling/ adolescents, treatment on Fiscal-policies are developed Promote fiscal policies to overweight – appropriate weight and implemented for food reduce unhealthy diets and BMI for age and gain products that high in sugar, fat, enhance accessibility of sex >1 SD, and and salt healthy foods (e.g. targeted Proportion of obese – BMI for subsidies for fruit and adolescents Policies for subsidizing local fruit age and sex >2 vegetables) receiving and vegetable are implemented SD) between counselling/ 2010 and 2025 Legislation enacted to ensure Enact legislation on treatment on mandatory nutrient content provision of appropriate The change of appropriate weight labelling based on codex nutritional information for age-standardized gain guidance and interpretative packaged food products prevalence of Proportion of labelling of food products (front overweight children and of pack) and obesity in adolescent persons aged A watchdog mechanism is diagnosed as 18+ years established to ensure that overweight (defined as body health and nutrition claims are or obese mass index ≥ based on codex guidelines and who received 25 kg/m2 for adequate scientific evidence appropriate weight overweight and management Healthy and safe food Promote healthy and safe body mass index serviced guidelines are developed foods in the informal food ≥ 30 kg/m² for for informal food sector, sector to enable a healthy obesity) between disseminated and their dietary environment 2010 and 2025. utilization monitored National guidelines developed Review, develop and and in use for relevant diseases/ disseminate national conditions including obesity guidelines on prevention and treatment of nutritional care in the management of common diseases Nutrition Guidelines for Review, develop and disaster preparedness or disseminate guidelines emergencies are developed and for disaster preparedness, disseminated response and management of nutrition emergencies
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 59 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes International Code of Marketing Promote protect and of Breast milk Substitutes (the support breastfeeding Code) and subsequent relevant and complementary WHA resolutions are legislated feeding practices and implemented through comprehensive legislation and monitoring Maternity protection measures mechanisms enacted and aligned with ILO Convention 183 Institutions where deliveries take place successfully implemented the 10 steps to breastfeeding Infant and Young Child Feeding Guidelines are updated with information on promoting a nutritious diet low in salt, sugar, and fat Measures to prevent inappropriate promotion of foods for infants and young children are in place Legislation enacted Enact legislation/regulations to implement WHO’s and implement actions to Recommendations on promote nutritious foods to Marketing of unhealthy foods reduce undernutrition and and beverages to children overweight and obesity in women and children School guidelines and standards ensuring a healthy food environment are developed and implemented Health systems have defined an Ensure health systems essential package of nutrition incorporate Maternal and interventions reflecting the Child Health and Nutrition double burden of malnutrition in essential primary health- care packages Adequate resources are Ensure adequate financing earmarked and available for for nutrition through implementation of nutrition identified budget lines for interventions nutrition related activities Existing curricula/programmes Ensure qualified for health and nutrition workers personnel with skills and have been evaluated and competencies to develop, revised to include the double deliver and evaluate burden of malnutrition population based nutrition services Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population
60 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes Proportion of health-care Promote nutrition services facilities that offer prevention/ in clinical conditions and treatment counselling and settings for prevention and other nutrition services for treatment of severe acute undernutrition and overweight malnutrition, obesity, and and obesity other nutrition related conditions Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded Establish/upgrade health to ensure food safety and Infrastructure to facilitate support implementation of the implementation of healthy diet legislation policy and legal directions to ensure food safety and promote healthy diets Efficient and effective nutrition Initiate actions to develop surveillance actions suitable for and operationalize tracking the double burden of comprehensive nutrition malnutrition established surveillance systems and identify relevant indicators Disaggregated data on to inform, monitor and nutritional status (reflecting the evaluate policies and double burden) available and programmes to track data utilized on double burden of malnutrition Relevant professional and civil Recognize the importance society organizations have of professional and civil formed networks and action society organizations to groups to support nutrition- promote and support promoting programmes and healthy diets education campaigns Academia are engaged in locally Engage academic relevant nutrition research, institutions to address monitoring, evaluation and knowledge and evidence surveillance to reduce the gaps in promoting and double burden of malnutrition creating healthy dietary and physical activity promoting environments Community advocacy plan Create a demand for developed and implemented healthy lifestyles (diversified to promote healthy, diversified diets and physical activity) diets in communities to reduce all forms of malnutrition Evidence-informed public campaigns and social marketing initiatives conducted to inform and encourage consumers about healthy dietary practice
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 61 Targets and its Intermediate Process indicators Policy indicators Policy actions measure(s) outcomes Teacher training and guidance Require child-care settings, are available to support pre-schools, schools, participative, skills-based children’s and youth nutrition education in schools sports facilities and events to create healthy food environments Relevant stakeholders including Engage with stakeholders private sector are appropriately including private sector engaged to implement actions, to reduce the obesogenic aimed at reducing overweight, environment, while obesity and dietary risk of instituting essential checks NCDs with necessary checks and balances to prevent and balances in place. undue influences on policymaking Healthy diets and lifestyle Promote healthy diets and legislation and guidance are lifestyle at the workplaces developed and implemented in workplaces
62 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Annex 5
Examples of sector(s) key policies and interventions
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 63 Education •• Policies that encourage girls in school for longer •• Increase equitable and sustainable access to education, especially for girls, including during periods of conflict and emergency •• Nutrition and physical activity as a core component of education curriculum •• Healthy dietary environment in schools and surrounding premises •• Regular assessment of health including BMI in schools and follow up Social protection •• Social protection and assistance measures ensuring access for most vulnerable women, children and adolescents. Specific design features are needed to increase nutrition sensitivity. •• Implement Targeted specific programmes to the critical window of opportunity (i.e. the first 100 days). •• Include education activities in social protection (SP) interventions to increase household awareness of health and nutrition care giving and health seeking behaviors. •• Reduce acute and long-term negative impacts of external financial, price, and weather shocks by scaling up programs in times of crises Water and •• Provide universal access to safely managed, affordable and sustainable drinking water sanitation •• Invest in education on the importance of safely managed water use and infrastructure in •• households, communities, schools and health facilities •• Provide universal access to improved sanitation facilities and hygiene measures and end open defecation •• Encourage implementation of sanitation safety plans Agriculture •• Programmes that boost agricultural production, keep prices low, and enhance food security, especially in disadvantaged communities with a high poverty rates. •• Sustainable and healthy food systems with increased availability of healthy foods including vegetables and fruit to enhance access to diverse diets •• Increased focus on food safety and food processing Labour •• Provide entitlements for parental leave and for childcare •• Eliminate child labour Finance, trade •• Shifting government incentives from supporting unhealthy products to healthier products. and commerce •• Fiscal policies that tax unhealthy foods and subsidize healthy options (fruit and vegetables) •• Modifying trade policies to be nutrition sensitive Infrastructure •• Build health-enabling urban environments for women, children and adolescents, through •• Improved access to green spaces and walking and cycling networks that offer dedicated •• transit, safe mobility and physical activity Information and •• Improve access to nutrition information and communication technologies, communication •• Ensure accurate and ethical messaging regarding advertisement of food products •• Improve nutrition and health literacy of population through varied means
64 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 Annex 6
Resolution of the WHO Regional Committee for South-East Asia
SEA/RC69/R5
STRATEGIC ACTION PLAN TO REDUCE THE DOUBLE BURDEN OF MALNUTRITION IN THE SOUTH-EAST ASIA REGION 2016–2025
The Regional Committee,
Having considered the Strategic Action Plan to reduce the double burden of Malnutrition in the South-East Asia Region 2016–2025,
Recognizing the global commitment and the adoption of “Transforming our world: the 2030 Agenda for Sustainable Development” that aims to end poverty and hunger everywhere; to combat inequalities within and among countries; to build peaceful, just and inclusive societies; to protect human rights and promote gender equality and the empowerment of women and girls; and to ensure the lasting protection of the planet and its natural resources,
Recognizing that reducing the double burden of malnutrition contributes to the achievement of a number of global goals and targets including the 2030 Agenda for Sustainable Development, Global nutrition targets 2025, Global Action Plan for the Prevention and Control of NCDs 2013-2020 and the Global Strategy for Women’s, Children’s and Adolescent’s Health 2016-2030,
Alarmed at the ongoing nutrition transition in the South-East Asia Region which is characterized by persistent under-nutrition including micronutrient deficiencies, and the emergence of overweight and obesity, which increases the risk of noncommunicable diseases (NCDs),
Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025 65 Emphasizing the varying extent and nature of challenges of the double burden of malnutrition across Member States in the Region which require urgent and sustained efforts,
Noting with appreciation that the Strategic Action Plan was developed through an extensive consultative process with Member States and nutrition experts, bringing together guidance from global and regional policy platforms,
Acknowledging the importance of country commitment, leadership and actions, and the need for applying the Strategic Action Plan into national health/nutrition plans, as appropriate to country context,
Recognizing the need for a life-course approach, multi-stakeholder and multisectoral partnerships including the private sector and civil society for effective and concerted actions,
Emphasizing the crucial role of data and information systems at all levels,
1. ENDORSES the Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region 2016–2025;
2. URGES Member States:
a) To consider adopting and implementing, in accordance with their national priorities and context, the strategic action plan including multisectoral actions, in order to reduce the double burden of malnutrition;
b) To strengthen policy and legislative framework for this purpose, as well as monitoring, evaluation, accountability, policy uses and follow-up at all levels, including through improving the quality of national health information systems, and
3. REQUESTS the Regional Director:
a) To provide adequate technical support to Member States in the implementation of the strategic action plan including for strengthening monitoring and evaluation systems;
b) To continue to collaborate with the United Nations agencies, funds and programmes and other relevant partners and stakeholders, to advocate and leverage assistance for aligned and effective implementation of the strategic action plan in Member States, and
c) To conduct mid-term (2021) and end-term (2025) assessments of the progress and achievements of the strategic action plan and report to the subsequent Regional Committee meetings.
Seventh session, 9 September 2016
66 Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia Region, 2016–2025
As the WHO South-East Asia Region enters the era of the Sustainable Development Goals with remarkable Strategic Action Plan to reduce the social and economic development in all Member States, the nutrition status of the population, however, double burden of has not kept pace with development in other sectors. Large segments of the population continue to suffer from malnutrition. An ongoing transition is reshaping malnutrition the nutrition profile across all countries where undernutrition predominated previously. While in the South-East Asia Region undernutrition rates, including micronutrient malnutrition, are declining, albeit slowly, a significant rise in overweight and obesity – the double burden– is 2016–2025 seen across many age groups. There is also an associated rapid upsurge in noncommunicable diseases. The key challenge in the Region is to ensure that interventions for undernutrition remain in focus and are scaled up, while addressing overweight and obesity.
The Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016–2025 aims to provide guidance to Member States on comprehensive approaches to prevent malnutrition. This plan will serve Member States as an advocacy and reference tool to ensure that interventions covering all forms of malnutrition are addressed comprehensively in country policies, strategies and actions.
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