SEA/RC69/16Rev.3: Strategic action plan to reduce the double burden of malnutrition in the South-East Asia Region 2016-2025

REGIONAL COMMITTEE Sixty-ninth Session Colombo, Sri Lanka 5–9 September 2016

Provisional Agenda item 9.8 SEA/RC69/16 22 July 2016

Regional Strategic Plan to Address Double Burden of Malnutrition in the South-East Asia Region Malnutrition in all its forms threatens human development. Both undernutrition and overweight and obesity throughout the life course are public health problems in the WHO South-East Asia Region, affecting Member States to varying degrees. Undernutrition, including micronutrient deficiencies, contributes to about 45% of preventable deaths of children under five years of age annually, while overweight resulting from unhealthy diets and sedentary lifestyle underpins high rates of noncommunicable diseases (NCDs) in Member States. Therefore, urgent attention is needed to reduce malnutrition. While the previous Regional Nutrition Strategy, “Addressing malnutrition and micronutrient deficiencies (2011–2015)”, emphasized a multisectoral approach (SEA/RC64/R4), it cannot adequately address the current need in the Region to tackle both undernutrition and overweight and obesity. Many global actions and policies have focused attention on the rise of overweight and obesity, including the recent Sustainable Development Goals agenda, which calls for an end to all forms of malnutrition. In response, the WHO Regional Office, in consultation with Member States, has developed a Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016–2025, through extensive consultation with Member States, technical experts and WHO country offices and headquarters. The Plan focuses on creating an enabling environment that will facilitate the implementation of interventions focused towards both undernutrition and overweight and obesity. The attached Working Paper was presented to the High-Level Preparatory (HLP) Meeting for its review and recommendations. It was discussed that the title of the Regional Committee agenda item may be reflected as “Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016–2025”. The recommendations made by the HLP Meeting for consideration to the Sixty-ninth Session of the Regional Committee are as follows: Actions by Member States (1) Propose a resolution based on the Draft Regional Strategic Plan to Address the Double Burden of Malnutrition in the South-East Asia Region at the Sixty-ninth Session of the Regional Committee for South-East Asia in September 2016.

(2) Use the draft plan – based on the national context in each country – as an advocacy and reference tool to guide the process of updating national plans and strategies to address the double burden of malnutrition. Actions by WHO (1) Provide technical guidance and support to Member States for adapting and revising their policies and plans on nutrition to address the double burden. (2) Support operationalizing of actions to address the double burden of malnutrition through technical support to mobilize resources, develop capacity, and frame and enact new legislations and regulations based on country-level contexts and specificities. (3) Adapt and develop region-specific tools and frameworks to support development of an enabling environment for implementation of evidence-based nutrition interventions. This Working Paper and the HLP Meeting recommendations are submitted to the Sixty-ninth Session of the WHO Regional Committee for South-East Asia for its consideration and decision.

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Introduction 1. Economic growth and investments, demographic changes, globalization and social and health development have altered the nutrition profile and its determinants across the WHO South-East Asia Region. Despite progress in reducing hunger and undernutrition, malnutrition continues to undermine the health of populations. The current nutrition landscape in the Region is characterized by persistent undernutrition and emerging overweight and obesity existing side by side, often within the same community; i.e. the double burden. The extent of the double burden varies across Member States, and urgent and sustained efforts are needed in improving nutrition status. 2. Undernutrition contributes to about 45% of preventable deaths of children under five years of age annually. Meanwhile, increased rates of overweight and obesity mainly resulting from unhealthy diets and sedentary lifestyle have led to unprecedented rates of noncommunicable diseases (NCDs) in Member States, with 55% of all deaths attributed to NCDs. Regionally, an estimated 60 million children in the 0–5-year age group are stunted, 45 million are underweight and 8.8 million are overweight. Thinness in adolescent girls aged 15–19 years ranges from 24% to 47%, and overweight between 2% and 24%. Among adult women, prevalence of overweight is greater than underweight and ranges from 18% to 34% across Member States. Anaemia and other micronutrient deficiencies affect both the undernourished and overweight and obese, and is of a magnitude to be recognized as a public health problem in all Member States. High salt intake in all Member States compounds the rise in NCDs and hypertension rates, with one in three adults estimated to have high blood pressure.

Current responses and challenges 3. Previous nutrition policy initiatives of the SEA Region have not comprehensively addressed both aspects of malnutrition. The Regional Nutrition Strategy, “Addressing malnutrition and micronutrient deficiencies (2011–2015)”, emphasized a multisectoral approach and the identification of core nutrition interventions (SEA/RC64/R4). WHO has supported Member States to review national nutrition policies and plans and strengthen multisectoral collaboration. WHO has also facilitated initial policy dialogue and advocated Member States to focus on the double burden of malnutrition. 4. Maternal undernutrition, as well as overweight and obesity, have a transgenerational impact with significant repercussions for future generations. Undernutrition and overweight and obesity result from suboptimum dietary practices through the life cycle, with low physical activity exacerbating effects of unhealthy diets. In addition to the traditional determinants of malnutrition, which include inequity, inadequate nutrition and inadequate care, newer drivers of the epidemic of overweight and obesity are the obesogenic environment caused by urbanization and changing lifestyles, unhealthy food systems and globalization of markets resulting in the increasing availability of energy-dense, nutrient-poor foods high in sugar, salt and fat, aggressive marketing of unhealthy foods and low physical activity. Emerging challenges such as climate change and migration compound the problem.

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5. Due to the historic and the significant burden of undernutrition in the past decades, most health systems in Member States are geared towards reducing undernutrition. Therefore, countries in this Region are challenged to concurrently develop systematic multisectoral policy actions and implement interventions for reducing overweight and obesity, and dietary risk factors for NCDs, in addition to the current focus on undernutrition. 6. Many global actions and policies have focused attention on the double burden of Malnutrition. These include: • • • • • WHO Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition (resolution WHA65.6) and Global Nutrition Targets 2025; The Outcome of the Second International Conference on Nutrition (resolution WHA68.19); The United Nations Decade of Action on Nutrition (2016 –2025) (UNGA A/70/L.42 and resolution WHA69.7); Nutrition-related SDGs, including SDG2 which calls for an end to all forms of malnutrition by 2030 and reaffirms attaining the global nutrition targets by 2025; Sixty-ninth World Health Assembly resolution and decision (the guidance on ending inappropriate promotion of foods for infants and young children (resolution WHA69.9) and the Report of the Commission on Ending Childhood Obesity (resolution WHA 69(12)).

The way forward 7. In view of the rising double burden of malnutrition reflected in the unfinished agenda of reducing undernutrition and diet-related noncommunicable diseases, a Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016–2025 has been developed. The Action Plan advances efforts established under the previous regional strategy and incorporates recent global and regional guidance in encouraging comprehensive implementation of policy actions that simultaneously deal with both undernutrition and overweight and obesity as well as new and emerging challenges such as climate change and emergencies. The draft action plan was developed through an extensive consultative process with Member States, including: the Commission on Ending Childhood Obesity—South-East Asia Regional Consultation (28–29 September 2015, New Delhi, India); an Informal Member State Consultation—Developing a regional action plan of multisectoral actions for ending childhood obesity (29 September 2015, New Delhi, India); an expert group consultation to review the draft strategic action plan for addressing the dual burden of malnutrition in South-East Asia Region (2–3 February 2016, New Delhi, India); and a regional meeting to review the Draft Strategic Acton Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region (21–22 March 2016, New Delhi, India). UN agencies and donors also participated in these consultations. 8. The Action Plan is structured in a theory-of-change model, which is based on the premise that creating an enabling environment is the key to successful implementation and scaling up of context-specific nutrition interventions to achieve the six global nutrition targets and two nutrition-related global voluntary targets for the prevention and control of NCDs (halt the rise in

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diabetes and obesity and reduction of salt intake). Moreover, it takes into account the outcomes of recent international movements on nutrition, including the Scaling Up Nutrition and Zero Hunger Challenge. 9. The Action Plan recommends that Member States examine their policies and strategies on nutrition, NCDs and any multisectoral action plans to ensure inclusion of policy actions to reduce the double burden with an emphasis on the first 1000 days, school-aged children and on adolescents. It provides guidance for Member States via key policy actions to be undertaken across four strategic areas. These include improving nutrition governance through enhanced political commitment and evidence-informed multisectoral policies; developing and adapting relevant legislation and guidelines; strengthening health workforce capacity and information systems; and tactical engagement with stakeholders including the community, academia, civil society and the private sector. The Action Plan also provides direction to the WHO Regional Office and country offices on their role in supporting Member States to deal with the double burden, while acknowledging that countries are at different stages along the double burden continuum.

Conclusions 10. The Action Plan would be an advocacy and reference tool for Member States, to ensure that interventions covering the double burden of malnutrition are addressed comprehensively through country nutrition or NCD strategies, action plans and programmes. As appropriate to the national context, countries are encouraged to prioritize actions recommended in this Action Plan. The Action Plan suggests a timeframe for review of actions through a brief monitoring framework at the regional level. The plan would be reviewed in 2021 and then revised as needed. 11. The draft Strategic Action Plan to Reduce the Double Burden of Malnutrition in the SouthEast Asia Region (2016–2025) (Annexure 1) is submitted for consideration of its endorsement and further guidance.

Annexure-1 STRATEGIC ACTION PLAN TO REDUCE THE DOUBLE BURDEN OF MALNUTRITION IN SOUTH-EAST ASIA REGION, 2016–2025

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

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Table of Contents Abbreviations ........................................................................................................................................................................... iii Executive summary ............................................................................................................................................................... iv 1. Introduction .......................................................................................................................................................................... 1 1.1 Suboptimal diets .......................................................................................................................................................... 1 1.2 Consequences of malnutrition ............................................................................................................................... 2 1.3 Addressing the determinants of the double burden of malnutrition .................................................... 2 1.4 Emerging challenges in nutrition ......................................................................................................................... 3 2. Profile of Nutritional status in the WHO South-East Asia Region................................................................... 5 2.1 Nutritional status of children aged 0–5 years ................................................................................................. 5 2.1.1 Stunting and overweight in children < 5 years ...................................................................................... 5 2.1.2 Wasting in children < 5 years of age ........................................................................................................... 6 2.1.3 Underweight in children < 5 years .............................................................................................................. 7 2.1.4 Low birth weight (LBW) .................................................................................................................................. 8 2.2 Nutritional status of adolescents .......................................................................................................................... 8 2.3 Nutritional status of adult population ................................................................................................................ 9 2.4 Nutrition in older adults ......................................................................................................................................... 10 2.5 Micronutrient Deficiencies in the South-East Asia Region ...................................................................... 10 2.5.2 Status of other micronutrient deficiencies ............................................................................................. 12 2.6 Diets in the WHO South-East Asia Region....................................................................................................... 12 2.6.1Consumption of minimum acceptable diets by young children ..................................................... 12 2.6.2 Dietary risk factors for noncommunicable disease risk ................................................................... 12 2.6.3 Fruit and vegetable consumption .............................................................................................................. 13 3. The Strategic Framework and Action Plan............................................................................................................. 14 3.1 Goal.................................................................................................................................................................................. 14 3.2 Objectives ..................................................................................................................................................................... 14 3.3 Scope and purpose .................................................................................................................................................... 14 3.4 Policy context .............................................................................................................................................................. 14 3.5 Time frame ................................................................................................................................................................... 14 3.6 Monitoring.................................................................................................................................................................... 14 3.7 Guiding principles ..................................................................................................................................................... 15 3.8 Strategic directions and outcomes of the action plan are set out in the following theory of change ......................................................................................................................................................................... 16 3.9 Role of the WHO ........................................................................................................................................................ 17 3.10 Nutrition and diet-related noncommunicable diseases risk targets ................................................. 17 4. The Action Plan .................................................................................................................................................................. 19 5. References ........................................................................................................................................................................... 23

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List of tables Table 1: Level of public health burden caused by anaemia among nonpregnant women, children and pregnant women. ................................................................................................................................................................... 11

List of figures Figure 1: The double burden of malnutrition across the life course.................................................................. 2 Figure 3: Prevalence of stunted children and overweight children aged < 5 years (-2SD Height-forage Z scores) in SEAR. ............................................................................................................................................................ 6 Figure 4: Prevalence of wasting in children aged <5 years (-2SD Weight-for-height Z scores) in SEAR. ............................................................................................................................................................................................. 7 Figure 5: Prevalence of underweight (-2SD Weight-for-age Z scores) in children <5 years in SEAR. . 7 Figure 6: Prevalence of low birth weight children in SEAR. .................................................................................. 8 Figure 7: Proportion of stunted, underweight and overweight/obese female adolescents aged 15–19 years in selected countries of SEAR........................................................................................................................... 9 Figure 8: Trend in prevalence of overweight (mean BMI ≥25 kg/m2) in adults (both sexes) in 2010 and 2014 in SEAR. ................................................................................................................................................................... 9 Figure 9: Proportion of older persons (aged 60 years and over) in SEAR..................................................... 10 Figure 10: Prevalence of anaemia among children aged < 5years and nonpregnant women in SEAR. ....................................................................................................................................................................................................... 11 Figure 11: Consumption of minimum acceptable diets by 6–23 month old children in SEAR. ............ 12 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 Region. ................................................................ 13 Figure 13: Percentage of adults who ate < 5 servings of fruits and vegetables per day. ......................... 13 Figure 14: Strategic directions and outcomes of the action plan are set out in the following theory of change. ....................................................................................................................................................................................... 16 Figure 15: Global nutrition and diet-related noncommunicable disease targets. ...................................... 18 List of annexes Annex 1. Supporting global and regional resolutions/mandates and content analysis of technical areas covered. ......................................................................................................................................................................... 25 Annex 2. Regional monitoring framework for policy, capacity and legislative indicators. ................... 26 Annex 3. Selected evidence-based interventions (e-Library of Evidence Based Nutrition Actions) to reduce the double burden of malnutrition. ................................................................................................................ 27 Annex 4. Indicator definitions for Global Nutrition and diet related Noncommunicable Diseases targets......................................................................................................................................................................................... 30 Annex 5. 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). .................................................................................................................................................................... 31 Annex 6. Example of cross-sectoral Government engagement and potential multisectoral action.... 46

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Abbreviations BMI BMS CIP DHS eLENA FAO GDP GHI GNP HDI ICN 2 IDD USI IYCF IMR LBW MDG NCD REACH SAM SD SEAR SUN SDG U5MR UNICEF WASH WHA WHO WIFS IDA IEC IFA IYCF LMICs Body Mass Index breast milk substitutes Comprehensive Implementation Plan Demographic and Health Survey Electronic Library of Evidence for Nutrition Actions Food and Agriculture Organization Gross Domestic Product Global Hunger Index Gross National Product Human Development Index Second International Conference on Nutrition Iodine Deficiency Disorder Universal Salt Iodization Infant and Young Child Feeding Practices Infant Mortality Rate Low Birth Weight Millennium Development Goal Noncommunicable Diseases Renewed Efforts Against Child Hunger and Undernutrition Severe Acute Malnutrition standard deviation South-East Asia Region Scaling Up Nutrition Sustainable Development Goal Under Five Mortality Rate United Nations Children’s Fund Water, Sanitation and Hygiene World Health Assembly World Health Organization Weekly Iron and Folate Supplementation Iron Deficiency Anaemia Information, Education and Communication Iron Folic Acid Infant and Young Children Feeding Low and Middle-Income Countries

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Executive summary Economic growth accompanied by investments in social development and health have resulted in improvements in the nutritional status of the populace in the WHO South-East Asia Region. However, despite progress on the Millennium Development Goals (MDGs), targets of halving poverty and hunger, reducing child mortality and underweight, malnutrition continues to persist. The ongoing nutrition transition in the Region is characterized by persistent undernutrition, which includes micronutrient deficiencies, and concomitant overweight and obesity (the double burden), and associated risk of noncommunicable diseases (NCDs). An estimated 60 million children in the 0–5 year age group are stunted, 45 million are underweight and 8.8 million are overweight. Anaemia and other micronutrient deficiencies are a significant public health problem in many Member States. Undernutrition contributes to about 45 % of preventable deaths of children under 5 years annually. Increased overweight and obesity underpin the high rates of NCDs in Member States, with 55 % of all deaths attributed to NCDs. Maternal undernutrition, as well as overweight and obesity have a transgenerational impact. Poor maternal nutrition is a determinant of low birth weight, associated with stunting. Both low birth weight and stunting in turn increase risk of overweight, obesity and noncommunicable diseases in later life. Maternal overweight and obesity are also related to child overweight. Poverty and inequity, inadequate nutrition, want of access to health and nutrition services, infections and lack of clean water and sanitation are some determinants of undernutrition. Changing dietary habits fuelled by globalization of markets with increased availability of energy dense, nutrient-poor foods, and inadequate physical activity lead to overweight and obesity. The double burden of malnutrition affects Member States to varying degrees, and urgent and sustained efforts are needed to address the problem. The strategic action plan to reduce the double burden of malnutrition the South-East Asia Region (2016–2025) was developed through an extensive consultative process between Member States, experts and the WHO secretariat. It advances efforts established under the previous regional strategy, and brings together guidance from global and regional policy platforms on promoting integrated approaches to address all forms of malnutrition concurrently. Policy actions from the Global Strategy on infant and young child feeding; the Comprehensive Implementation Plan for Maternal, Infant and Young Child Nutrition; the framework for action of the 2nd International Conference on Nutrition (ICN2); the Ending Childhood Obesity Commission report; and the post 2015 development agenda have informed the action plan. The emphasis of the action plan is on improving nutrition governance, adopting global guidance and institution of legislation, improving capacity, multisectoral engagement and community empowerment to ensure sustainable solutions to nutrition problems. These aspects are articulated through four strategic directions. This plan will serve Member States as an advocacy and reference tool, to ensure that interventions covering the double burden of malnutrition are addressed comprehensively and simultaneously in Member State policies, strategies and actions. The plan also provides direction to the Regional Office and country offices on the pertinent areas of support for Member States.

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1. Introduction Malnutrition,1 in all its forms, threatens human health and development. Today, most low and middle-income countries face an increasing 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)2 such as cardiovascular disease, diabetes mellitus and cancer is threatening already stretched and under-resourced health systems and economies.(2) By 2030, NCDs are expected to contribute to two thirds of the disease burden in low and middle-income countries.(2) The South-East Asia Region has historically carried a high burden of child undernutrition, caused by socioeconomic disadvantages, and other biological and social determinants. The picture is now changing with a concomitant rise in both child and adult overweight and obesity. Evidence indicates that 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. (3) As indicated in Figure 1, the behavioural and biological responses of a child to the obesogenic environment is shaped partly in utero, placing many on the pathway to obesity when faced with an unhealthy diet and low physical activity, as seen in today’s transitioning societies.(4) Low birth weight and stunted children who experience rapid weight gain during childhood and adolescence are at greater risk to develop NCDs. (5) For South-East Asia, and especially for its stunted populations, the risks of a mismatch between their genetic programming (in preparation for a resource-poor environment after birth) and the unhealthy diet environment after birth are greatly increasing NCD risk. (6) 1.1 Suboptimal diets The predominant dietary patterns in the South-East Asia Region are plant based, often inadequate in energy, protein, and micronutrients, and low in diversity giving rise to stunting, wasting and anaemia in young children. (7) Significant protein-energy deficits are common (8). At the same time, particularly in urban areas, diets higher in refined grains and sugars, and fats are getting more common. Healthy diets where adequate energy should be obtained mostly from unrefined carbohydrates, protein from plant and animal sources, are shifting away from saturated fats to unsaturated fats, and elimination of trans fatty acids; limiting intake of free sugars, sodium and increasing fruits, legumes, whole grains and nut consumption needs to be advocated. Intrauterine life, infancy and the preschool period have all been considered as critical periods where long-term regulation of energy balance is programmed. Therefore, a life-course perspective (Figure 1) along with measures to reduce the obesogenic environment3 has the greatest potential to address both undernutrition and overweight and obesity (4, 9), with an emphasis on prevention in children under five years of age, school aged children,4 adolescents5 and pregnant women. 1 2

Malnutrition is defined as nutritional excesses of macronutrients and micronutrients as well as deficiencies (WHO 1995). Noncommunicable diseases are cardiovascular diseases , cancers, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes. http://www.who.int/mediacentre/factsheets/fs355/en/ 3 An environment that promotes high energy intake and sedentary behaviour. 4 Children between ages 6 and 11 years.

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Figure 1: The double burden of malnutrition across the life course.

Source: Global Nutrition Targets 2025 Childhood Overweight Policy Brief, WHO 2014.

1.2 Consequences of malnutrition Worldwide, more than one third of child deaths and one fifth of the total disease burden are due to maternal and child undernutrition. (10) Final adult height, which is largely determined in childhood, reflects the nutrition quality during early life. (11) Stunting during the prenatal period and infancy impairs cognitive development, with reduced school performance. In adult life, work performance is reduced, and stunting is associated with an increased risk of noncommunicable diseases. (10, 12) Loss of attainment of height causes an annual loss of two to three percent of GDP, undermining efforts to eradicate poverty. (13) Micronutrient deficiencies add to the social and economic burden, compromising the immune system, diminishing cognitive functions and intellect, causing anaemia and other illnesses. (1) Of a total 13.7 million deaths in the South-East Asia Region during 2012, 6.8 million were due to NCDs, principally cardiovascular diseases, diabetes, cancer and chronic respiratory diseases (14). By 2030, an estimated 32 percent of the total proportion of diabetes cases will be from the South-East Asia Region. (15) Together, both undernutrition and NCDs represent a significant economic and social cost to countries with an estimated cost of more than US$ 30 trillion globally over the next 20 years. (15) 1.3 Addressing the 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) Poor diets, physical inactivity and infections contribute to immediate causes of malnutrition. Inadequate care, suboptimal and unhealthy diets, poor water and sanitation, lack of food safety, inadequate health care and sedentary behaviours underlie the double burden of malnutrition. Finally, basic causes of malnutrition at the societal level include inadequate access to food supply, maternal education, 5Boys

and girls between ages 11 and 19 years.

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inadequate investments in health services, social protection schemes and poverty. Such determinants should be examined and addressed through a nutrition lens that considers both aspects of the double burden of malnutrition that also considers country specific contexts. Figure 2: Conceptual framework of malnutrition.

Basic, underlying and immediate causes are included in this figure, as well as outcomes of malnutrition. ASEAN/UNICEF/WHO (2016) Regional Report on Nutrition Security in ASEAN, Volume 2, Bangkok, UNICEF.

1.4 Emerging challenges in nutrition 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.6 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 could play a part in the prevention of degenerative conditions of the elderly and an improvement in quality of life.

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National Institute on Aging, National Institutes of Health. United States: NIH Publication; 2011.Global Health and Ageing.

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Climate change Climate change increases the incidence and severity of extreme weather events and magnifies the risk of disasters globally.7 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, stability and utilization, thereby exacerbating current states of malnutrition. It is the poorest and vulnerable groups such as young children and women with inadequate resilience to cope that would be most affected. Obesogenic environment Mechanization and urban lifestyles that promote increased screen time and other sedentary behaviours are becoming more common in the South-East Asian Region, along with an abundance of low-cost, high-energy foods due to globalization and aggressive marketing by industry.

7http://www.unscn.org/files/Statements/SCN_statement_climate_change_final.pdf

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2. Profile of nutritional status in the WHO South-East Asia Region The WHO South-East Asia (SEA) Region represents a diverse range of 11 low- and middle-income countries, with wide variations in geography, culture, social development and nutrition transition. Over the past two to three decades, the Region has seen significant social, economic and demographic changes that have greatly influenced the nature of nutrition issues currently faced by countries. Of the world’s population, 26% lives in the South-East Asia Region, with more than 90 percent in Bangladesh, India and Indonesia. (17) The rate of urbanization in Asia (1.5% per annum) is the highest in 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 the population is rural. (19) The Region has the largest working age population in the Bangladesh world, representing enormous human resource potential. Bhutan Literacy rates, especially among women, are rising consistently, contributing to human and social capital. In Thailand, Sri Lanka, Indonesia 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) Democratic People’s Republic of Korea

India Robust economic growth accompanied by intensive efforts for social development have resulted in declining poverty and improvements in the Human Development Indonesia Index (HDI). A review of the HDI over a 5-year period shows positive changes in Maldives 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 Myanmar 26 deaths in 2015.8 Significant progress has been made in reducing undernutrition. Nepal Bangladesh (21) reported a 35–40% decline in child stunting and underweight Sri Lanka between 2004 and 2014. Similarly, a 60% reduction in stunting prevalence and 70% reduction in underweight among under-five children was reported from Bhutan Thailand between 2000 and 2015. (22) Available data for selected states from the India Timor-Leste National Family Health Survey (2015) also show a reduction in stunting and underweight in children under five years9 and a significant increase in exclusive breastfeeding rates. (23) However, while undernutrition is declining, micronutrient deficiencies, particularly anaemia, remains a significant problem, and child, adolescent and adult overweight and obesity is increasing in prevalence. 2.1 Nutritional status of children aged 0–5 years10,11 2.1.1 Stunting and overweight in children < 5 years: Stunting12 is the cumulative result of chronic malnutrition and deprivations from the prenatal period and childhood. Overweight may or 

Data not available for Democratic People’s Republic of Korea and Bhutan. Health Observatory data http://www.who.int/gho/child_health/mortality/mortality_under_five/en/index1.html 9http://rchiips.org/NFHS/factsheet_NFHS-4.shtml 10Nutritional 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. 11For the purpose of uniformity, the data for nutrition profile 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. 12Defined as height that is more than two standard deviations below the World Health Organization Child Growth Standards median. 8Global

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may not be superimposed on stunting and results from diets excessive in energy, together with reduced physical activity. Figure 3 indicates the prevalence of both stunting as well as overweight in young children.13 The double burden varies between countries with over 10% of children in under-five age group estimated to be overweight in India, Indonesia and Thailand and less than 3% in Bangladesh, Myanmar, Nepal and Sri Lanka. The regional prevalence of overweight in children under five years was 3.3% in 2005 and 4.9% in 2014.14 Prevalence of stunting is declining across all countries in the Region. The overall Annual Average Rate of Reduction of 1 percentage point per year is much slower than the estimated 3.9% needed to meet Global nutrition targets. Although the overall prevalence of stunting in SEAR countries has been reduced from 59% in 1990 to 32.9% in 2013, it translates to 60.8 million stunted children at present. (24) Figure 2: Prevalence of stunted children and overweight children aged < 5 years (-2SD Height-forage Z scores) in SEAR15. 100 90 80 70 60 50 40 30 20 10 0

Percentage of under five children (%)

50.2 36.1 33.6 38.7 36.4 27.9 20.3 35.1 37.4 14.7 16.3 32.9

Stunting Overweight

Source: WHO/UNICEF/World Bank joint monitoring estimates 2015. 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 noted that the prevalence of stunting is low. The most recent data from MICS indicate that the prevalence of stunting is 10.5% for children under 5 years of age and the prevalence of overweight is 8.2% in children under 5 years of age.16

2.1.2 Wasting in children < 5 years of age17: Wasting is the result of recurrent acute deprivations of nutrition. In 2014, in the SEA Region, 14.5% of the children were wasted (25.9 million children wasted and 8.1 million severely wasted) as indicated in Figure 4. (24)

13Defined 14

as weight for age more than 2 standard deviations above the WHO growth standards median (birth to less than 5 years of age). WHO/UNICEF/World Bank joint monitoring estimates 2015. 15 National Nutrition Survey 2015 of Bhutan showed that 21.2% of children are stunted. 16

Multiple Indicator Cluster Survey (MICS) 2015/16, Thailand.

17Defined

as more than two standard deviations below the median weight-for-height of the WHO Child Growth Standards median and below minus three standard deviations (-3 SD) are considered to be severely wasted.

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Figure 3: Prevalence of wasting in children aged <5 years (-2SD Weight-for-height Z scores) in SEAR18. Precentage of under five children (%) 100 90 80 70 60 50 40 30 20 10 0

14.3

5.9

15.1 4

13.5

21.4 10.2 7.9 11.3 6.7 11

Data updated by October 2015. The specific year when the data was obtained in each country is given in parenthesis. National data is mainly originated from various household surveys included in the WHO/UNICEF/World Bank joint monitoring estimates 2015.Threshold of public health significance >5 percent (green), high severity (>10 percent , yellow). Thailand noted that the prevalence of stunting is low. The most recent data from MICS indicates that prevalence of wasting is 5.4 percent in children under 5 years of age.

2.1.3 Underweight in children < 5 years: Most of the countries of the Region show a significant decline in prevalence of underweight (figure 5). Despite this decline, in 2014, 46 million children in the Region were estimated to have low weight for age (24). Figure 4: Prevalence of underweight (-2SD Weight-for-age Z scores) in children <5 years in SEAR19. Precentage of children under five (%) 100 90 80 70 60 50 40 30 20 10 0

32.6 12.8 15.2

29.4 19.9 17.8

22.6

30.1

26.3 9.2

37.7

Data updated by October 2015. The specific year when data were obtained in each country is given in parenthesis. National data are mainly originated from various household surveys included in the

18National 19

Nutrition Survey 2015 of Bhutan reported prevalence of 4.4% wasting and 9% underweight among children age 0-59 months Defined as weight for age less than 2 standard deviations below the WHO growth standards median (birth to less than 5 years of age).

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WHO/UNICEF/World Bank joint monitoring estimates 2015. Threshold of public health significance >30% (very high severity), high severity (>20%); <1 % (low severity).

2.1.4 Low birth weight (LBW): LBW (birth weight < 2500 g) is associated with higher morbidity and mortality especially in the neonatal period. The prevalence of LBW is the highest in India, followed by Bangladesh, Nepal and Sri Lanka (Figure 6). However, birth weight figures are likely to be underreported due to home deliveries. Figure 5: Prevalence of low birth weight children in SEAR. Percentage of children born with weight <2500g (%) 100 90 80 70 60 50 40 30 20 10 0

22 10 6

28 9 11 18 9 17 11 12

Source: State of World’s Children 2015: Reimagine the Future (UNICEF 2015).

2.2 Nutritional status of adolescents Stunting20. Approximately one-tenth of adolescents in South-East Asian countries, except in TimorLeste where more than 20% are stunted, fall below the cut-off point for stunting (145 cm of height). (Fig. 10) Thinness21.The DHS data from six countries of the Region show that thinness among adolescent girls is in the range of 24–47%, indicating significant energy deficits in diet. Overweight and obesity. Often seen side by side with thinness and stunting in the same community, overweight22/obesity23, caused by unhealthy diet and low physical activity is a growing concern among adolescents in the Region. (Figure 7)

20Short

stature/stunting among reproductive age women is frequently defined as height less than 145 cm, a cut-off chosen because of its association with increased obstetric risk. 21Thinness or underweight is defined as Body Mass Index (BMI) less 18.5 kg/m 2 22 From age 5 to less than 19 years: BMI-for-age more than 1 SD above WHO growth reference median. 23BMI-for-age more than 2 SD above the WHO growth reference median for ages 5-less than 19 years.

8

Figure 6: Proportion of stunted, underweight and overweight/obese female adolescents aged 15–19 years in selected countries of SEAR. 100 90 80 70 60 50 40 30 20 10 0 Percentage of adolescent aged 15-19 (%)

47 40 33 25 11 13 2 12 24 24 8 26 10 3 15 8 7 22

Bangladesh

India Maldives Nepal Sri Lanka Timor-Leste BMI ≥ 25kg/m2 BMI <18.5kg/m2 Height <145 cm

Source: Bangladesh DHS 2011; India NFHS3 2005-06; Maldives DHS 2009; Nepal DHS 2011; Sri Lanka DHS 2006; TimorLeste DHS 2009-10. BMI of > 25 kg/m2 has been taken as overweight, and BMI of 30 kg/m2 as obese.

2.3 Nutritional status of adult population More than one-fifth of adults are overweight in the Region, 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. The Global status report 2014 also shows high BMI levels in Maldives and Thailand. (25) Figure 7: Trend in prevalence of overweight (mean BMI ≥25 kg/m2) in adults (both sexes) in 2010 and 2014 in SEAR.

100 90 80 70 60 50 40 30 20 10 0

Percentage of adults (%)

18 16

24 27

20 22 20 19

25 21

30 27 18 15

18 16

25 22

30 27 15 13

2010 22 20

2014

Source: Global Health Observatory Data Repository, WHO 2013. http://www.who.int/gho/en

9

2.4 Nutrition in older persons Figure 9 provides the population projection estimates of older persons 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 8: Proportion of older persons (aged 60 years and over) in SEAR. 100 Percentage of older persons (%) 90 80 70 60 50 40 30 20 10 0 26.9 19.4 12.0 12.4 11.5 7.0 7.0 21.0 13.0 12.4 8.0 6.0 12.0 7.0 13.0 9.0 11.0 10.6 8.0 15.7 4.4 6.7

2015 2030

Source: Profiles of Aging 2015. http://esa.un.org/unpd/popdev/Profilesofageing2015/index.html, accessed on 26.1.2016.

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). 2.5.1Anaemia Anaemia prevalence across all countries is mainly nutritional in nature and primarily attributed to iron deficiency and partly to folic acid and vitamin B12 deficiencies. Iron deficiency is the most prevalent micronutrient deficiency across all age groups and affects physical, cognitive and social health.(28) Adolescents 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%) show that adolescent anaemia is a moderate to severe public health problem. 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 among children as indicated in Table 1.

10

Figure 9: Prevalence of anaemia among children aged < 5years and nonpregnant women in SEAR24. 100 90 80 70 60 50 40 30 20 10 0

Percentage (%)

56

55 44 43

59 48 34 25 32 22 30 37 40 30

51 36 36 26 29

45 24 22

Children <5 years Nonpregnant women Severe Moderate

Data are based on WHO’s modelled estimates (from 1995 to 2011) in national estimates of anaemia for the year 2011, WHO. The global prevalence of anaemia in 2011. Geneva: World Health Organization; 2015. 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).25

Table 1: Level of public health burden caused by anaemia among children, nonpregnant women, and pregnant women. Children aged 6–59 months Women 15–49 years Women 15–49 years – (nonpregnant) (pregnant) Country Anaemic Public Health Anaemic Public Health Anaemic Public Health children26 Significance nonpregnant27 Significance pregnant2 Significance Bangladesh 56% Severe 43% Severe 48% Severe Bhutan 55% Severe 44% Severe 46% Severe DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste 34% 59% 32% 30% 40% 51% 36% 29% 45% Moderate Severe Moderate Moderate Severe Severe Moderate Moderate Severe 25% 48% 22% 37% 30% 36% 26% 24% 22% Moderate Severe Moderate Moderate Moderate Moderate Moderate Moderate Moderate 27% 54% 30% 39% 33% 44% 25% 30% 24% Moderate Severe Moderate Moderate Moderate Severe Moderate Moderate Moderate

Adapted from Annex 3. 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). WHO Worldwide prevalence of anaemia 1993–2005: WHO global database on anaemia. WHO, Geneva, 2008 (De Benoist B, McLean E, Egli I, Cogswell M, editors).

24

Bhutan and Timor-Leste recent nutrition survey reported that 44% of children in Bhutan and 62.5% in Timor-Leste suffer from anaemia. (22, 31) 25 National Health Exam Survey. 26 Percentage with blood haemoglobin concentration <110 g/L (for children 6-59 months and pregnant women). 27 Percentage of nonpregnant women with blood haemoglobin concentration <120 g/L.

11

2.5.2 Status of other micronutrient deficiencies Vitamin A: Among young children< 5 years the estimated prevalence of night blindness in SouthEast 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 South-East Asia 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 the WHO South-East Asia Region 2.6.1Consumption of minimum acceptable diets by young children Breastfeeding and complementary feeding practices determine the nutritional status of young children. Figure 11 indicates that 6–23 month old breastfed children are consuming minimum acceptable diets, a composite indicator of dietary diversity (consuming foods from 3 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) Figure 10: Consumption of minimum acceptable diets by 6–23 month old children in SEAR.

Percentage of 6-23 month old children (%)

100 90 80 70 60 50 40 30 20 10 0

83 63 34 21 22 41 25

* 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.

12

Figure 11: 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 Region. Estimated sodium intake (g/d) 10 9 8 7 6 5 4 3 2 1 0

3.54

3.64

3.79

4.49 3.72 3.36 3.31

5.31 3.89 3.87

4.47

All data have been obtained from the publication from Powles et al.. (35) For comparability reasons, data from the most recent surveys for each country have not been included.

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 12: Percentage of adults who ate < 5 servings of fruits and vegetables per day. Percentage of adults (%) 100 90 80 70 60 50 40 30 20 10 0 969894 676570 838384 949395 878588 999999 979797 90 78 71

Total Men Women

Source: STEPs country fact sheets, http://www.who.int/chp/steps/reports/en/

13

3. The Strategic Framework and Action Plan 3.1 Goal Reduce the double burden of malnutrition in the South-East Asia Region. 3.2 Objectives   To promote and sustain an enabling environment for the implementation of nutrition interventions. To promote effective implementation and scaling up of evidence-based, cost-effective direct and indirect nutrition interventions through the life course 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 and decision-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. It provides overarching guidance/directions on policy actions to countries to ensure that interventions covering the double burden of malnutrition are addressed comprehensively through programmes, while taking into account the country context. This plan does not focus on physical activity, which is an integral component of healthy lifestyles, since it is addressed comprehensively in other regional plans. 3.4 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 1) and the objectives of policy platforms including the Scaling Up Nutrition (SUN) Movement and UN Secretary-General’s Zero Hunger Challenge. 3.5 Time frame The action plan spans the period of 10 years (2016–2025), in line with the Global Nutrition and NCD targets,28,29 and the Decade of Action for Nutrition 2016–2025. 3.6 Monitoring The Regional office will track progress of implementation of the action plan in the medium (2021) and long term (2025) through monitoring of key selected indicators that reflect the double burden of malnutrition (Annex 2). The plan will be reviewed in 2021 and revised as needed and an endterm assessment will be conducted in 2025.

28 29

http://www.who.int/nutrition/global-target-2025/en/ http://www.who.int/nmh/ncd-tools/definition-targets/en/

14

3.7 Guiding principles The following guiding principles underpin the action plan: Life-course approach: A continuum of interventions across the life course is essential for improvement in nutrition. A special focus will be on the “window of opportunity,” from conception to two years (first 1000 days) , which is the best opportunity to pause the intergenerational cycle of malnutrition. The action plan will also focus on nutrition of the school-aged child and adolescent. Schools offer the opportunity to promote healthy diets and provide life skills on nutrition and health that are the foundation for good nutrition. Ensuring human rights and the right to food: A human rights approach to policies, strategies and programmes designed to address equity, availability, accessibility, acceptability, quality and universality. The right to food is a human right, protecting the right for people to feed themselves in dignity, and have sufficient, accessible food that can adequately meet their dietary needs. Commitment and accountability: Political will and commitment to good governance is needed to address double burden of malnutrition. Robust mechanisms are needed to monitor policy development and implementation, thus facilitating the accountability of governments, civil society and the private sector on commitments. Sustainable solutions that build self-reliance and empowerment: Strengthening and reorienting strategies for food systems so that they become health promoting and are economically and environmentally sustainable. This would be done through a focus on policy coherence between nutrition and agriculture. Multisectoral approach: Collaboration and coordination with various sectors, e.g. health, education, environment, social protection, labour, water and sanitation, agriculture, transport, etc., through joint strategies with common goals are essential to address the multiple underlying causes of malnutrition. Equity: Equitable coverage of interventions, particularly for disadvantaged or otherwise vulnerable population groups, who are at high risk for all forms of malnutrition are promoted.

15

3.8 Strategic directions and outcomes of the action plan are set out in the following theory of change. INPUTS/PROCESSES Strategic directions to create an enabling environment for effective implementation of interventions 1. Improve nutrition governance through enhanced political commitment and evidence informed, context-specific sectoral policies. 2. Develop, adopt/adapt relevant guidelines, legislation and regulatory frameworks needed to implement evidence-based interventions. 3. Strengthen health systems to address the double burden of malnutrition with adequate resources, capacity strengthening and comprehensive monitoring. 4. Empower communities, support and strengthen academia and civil society to promote healthy diets and form strategic alliances with other stakeholders. OUTPUTS Evidence based interventions contextual to country context implemented and scaled up* OUTCOMES Global nutrition and diet related NCD targets IMPACT

Reduced double burden of malnutritio n in the South-East Asia Region

Figure 13: Strategic directions and outcomes of the action plan are set out in the following theory of change. *Evidence-informed guidance for nutrition interventions is available through the eLibrary of evidence for nutrition actions (eLENA) and other guidance documents. Selected direct and indirect interventions are provided in Annex 3.

16

3.9 Role of the WHO The Regional and country offices will be engaged in a variety of roles to support, facilitate and strengthen Member States to implement policy actions to reduce the double burden of malnutrition.

Policy advocacy and planning   Support in setting targets and developing national policies, strategies and action plans to reduce the double burden of malnutrition. Advocate for resources to nutrition, support the establishment of partnerships and coordination mechanisms within health and other sectors to promote healthy diets and 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.



Technical guidance and policy support to  Access normative products and tools.  Translate and establish global and regional guidance into effective interventions.  Monitor nutrition outcomes and implement national action plans.  Build additional capacity needed in special areas, such as legislation, standards and specifications for the promotion of healthy diets, food labelling and fortification of food with micronutrients.  Strengthen human resource capacity in countries for effective and sustainable implementation of relevant interventions. 3.10 Nutrition and diet-related noncommunicable diseases risk targets30 The policy actions and interventions stated in the plan will contribute to achieving the voluntary Global nutrition targets (Figure 15) in the Comprehensive Implementation Plan on Maternal, Infant and Young Child nutrition (WHA 2012), and the diet-related NCD targets of the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases (WHA 66.10). Annex 4 provides indicator definitions.

30

Definitions provided in annex.

17

Figure 14: Global nutrition and diet-related noncommunicable disease targets. Global nutrition targets 2025 40% reduction in the number of children under five who are stunted 50% reduction of anaemia in women of reproductive age 30% reduction in low birth weight No increase in childhood over weight Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50% Reduce and maintain childhood wasting to less than 5% The WHO Global Action Plan for the Prevention and Control of NCDs includes two further nutritionrelated targets. A 30 % relative reduction in mean population intake of salt/sodium

Halt the rise in diabetes and obesity

18

4. The Action Plan The framework for implementing the strategic directions to create an enabling environment for implementation of nutrition interventions is given below. Annex 5 provides a mapping of associations between policy actions, 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 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. Policy development needs 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 policy actions should be promoted. Policy actions Establish a high-level coordination mechanism to guide multisectoral nutrition actions Ensure policies that provide adequate financing for nutrition Develop/update national policies and plans in nutrition and related sectors to reflect the double burden of malnutrition Policy indicators Higher-level coordination mechanism established with specific terms of reference Adequate resources (as identified by costing analysis) are earmarked and available for implementation of nutrition action plans National nutrition and/or related health policies and plans have addressed the double burden of malnutrition 31 Multisectoral nutrition action plans with operational mechanisms are updated with identified budget lines Multisectoral nutrition action plans are implemented and monitored At least three key nonhealth policies address the double burden of malnutrition 32 Policy coherence ensured between nutrition and agriculture National nutrition targets and diet-related NCD targets identified and indicators based on the global monitoring framework are included in monitoring mechanism Country frameworks are developed and implemented to protect food policies and dietary guidance from conflict of interest Nutrition is addressed in policies, strategies and plans on healthy ageing Country health emergency /disaster preparedness plans explicitly address the double burden of malnutrition

Identify national targets and indicators for nutrition and diet-related NCD risk factors that address country priorities Ensure policy actions to insulate nutrition policy-making from conflict of interest to safeguard public good Build on existing WHO policy frameworks relevant to healthy and active ageing to include nutrition Ensure that emerging challenges such as climate change and natural disasters address nutrition in related policies and plans 31 32

Annex 6 provides an example of multisectoral actions. Education, social protection, sports (or relevant policies) identified as important in the country context.

19

Strategic direction 2 Develop, adopt /adapt relevant guidelines, legislation and regulatory frameworks needed to implement evidence-based interventions. Development and adaptation of guidelines and legislation and regulatory frameworks are vital in reducing the double burden of malnutrition. Evidence-based guidance is available at the global level and should be adopted by countries to enable successful implementation of nutrition actions. Policy actions Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet-related risk of NCDs Policy indicators Country food-based dietary guidelines that promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized Strategies and roadmap developed for population reduction of salt, sugar and fat intake Country develops a national nutrition plan that includes WASH (Water, Sanitation, and Hygiene) Fiscal policies are developed and enacted for food products that are high in sugar , fat and salt Policies for subsidizing local fruits and vegetables are enacted Micronutrient (supplementation) guidelines within the country are updated regularly Food fortification legislation for iodization of salt and other relevant-identified micronutrients are developed and implemented Legislation enacted and implemented to ensure mandatory labelling of food products for both front of pack and back of pack labelling of nutrients A watchdog mechanism established in a country to ensure that health and nutrition claims are based on codex guidelines and adequate scientific evidence Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions are legislated and implemented Maternity protection measures 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 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

Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruits and vegetables Ensure that regulations and guidelines are in place for supplementation and fortification of products as suitable for the country context Enact legislation and its implementation on appropriate nutritional information for processed , pre-packaged food products

Promote healthy and safe foods for informal sector to enable the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Promote, protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms

20

Policy actions Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and dietrelated risks of NCDs Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status

Policy indicators Legislation enacted to implement WHO’s Recommendations on Marketing of unhealthy foods and beverages to children School guidelines and standards ensuring a healthy food environment are developed and implemented Guidance provided on food supplementation for pregnant and lactating women and young children

Strategic direction 3 Strengthen health systems to address the double burden of malnutrition with adequate resources, capacity strengthening and comprehensive monitoring. Availability, access and affordability of nutrition services is critical to achieving the Global Nutrition and diet related NCD targets. A comprehensive, evidence-based capacity development process that will integrate latest research, learning tools and technology to enhance leadership and workforce capacity are essential. Policy actions Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary health-care packages Ensure adequate financing for nutrition through separate budget line for nutrition-related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population-based nutrition services Policy indicators Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions. Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition-related conditions Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation Established management of safe water and the accessibility of sanitation facilities at community settings is supported Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity and other nutritionrelated conditions

Health infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition

21

Strategic direction 4 Empower communities, support and strengthen academia and civil society to promote healthy diets and form strategic alliances with other stakeholders. Policy action to promote empowerment through strengthening civil society organizations is key to promoting community empowerment. Support for academia to promote country-based research would ensure selection and implementation of actions based on country context. Forming strategic partnerships with the food sector is also important in promoting healthy diets to reduce the double burden of malnutrition. Policy actions Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require childcare settings, pre-schools, schools, children’s and youth sports facilities and events to create healthy food environment Engage with private sector to reduce the obesogenic environment Promote healthy diets and lifestyle at the workplace Policy indicators Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available Policy measures that appropriately engage relevant private sector, to implement actions, aimed at reducing overweight, obesity and dietary risk of NCDs are instituted Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces

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5. References 1. 2. 3. 4. 5. 6. 7. Shrimpton R and Rokx C, The Double Burden of Malnutrition: A Review of Global Evidence, 2012; Health, Nutrition and Population (HNP) Discussion Paper World Health Organization, (2014), ‘Global Status report on Non Communicable Diseases 2014 Barker D. J. P. 1998.Mothers, Babies and Health in Later Life. Edinburgh: Churchill Livingstone. World Health Organization (2016), ‘Report of the Commission on Ending Childhood Obesity’. Darnton-Hill I., C. Nishida, W. P. T. James. 2004. “A Life Course Approach to Diet, Nutrition and the Prevention of Chronic Diseases.” Public Health Nutrition. 7 (1A): 101–121. Deurenberg P, Yap M, van Staveren WA, ‘Body mass index and percent body fat: a meta analysis among different ethnic groups’.Int J ObesRelatMetabDisord. 1998 Dec; 22(12):1164-71. The state of food and agriculture in Asia and the Pacific region 2008 Food and Agriculture organization of the united nations regional office for Asia and the Pacific, Bangkok, 2008 FAO. 8. http://www.fao.org/docrep/010/ai411e/AI411E02.htm Lee, Da Eun Rachel, "Children's Protein Consumption in Southeast Asia: Consideration of Quality as Well as Quantity of Children's Protein Consumption in Southeast Asia" (2014). Wharton Research Scholars Journal. Paper 115.http://repository.upenn.edu/wharton_research_scholars/115 Scaling Up Nutrition: Couldn’t find reference number 9 in the text Diet, nutrition and the prevention of chronic diseases. Report of a joint WHO/FAO expert consultation. Geneva: World Health Organization; 2003 (WHO Technical Report Series 916; http://whqlibdoc.who.int/trs/who_trs_916.pdf, accessed 17 October 2014 http://scalingupnutrition.org/about/why-nutrition(accessed on July 21, 2015) Victora C. G., M. de Onis, P. C. Hallal, M. Blössner, R. Shrimpton. 2010. “Worldwide Timing of Growth Faltering: Revisiting Implications For Interventions.” Pediatrics.125(3): e473-80. Prendergast, A. J., & Humphrey, J. H. (2014), The stunting syndrome in developing countries, Paediatrics and International Child Health, 34(4), 250–265. http://doi.org/10.1179/2046905514Y.0000000158, (accessed on October 9, 2015). Horton S, Steckel R H, “Global Economic Losses Attributable to Malnutrition 1990 -2000” in How much have global problems cost the world? World Health Organization 2003.Diet, Nutrition and the Prevention of Chronic Diseases. Report of a Joint WHO/FAO Expert consultation. Geneva: WHO. World Health Organization , 2014 Global Health Estimates ASEAN/UNICEF/WHO (2016).Regional Report on Nutrition Security in ASEAN, Volume 2.Bangkok; UNICEF. The World Bank: http://data.worldbank.org/indicator/SP.POP.TOTL, )accessed on July 9, 2015)

9. 10. 11. 12. 13. 14. 15. 16. 17.

18. United Nations (2014), World Urbanization Prospects, Department of Social and Economics Affairs, United Nations.available at http://esa.un.org/unpd/wup/Highlights/WUP2014-Highlights.pdf, (accessed on October 9, 2015) 19. The World Bank : http://data.worldbank.org/indicator/SE.ADT.LITR.ZS/countries, (accessed on October 7, 2015) 20. UNDP, Human Development Reports, UNDP, available athttp://hdr.undp.org/en/content/table-2human-development-index-trends-1980-2013(accessed on July 21, 2015) 21. Bangladesh Demographic and Health Survey 2014 22. 2015 National Nutrition Survey (NNS). Nutrition Program, Department of Public Health, Ministry of Health, Thimphu, Bhutan. 23. India National Family Health Survey (2015), 24. WHO, UNICEF, World Bank, Joint child malnutrition estimates (UNICEF-WHO-WB) Compare regional trends in numbers of children affected by malnutrition (1990-2014). Available

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25.

26. 27. 28. 29. 30. 31. 32. 33.

athttp://apps.who.int/gho/data/view.wrapper.nutrition-1-3?lang=en&showonly=nutrition, (accessed on October 9, 2015). Mariel M Finucane, AM,, Gretchen A Stevens, DSc, Melanie Cowan, MPH, GoodarzDanaei, MD, DSc, John K Lin, AB, Christopher J Paciorek, PhD, Gitanjali M Singh, PhD, Hialy R Gutierrez, BS, Yuan Lu, MSc, Adil N Bahalim, MEng, FarshadFarzadfar, MD, Leanne M Riley, MSc, and Majid Ezzati, ‘National, regional, and global trends in body mass index since 1980: Systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants’, Lancet. 2011 Feb 12; 377(9765): 557–567. United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Ageing 2015 - Highlights (ST/ESA/SER.A/368). World Health Organization, UNICEF: Joint statement by the World Health Organization, the World Food Programme and the United Nations Children’s Fund Preventing and controlling micronutrient deficiencies in populations affected by an emergency. http://www.who.int/nutrition/publications/WHO_WFP_UNICEFstatement.pdf,(accessed on September 30, 2015). Iron Deficiency Anaemia Assessment, Prevention and Control A guide for programme managers, 2001, WHO Global prevalence of vitamin A deficiency in populations at risk 1995–2005. WHO Global Database on Vitamin A Deficiency. Geneva, World Health Organization, 2009. Bleichrodt N, Born MP.A meta-analysis of research on iodine and its relationship to cognitive development. In: “Stanbury JB, ed.The damaged brain of iodine deficiency”, New York, Cognizant Communication, 1994: 195–200. Global Iodine Nutrition Scorecard 2015, http://www.ign.org/cm_data/Scorecard_2015_August_26_new.pdf World Health Organization, Nutrition Landscape Information System: http://www.who.int/nutrition/nlis/en/; (accessed on October 10, 2015)

34. From Burden to “Best Buys”: Reducing the Economic Impact of Non -Communicable Diseases in Lowand Middle-Income Countries, 2011. World Health Organization, the World Economic Forum or the Harvard School of Public Health. 35. Powles J, Fahimi S, Micha R, et al. Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open 2013; 3:e003733.doi:10.1136/bmjopen-2013- 003733. Available at:

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Annexes Annex 1. Supporting global and regional resolutions/mandates and content analysis of technical areas covered. Targets Technical areas NCDs (salt/sweet/fat) Infant + Young child Children + adolescent General population (adult) Undernutrition (stunting, wasting underweight) and nutrient Micro + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Global Global Strategy on infant and young child feeding 2003 Global Strategy on Diet, Physical Activity and Health 2004 Comprehensive Implementation Plan on Maternal Infant and Young Child Nutrition (WHO, 2014) and 2025 Global Nutrition targets (WHA65.6) Rome Declaration and 2nd International Conference on Nutrition and the framework for actions 2014, adopted by the WHA in 2015 Report of the Commission on ending Childhood Obesity 2016 Global Action Plan for prevention and control of NCD’s 2013–2020 Sustainable Development Goal 2 targets at 2025, 2030 UN Decade of Action on Nutrition. 2016– 2025 Regional Regional Nutrition Strategy; Addressing malnutrition and micronutrient deficiencies 2011–2015 Action plan for the prevention and control of noncommunicable diseases in South-East Asia 2013–2020 South-East Asia Regional Strategic Framework for Improving Neonatal and Child Health and Development 2012 Strategic Action Plan to reduce the double burden of malnutrition in South- East Asia Region 2016–2025

+ + + + + + +

+

+

+

+

+

+

+

+

(+ ) +

+

+ +

+ +

+

+ + (+)

+ +

+ + + + +

+

+

+

Healthy systems + + + +

Overweight and Obesity

Breastfeeding

Maternal

25

Annex 2. Regional monitoring framework for policy, capacity and legislative indicators. These indicators will be assessed in 2016 (baseline), 2021 (mid- term) and 2025 (end term). Policy and progress indicators for Indicator definitions monitoring by WHO SEARO

1

2 3

4 5.

National nutrition policies, strategies or action plans with explicit reference to both undernutrition and overweight and obesity are available Government has a functioning a multistakeholder coordination process for nutrition Countries have identified time-bound nutrition targets based on global nutrition targets and diet related noncommunicable diseases (NCD) targets. Appropriately skilled personnel with competencies to deliver nutrition services are available Countries have conducted regular national level nutrition surveys

National nutrition policies, strategies or action plans with explicit reference to implementing actions to reduce undernutrition and overweight and obesity are available33. Yes=2, In process= 1, No=0 A multi-stakeholder coordination mechanism for nutrition is established and functional 34 Yes=2 In process=1, No=0 Country has identified time-bound nutrition targets and diet-related NCD targets in public policy documents. Yes=2, In process= 1, No=0 No. of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population32 Country has conducted a Demographic and Health Survey / 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) new surveys undertaken33 Country has food-based dietary guidelines that promote healthy diets are developed and used for nutrition promotion. Yes=2, In process= 1, No=0 Country has a comprehensive legislation for effective implementation of the International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions 32 Yes=2, In process= 1, No=0 Country has legislation enacted to implement WHO’s Recommendations on Marketing of unhealthy foods and non-alcoholic beverages to children32 Yes=2, In process= 1, No=0 Country has developed and implemented a mechanism for promoting healthy diets for the informal food sector. Yes=2, In process= 1, No=0 Country has developed/implemented the following 35  Meals provided in schools adhere to minimum nutrition standards based on national or regional dietary guidelines (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,)

6

Country food-based dietary guidelines that promote healthy diets are developed and used for nutrition promotion Government has adopted legislation for effective national implementation and monitoring of the International Code of Marketing of Breast milk Substitutes (ICBMS) and subsequent relevant WHA resolutions Legislation or regulations enacted to implement WHO’s Recommendations on Marketing of unhealthy foods and nonalcoholic beverages to children. Country has developed and implemented a mechanism for promoting health diets in the informal food sector Countries have developed and implemented processes to promote healthy dietary environments in schools to reduce the double burden of malnutrition

7

8

9 10

33

Indicators for the Global Monitoring Framework on Maternal, Infant and Young Child Nutrition 2014. HANCI: Hunger and Nutrition Commitment Index. http://www.hancindex.org/explore-the-data/understanding-theindicators/ 35 School policy framework: implementation of the WHO global strategy on diet, physical activity and health. WHO 2008. 34

26

Annex 3. Selected evidence-based interventions (e-Library of Evidence Based Nutrition Actions) to reduce the double burden of malnutrition. Direct Nutrition Interventions Breastfeeding Breastfeeding: continued breastfeeding Breastfeeding education for increased breastfeeding duration Breastfeeding: early initiation Breastfeeding: exclusive breastfeeding Breastfeeding: implementation of the Baby-friendly Hospital Initiative Breastfeeding: regulation of marketing breast-milk substitutes Complementary feeding Supplementary feeding in community settings for promoting child growth Deworming to combat the health and nutritional impact of helminth infections Anaemia/iron deficiency Optimal timing of cord clamping for the prevention of iron deficiency anaemia in infants 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 children in malaria-endemic areas Iron: intermittent supplementation in preschool and school-age children Deworming to combat the health and nutritional impact of helminth infections*36 Intermittent iron and folic acid supplementation in menstruating women Intermittent iron and folic acid supplementation in menstruating women in malaria-endemic areas Low birth weight Low birth weight: breastfeeding of low-birth-weight infants Low birth weight: cup-feeding for low-birth-weight infants unable to fully breastfeed Low birth weight: demand feeding for low-birth-weight infants Low birth weight: donor human milk for low-birth-weight infants Low birth weight: feeding of very-low-birth-weight infants Low birth weight: kangaroo mother care to reduce morbidity and mortality in low-birth-weight infants Low birth weight: micronutrient supplementation in low-birth-weight and very-low-birth-weight infants Low birth weight: mother’s milk for low-birth-weight infants Low birth weight: standard formula for low-birth-weight infants following hospital discharge Moderate acute malnutrition Moderate acute malnutrition: supplementary foods for the management of moderate acute malnutrition in children Severe Acute Malnutrition Severe acute malnutrition: identification of severe acute malnutrition in children 6–59 months of age Severe acute malnutrition: identification of severe acute malnutrition requiring inpatient care in children 6–59 months of age Severe acute malnutrition: management of infants under 6 months of age with severe acute malnutrition Severe acute malnutrition: management of severe acute malnutrition in children 6–59 months of age with oedema Severe acute malnutrition: micronutrient intake in children with severe acute malnutrition

36

Also relevant to growth

27

Childhood Obesity Exclusive breastfeeding to reduce the risk of childhood overweight and obesity 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 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 Vitamin D supplementation in children with respiratory infections Water, sanitation and hygiene interventions to prevent diarrhoea Zinc supplementation in the management of diarrhoea 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 Noncommunicable diseases Noncommunicable diseases: increasing fruit and vegetable consumption to reduce the risk of noncommunicable diseases Potassium: increasing intake to control blood pressure in children Sodium: reducing sodium intake to control blood pressure in children 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 Pregnancy and post-partum women Maternal nutrition; balanced energy and protein supplementation during pregnancy 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: periconceptional 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

28

Other guidance and recommendations selected from the Ending Childhood Obesity Commission Report Appropriate and context-specific nutrition information and guidelines for both adults and children are developed and disseminated in a simple, understandable and accessible manner to all groups in society. Implement an effective tax on sugar-sweetened beverages. Develop nutrient-profiles to identify unhealthy foods and beverages. Establish cooperation between Member States to reduce the impact of cross-border marketing of unhealthy foods and beverages. Implement interpretive front-of-pack labelling, supported by public education of both adults and children for nutrition literacy. Require settings such as schools, child-care settings, children’s sports facilities and events to create healthy food environments. Monitor and manage appropriate gestational weight gain. Provide clear guidance and support to caregivers to encourage the consumption of a wide variety of healthy foods for children. Establish standards for meals provided in schools, or foods and beverages sold in schools and other child-care settings meet healthy nutrition guidelines. Require inclusion of nutrition and health education within the core curriculum of schools . Improve the nutrition literacy and skills of parents and caregivers Develop and support appropriate multicomponent weight management services for children and adolescents who are overweight or obese as part of universal health coverage. Indirect Nutrition Interventions Supporting women's empowerment and changes to intra household food allocation. Promoting agriculture and nutrition friendly healthy food systems. In-kind household food distributions Early Child development interventions Classroom education for girls Social protection and safety nets including cash transfers: Water and sanitation initiatives: the critical importance of water, sanitation and hygiene (WASH) for nutrition status children have been demonstrated. Along with several other factors, poor hygiene and sanitation cause high levels of maternal and child undernutrition37

37

Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Ruel MT & Alderman H.the Maternal and Child Nutrition Study Group. Lancet, Volume 382, Issue 9891, 10 –16 August 2013, Pages 536–551.

29

Annex 4. Indicator definitions for Global Nutrition and diet related Noncommunicable Diseases targets. Indicator Indicator definition (assessment method) Stunting Prevalence of low height-for-age in children under five years of age Wasting Prevalence of weight-for-height <2 SD in children under five years of age Low birth weight Prevalence of infants born <2500 g Overweight Prevalence of weight-for-height >2 SD in children under five years of age Anaemia among pregnant women Prevalence of haemoglobin<11 g/dL in pregnant women Anaemia among nonpregnant women Prevalence of haemoglobin<12 g/dL in nonpregnant women Exclusively breastfed children Prevalence of exclusive breastfeeding in infants aged six months or less Salt intake Age standard mean population intake of salt (sodium Chloride) per day in grams in persons aged 18+ years Diabetes Age standard prevalence of raised blood glucose/diabetes among persons aged 18+ years or on medication for raised blood glucose Underweight women The prevalence of underweight in women of reproductive age Numerator: Number of children under five with height-for age below -2SD Denominators: Total number of children under five measured Numerator: Number of children under five with weight for height below -2SD Denominators: Total number of children under five measured Numerator: Number of LBW singleton live births to women <2500g Denominator: Total number of singleton live births to women Numerator: Number of children under five with weight for height above+2SD Denominators: Total number of children under five measured Numerator: Number of pregnant women aged 15-49 years who had haemoglobin concentration <11g/dl Denominator: Total number of pregnant women 15-49 years old Numerator: Number of non-pregnant women aged 15-49 years who had haemoglobin concentration <12g/dl Denominator: Total number of nonpregnant women 15-49 years old Numerator: Infants 0–5 months of age who received only breast milk during the previous day Denominator: Infants 0-5 months of age Numerator: Sum of sodium excretion in urine samples from all respondents aged 18+years Denominator: Number of survey respondents aged 18+ years Numerator: Number of respondents aged 18+ years with fasting plasma glucose value ≥126 mg/dl or on medication for raised blood glucose Denominator: Number of survey respondents aged 18+ years

Numerator: Number of women aged 15–49 years in the sample with BMI<18.5 kg/m² Denominator: Total number of women aged 15–49 years in the sample Overweight women Numerator: Number of women aged 15–49 years in the The prevalence of overweight in women of sample with BMI≥25 kg/m² reproductive age Denominator: Total number of women aged 15–49 years in the sample Source: Indicators for assessing infant and young child feeding practices, WHO, 2010; Noncommunicable Diseases Global Monitoring Framework: Indicator Definitions and Specifications, WHO, 2014.

30

Annex 5. 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 direction 1 Strategic direction 2 Strategic direction 3 Strategic 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 measure(s) Intermediate outcomes Proportion of women aged 15-49 years with low body mass index (<18.5 kg/m2) a Number of births during a given reference period to women aged 15-19 years /1000 females aged 15-19 years *a Prevalence of diarrhea in children under 5 years of age a

40% reduction in the number of children under five who are stunted The change in the number of heightfor-age < (-)2 SD in children under five years of age between 2010 and 2025

Process indicators Proportion of children aged 6-23 months receiving a minimum acceptable diet a Percentage of births in baby friendly facilities a Proportion of mothers of children 0-23 months receiving counselling, support or messages on optimal breastfeeding at least once in the last year a

Policy indicators --Strategic direction 1—

Policy actions --Strategic direction 1--

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized Country develops a national nutrition plan that includes WASH (Water, Sanitation, and Hygiene (WASH)

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs

Reduce and maintain childhood wasting to less than 5% The prevalence of weight-for-height <(-)2 SD in children under five years of age between 2010 and 2025

Policies for subsidizing local fruit and vegetable are enacted

Proportion of stunted women of reproductive age (15-49 years) a

Proportion women aged 15-49 years receiving counselling /treatment on appropriate weight gain Proportion of population using a safely managed drinking service a Proportion of

Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables Ensure that regulations and guidelines are in place for supplementation and fortification of products as suitable for the country context Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases

Micronutrient (supplementation) guidelines within the country are updated regularly Food fortification legislation for iodization of salt and other relevant identified micronutrients are developed and implemented Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity

31

Targets and its measure(s)

Intermediate outcomes

Process indicators population using a safely managed sanitation service a Proportion of children with severe acute malnutrition having access to appropriate treatment including therapeutic foods and nutrition counselling a Proportion of children aged 12-59 months receiving at least one dose of deworming medication a Percentage of pregnant women aged 15-49 years receiving 1+ ANC visit (including nutrition counselling) b Percentage of pregnant women aged 15-49 years receiving 4+ ANC visit (including nutrition counselling) b Proportion of children under five years old with diarrhea (in last two weeks) receiving oral dehydration salts (ORS packets or pre-packaged ORS fluids) a

Policy indicators Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions are legislated and implemented Maternity protection measures 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 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 School guidelines and standards ensuring a healthy food environment are developed and implemented

Policy actions Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Promote protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms

Guidance provided on food supplementation for pregnant and lactating women and young children Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available

Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary health-care packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions

Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track

32

Targets and its measure(s)

Intermediate outcomes

Process indicators and utilized

Policy indicators

Policy actions data on double burden of malnutrition Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require child-care settings, preschools, schools, children’s and youth sports facilities and events to create healthy food environments Policy actions --Strategic direction 1--

Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available

Targets and its measure(s)

50% reduction of anaemia in women of reproductive age The change of number of haemoglobin<11 g/dL in pregnant women aged 1549 years between (period of 1993-2005) and 2025 The change of number of haemoglobin<12 g/dL in nonpregnant women aged 15-49 years between (period of 1993-2005) and 2025

Intermediate outcomes Proportion of women aged 15-49 years with low body mass index (<18.5 kg/m2) a Number of births during a given reference period to women aged 15-19 years /1000 females aged 15-19 years a

Process indicators Proportion of pregnant women aged 15-49 years receiving weekly iron-folic acid supplementation a Proportion of nonpregnant women aged 15-49 years receiving weekly ironfolic acid supplementation a Proportion women aged 15-49 years receiving counselling/treatment on appropriate weight gain Proportion of population using a safely managed drinking service a Proportion of population using a safely managed sanitation service a Percentage of pregnant women aged 15-49 years receiving 1+ ANC visit (including nutrition

Policy indicators --Strategic direction 1--

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs

Country develops a national nutrition plan that includes WASH (Water, Sanitation, and Hygiene (WASH)

Policies for subsidizing local fruit and vegetable are enacted

Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables

33

Targets and its measure(s)

Intermediate outcomes

Process indicators counselling) b Percentage of pregnant women aged 15-49 years receiving 4+ ANC visit (including nutrition counselling) b

Policy indicators Micronutrient (supplementation) guidelines within the country are updated regularly Food fortification legislation for iodization of salt and other relevant identified micronutrients are developed and implemented Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated School guidelines and standards ensuring a healthy food environment are developed and implemented Guidance provided on food supplementation for pregnant and lactating women and young children Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation

Policy actions Ensure that regulations and guidelines are in place for supplementation and fortification of products as suitable for the country context

Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary healthcare packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions

Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets

34

Targets and its measure(s)

Intermediate outcomes

Process indicators

Policy indicators Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skillsbased nutrition education in schools is available Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces

Policy actions Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition Recognize the importance of professional and civil society organizations to promote and support healthy diets

Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition

Require child-care settings, preschools, schools, children’s and youth sports facilities and events to create healthy food environments Promote healthy diets and lifestyle at the workplaces

Targets and its measure(s)

30% reduction in low birth weight The change of number of infants born <2500 g between (period of 2006-2010) and 2025

Intermediate outcomes Proportion of women aged 15-49 years with low body mass index (<18.5 kg/m2) a

Process indicators Proportion of pregnant women aged 15-49 years receiving weekly iron and folic acid supplements a Percentage of births in baby friendly facilities a Proportion women aged 15-49 years receiving counselling/treatment on appropriate weight gain Percentage of pregnant women aged 15-49 years receiving 1+ ANC visit (including nutrition counselling) b

Policy indicators --Strategic direction 1--

Policy actions --Strategic direction 1--

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs

Policies for subsidizing local fruit and vegetable are enacted

Micronutrient (supplementation) guidelines within the country are updated regularly

Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables Ensure that regulations and guidelines are in place for supplementation and fortification of products as suitable for

35

Targets and its measure(s)

Intermediate outcomes

Process indicators Percentage of pregnant women aged 15-49 years receiving 4+ ANC visit (including nutrition counselling) b

Policy indicators Food fortification legislation for iodization of salt and other relevant identified micronutrients are developed and implemented Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated Maternity protection measures enacted and aligned with ILO Convention 183 School guidelines and standards ensuring a healthy food environment are developed and implemented Guidance provided on food supplementation for pregnant and lactating women and young children Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Established management of safe water and the accessibility of sanitation facilities at community settings is supported Efficient and effective nutrition surveillance actions suitable for

Policy actions the country context

Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Promote protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary health-care packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions

Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition

36

Targets and its measure(s)

Intermediate outcomes

Process indicators

Policy indicators tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available

Policy actions surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition Recognize the importance of professional and civil society organizations to promote and support healthy diets

Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require child-care settings, pre-schools, schools, children’s and youth sports facilities and events to create healthy food environments Policy actions --Strategic direction 1--

Targets and its measure(s)

No increase in childhood overweight The change of prevalence of weight-forheight >2 SD in children under five years of age between 2010 and 2025

Intermediate outcomes Proportion of overweight and obese women 1849 years of age (body mass index ≥25 kg/m2) a Proportion of overweight in schoolage children and adolescents 5-18 years (BMI-for-age >+1 SD) a

Process indicators Proportion of children 6-23 months of age receiving a minimum acceptable diet a Percentage of births in baby friendly facilities a Proportion of mothers of children 0-23 months receiving counselling, support or messages on optimal breastfeeding at least once in the last year a Proportion women who received counselling/treatment of appropriate body weight Proportion of schoolage children and adolescents 5-18 years receiving counselling/treatment on appropriate weight gain

Policy indicators --Strategic direction 1--

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs

Strategies and roadmap developed for population reduction of salt, sugar, and fat intake Fiscal-policies are developed and enacted for food products that high in sugar , fat, and salt Policies for subsidizing local fruit and vegetable are enacted Legislation enacted and implemented to ensure mandatory labelling of food products for both front of pack and back of pack nutrient labelling A watchdog mechanism established in country to ensure that health and nutrition claims are based on codex Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables Enact legislation and its implementation on appropriate nutritional information for processed, pre-packaged food products

37

Targets and its measure(s)

Intermediate outcomes

Process indicators Proportion of children and adolescent diagnosed as overweight or obese who received appropriate weight management service d

Policy indicators guidelines and adequate scientific evidence Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity

Policy actions Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Promote protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms

Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions are legislated and implemented Maternity protection measures 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 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 to implement WHO’s Recommendations on Marketing of unhealthy foods and beverages to children School guidelines and standards ensuring a healthy food environment are developed and implemented Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded to ensure food safety and support implementation of

Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary health-care packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions

Health Infrastructure established or upgraded to

38

Targets and its measure(s)

Intermediate outcomes

Process indicators

Policy indicators healthy diet legislation

Policy actions facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition

Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established

Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition

Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require child-care settings, pre-schools, schools, children’s and youth sports facilities and events to create healthy food environments Engage with private sector to reduce the obesogenic environment Promote healthy diets and lifestyle at the workplaces

Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available Policy measures that appropriately engage relevant private sector, to implement actions, aimed at reducing overweight, obesity and dietary risk of NCDs are instituted Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces Targets and its measure(s) Intermediate outcomes Proportion of children born in the last 24 months who were put to the breast within one hour of birth a

Process indicators Percentage of births in baby friendly facilities a Proportion of mothers of children 0-23 months receiving counselling,

Policy indicators --Strategic direction 1--

Policy actions --Strategic direction 1--

Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50%

39

Targets and its measure(s) The prevalence of infants aged 0-5 months received only breast milk during the previous day between (period of 2006-2010) and 2025

Intermediate outcomes Number of births during a given reference period to women aged 15-19 years/1000 females aged 15-19 years a

Process indicators support or messages on optimal breastfeeding at least once in the last year a

Policy indicators Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized

Policy actions Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCD’s

Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions are legislated and implemented Maternity protection measures 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 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 food supplementation for pregnant and lactating women and young children Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and

Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Promote protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms

Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary healthcare packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition Recognize the importance of professional and civil society organizations to promote and

40

Targets and its measure(s)

Intermediate outcomes

Process indicators

Policy indicators physical activity as well as support nutritionpromoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces

Policy actions support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Promote healthy diets and lifestyle at the workplaces

Targets and its measure(s)

Intermediate outcomes

A 30% relative reduction in mean population intake of salt/sodium The change of agestandardized mean population intake of salt (sodium Chloride) per day in grams in persons aged 18+ years between 2010 and 2025

Process indicators Agestandardized mean population intake of salt (sodium Chloride) per day in grams in persons aged 18+ years c Percentage of households that have adequately iodized salt (>15 ppm) a

Policy indicators --Strategic direction 1--

Policy actions --Strategic direction 1--

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs

Strategies and roadmap developed for population reduction of salt, sugar, and fat intake Fiscal-policies are developed and enacted for food products that high in sugar , fat, and salt Policies for subsidizing local fruit and vegetable are enacted Micronutrient (supplementation) guidelines within the country are updated regularly Food fortification legislation for iodization of salt and other relevant identified micronutrients are developed and implemented Legislation enacted and implemented to ensure mandatory labelling of food products for both front of pack and back of pack Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables Ensure that regulations and guidelines are in place for supplementation and fortification of products as suitable for the country context Enact legislation and its implementation on appropriate nutritional information for

41

Targets and its measure(s)

Intermediate outcomes

Process indicators

Policy indicators nutrient labelling A watchdog mechanism established in country to ensure that health and nutrition claims are based on codex guidelines and adequate scientific evidence Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated Legislation enacted to implement WHO’s Recommendations on Marketing of unhealthy foods and beverages to children School guidelines and standards ensuring a healthy food environment are developed and implemented Guidance provided on food supplementation for pregnant and lactating women and young children Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutritionpromoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition

Policy actions processed, pre-packaged food products

Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition

42

Targets and its measure(s)

Intermediate outcomes

Process indicators

Policy indicators Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available Policy measures that appropriately engage relevant private sector, to implement actions, aimed at reducing overweight, obesity and dietary risk of NCDs are instituted Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces

Policy actions Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require child-care settings, preschools, schools, children’s and youth sports facilities and events to create healthy food environments Engage with private sector to reduce the obesogenic environment Promote healthy diets and lifestyle at the workplaces

Targets and its measure(s)

Halt the rise in diabetes and obesity The change of agestandardized prevalence of raised blood glucose/diabetes among persons aged 18+ years(defined as fasting plasma glucose concentration ≥ 7.0 mmol/l (126 mg/dl) or on medication for raised blood glucose) between 2010 and 2025 The change of prevalence of overweight and obesity in adolescents (defined according to the WHO growth reference for school-aged children and adolescents, overweight – BMI for age and

Intermediate outcomes Agestandardized prevalence of raised total cholesterol among persons aged 18+ years (defined as total cholesterol ≥5.0 mmol/l or 190 mg/dl); and mean total cholesterol concentration c

Process indicators Age-standardized prevalence of persons (aged 18+ years) consuming less than five total servings (400 grams) of fruit and vegetables per day c Age-standardized mean proportion of total energy intake from saturated fatty acids in persons aged 18+ years c Age-standardized mean proportion of persons aged 18+ years receiving counselling/treatment on appropriate weight gain Proportion of adolescents receiving counselling/treatment on appropriate weight gain Proportion of children and adolescent diagnosed as overweight or obese who received appropriate weight management service d

Policy indicators --Strategic direction 1--

Policy actions --Strategic direction 1--

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized Strategies and roadmap developed for population reduction of salt, sugar, and fat intake Fiscal-policies are developed and enacted for food products that high in sugar , fat, and salt Policies for subsidizing local fruit and vegetable are enacted Legislation enacted and implemented to ensure mandatory labelling of food products for both front of pack and back of pack nutrient labelling A watchdog mechanism established in country to ensure that health and nutrition claims are based on codex guidelines and adequate scientific evidence Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables Enact legislation and its implementation on appropriate nutritional information for processed, pre-packaged food products

Nutrition Guidelines for disaster preparedness or emergencies are

Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for

43

Targets and its measure(s) sex >1 SD, and obese – BMI for age and sex >2 SD) between 2010 and 2025 The change of agestandardized prevalence of overweight and obesity in persons aged 18+ years (defined as body mass index ≥ 25 kg/m2 for overweight and body mass index ≥ 30 kg/m² for obesity) between 2010 and 2025

Intermediate outcomes

Process indicators

Policy indicators developed and disseminated International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions are legislated and implemented Maternity protection measures 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 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 to implement WHO’s Recommendations on Marketing of unhealthy foods and beverages to children School guidelines and standards ensuring a healthy food environment are developed and implemented Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation

Policy actions disaster preparedness, response and management of nutrition emergencies Promote protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms

Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary health-care packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of

Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized

44

Targets and its measure(s)

Intermediate outcomes

Process indicators

Policy indicators

Policy actions malnutrition Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require child-care settings, pre-schools, schools, children’s and youth sports facilities and events to create healthy food environments Engage with private sector to reduce the obesogenic environment Promote healthy diets and lifestyle at the workplaces

Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition

Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available Policy measures that appropriately engage relevant private sector, to implement actions, aimed at reducing overweight, obesity and dietary risk of NCDs are instituted Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces

45

Annex 6. Example of cross-sectoral Government engagement and potential multisectoral action. Sector Health Nutrition Areas Food security Food safety Food safety and hygiene regulations Food inspections Food standards

Healthy lifestyle Promoting healthy diets Promotion of exercise Infection control Family Planning

Nutrition Micronutrient supplementation Management of SAM Dietary guidelines Baby friendly hospitals Breast and complementary feeding promotion

Public works/Urban development

Rural roads Irrigation

Water and sanitation improvement

Urban bike lanes Pedestrian walk ways Road safety Smoke free environment Bio-fortification to improve nutrition density Nutrition oriented agriculture research Nutrient promoting farming systems, agronomic practices and crops Nutrition education Anaemia control

Agriculture

Food and agriculture policies to promote availability, affordability and quality Sustainable intensification of production Promotion of home gardens

Regulation to improve food safety in processing, transport and storage

Education

Promotion of gardens School meals

school

Food safety and hygiene education

Physical exercise Life skills and sex education Gender equality

Industry/trade/commerce

Food availability (manufacturing marketing)

Food standards and

Food regulations

safety

Product formulation to reduce saturated and trans fats, sodium and sugar content Food fortification Nutrition labelling Code of breast milk substitutes Nutrition information campaigns Nutrition labelling Food taxes

Public information

Marketing of foods to children

Finance and economy

Food subsidies

Source: Adapted from Shrimpton and Rokx, 2012 (1).

46



REGIONAL COMMITTEE Sixty-ninth Session Colombo, Sri Lanka 5–9 September 2016

Provisional Agenda item 9.8 SEA/RC69/16 Rev.2 3 August 2016

Regional Strategic Plan to Address Double Burden of Malnutrition in the South-East Asia Region Malnutrition in all its forms threatens human development. Both undernutrition and overweight and obesity throughout the life course are public health problems in the WHO South-East Asia Region, affecting Member States to varying degrees. Undernutrition, including micronutrient deficiencies, contributes to about 45% of preventable deaths of children under five years of age annually, while overweight resulting from unhealthy diets and sedentary lifestyle underpins high rates of noncommunicable diseases (NCDs) in Member States. Therefore, urgent attention is needed to reduce malnutrition. While the previous Regional Nutrition Strategy, “Addressing malnutrition and micronutrient deficiencies (2011–2015)”, emphasized a multisectoral approach (SEA/RC64/R4), it cannot adequately address the current need in the Region to tackle both undernutrition and overweight and obesity. Many global actions and policies have focused attention on the rise of overweight and obesity, including the recent Sustainable Development Goals agenda, which calls for an end to all forms of malnutrition. In response, the WHO Regional Office, in consultation with Member States, has developed a Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016–2025, through extensive consultation with Member States, technical experts and WHO country offices and headquarters. The Plan focuses on creating an enabling environment that will facilitate the implementation of interventions focused towards both undernutrition and overweight and obesity. The attached Working Paper was presented to the High-Level Preparatory (HLP) Meeting for its review and recommendations. It was discussed that the title of the Regional Committee agenda item may be reflected as “Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016–2025”. The recommendations made by the HLP Meeting for consideration to the Sixty-ninth Session of the Regional Committee are as follows: Actions by Member States (1) Propose a resolution based on the Draft Regional Strategic Plan to Address the Double Burden of Malnutrition in the South-East Asia Region at the Sixty-ninth Session of the Regional Committee for South-East Asia in September 2016.

(2) Use the draft plan – based on the national context in each country – as an advocacy and reference tool to guide the process of updating national plans and strategies to address the double burden of malnutrition. Actions by WHO (1) Provide technical guidance and support to Member States for adapting and revising their policies and plans on nutrition to address the double burden. (2) Support operationalizing of actions to address the double burden of malnutrition through technical support to mobilize resources, develop capacity, and frame and enact new legislations and regulations based on country-level contexts and specificities. (3) Adapt and develop region-specific tools and frameworks to support development of an enabling environment for implementation of evidence-based nutrition interventions. This Working Paper and the HLP Meeting recommendations are submitted to the Sixty-ninth Session of the WHO Regional Committee for South-East Asia for its consideration and decision.

SEA/RC69/16 Rev.2

Introduction 1. Economic growth and investments, demographic changes, globalization and social and health development have altered the nutrition profile and its determinants across the WHO South-East Asia Region. Despite progress in reducing hunger and undernutrition, malnutrition continues to undermine the health of populations. The current nutrition landscape in the Region is characterized by persistent undernutrition and emerging overweight and obesity existing side by side, often within the same community; i.e. the double burden. The extent of the double burden varies across Member States, and urgent and sustained efforts are needed in improving nutrition status. 2. Undernutrition contributes to about 45% of preventable deaths of children under five years of age annually. Meanwhile, increased rates of overweight and obesity mainly resulting from unhealthy diets and sedentary lifestyle have led to unprecedented rates of noncommunicable diseases (NCDs) in Member States, with 55% of all deaths attributed to NCDs. Regionally, an estimated 60 million children in the 0–5-year age group are stunted, 45 million are underweight and 8.8 million are overweight. Thinness in adolescent girls aged 15–19 years ranges from 24% to 47%, and overweight between 2% and 24%. Among adult women, prevalence of overweight is greater than underweight and ranges from 18% to 34% across Member States. Anaemia and other micronutrient deficiencies affect both the undernourished and overweight and obese, and is of a magnitude to be recognized as a public health problem in all Member States. High salt intake in all Member States compounds the rise in NCDs and hypertension rates, with one in three adults estimated to have high blood pressure.

Current responses and challenges 3. Previous nutrition policy initiatives of the SEA Region have not comprehensively addressed both aspects of malnutrition. The Regional Nutrition Strategy, “Addressing malnutrition and micronutrient deficiencies (2011–2015)”, emphasized a multisectoral approach and the identification of core nutrition interventions (SEA/RC64/R4). WHO has supported Member States to review national nutrition policies and plans and strengthen multisectoral collaboration. WHO has also facilitated initial policy dialogue and advocated Member States to focus on the double burden of malnutrition. 4. Maternal undernutrition, as well as overweight and obesity, have a transgenerational impact with significant repercussions for future generations. Undernutrition and overweight and obesity result from suboptimum dietary practices through the life cycle, with low physical activity exacerbating effects of unhealthy diets. In addition to the traditional determinants of malnutrition, which include inequity, inadequate nutrition and inadequate care, newer drivers of the epidemic of overweight and obesity are the obesogenic environment caused by urbanization and changing lifestyles, unhealthy food systems and globalization of markets resulting in the increasing availability of energy-dense, nutrient-poor foods high in sugar, salt and fat, aggressive marketing of unhealthy foods and low physical activity. Emerging challenges such as climate change and migration compound the problem.

SEA/RC69/16 Rev.2 Page 2

5. Due to the historic and the significant burden of undernutrition in the past decades, most health systems in Member States are geared towards reducing undernutrition. Therefore, countries in this Region are challenged to concurrently develop systematic multisectoral policy actions and implement interventions for reducing overweight and obesity, and dietary risk factors for NCDs, in addition to the current focus on undernutrition. 6. Many global actions and policies have focused attention on the double burden of Malnutrition. These include: • • • • • WHO Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition (resolution WHA65.6) and Global Nutrition Targets 2025; The Outcome of the Second International Conference on Nutrition (resolution WHA68.19); The United Nations Decade of Action on Nutrition (2016 –2025) (UNGA A/70/L.42 and resolution WHA69.7); Nutrition-related SDGs, including SDG2 which calls for an end to all forms of malnutrition by 2030 and reaffirms attaining the global nutrition targets by 2025; Sixty-ninth World Health Assembly resolution and decision (the guidance on ending inappropriate promotion of foods for infants and young children (resolution WHA69.9) and the Report of the Commission on Ending Childhood Obesity (resolution WHA 69(12)).

The way forward 7. In view of the rising double burden of malnutrition reflected in the unfinished agenda of reducing undernutrition and diet-related noncommunicable diseases, a Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016–2025 has been developed. The Action Plan advances efforts established under the previous regional strategy and incorporates recent global and regional guidance in encouraging comprehensive implementation of policy actions that simultaneously deal with both undernutrition and overweight and obesity as well as new and emerging challenges such as climate change and emergencies. The draft action plan was developed through an extensive consultative process with Member States, including: the Commission on Ending Childhood Obesity—South-East Asia Regional Consultation (28–29 September 2015, New Delhi, India); an Informal Member State Consultation—Developing a regional action plan of multisectoral actions for ending childhood obesity (29 September 2015, New Delhi, India); an expert group consultation to review the draft strategic action plan for addressing the dual burden of malnutrition in South-East Asia Region (2–3 February 2016, New Delhi, India); and a regional meeting to review the Draft Strategic Acton Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region (21–22 March 2016, New Delhi, India). UN agencies and donors also participated in these consultations. 8. The Action Plan is structured in a theory-of-change model, which is based on the premise that creating an enabling environment is the key to successful implementation and scaling up of context-specific nutrition interventions to achieve the six global nutrition targets and two nutrition-related global voluntary targets for the prevention and control of NCDs (halt the rise in

SEA/RC69/16 Rev.2 Page 3

diabetes and obesity and reduction of salt intake). Moreover, it takes into account the outcomes of recent international movements on nutrition, including the Scaling Up Nutrition and Zero Hunger Challenge. 9. The Action Plan recommends that Member States examine their policies and strategies on nutrition, NCDs and any multisectoral action plans to ensure inclusion of policy actions to reduce the double burden with an emphasis on the first 1000 days, school-aged children and on adolescents. It provides guidance for Member States via key policy actions to be undertaken across four strategic areas. These include improving nutrition governance through enhanced political commitment and evidence-informed multisectoral policies; developing and adapting relevant legislation and guidelines; strengthening health workforce capacity and information systems; and tactical engagement with stakeholders including the community, academia, civil society and the private sector. The Action Plan also provides direction to the WHO Regional Office and country offices on their role in supporting Member States to deal with the double burden, while acknowledging that countries are at different stages along the double burden continuum.

Conclusions 10. The Action Plan would be an advocacy and reference tool for Member States, to ensure that interventions covering the double burden of malnutrition are addressed comprehensively through country nutrition or NCD strategies, action plans and programmes. As appropriate to the national context, countries are encouraged to prioritize actions recommended in this Action Plan. The Action Plan suggests a timeframe for review of actions through a brief monitoring framework at the regional level. The plan would be reviewed in 2021 and then revised as needed. 11. The draft Strategic Action Plan to Reduce the Double Burden of Malnutrition in the SouthEast Asia Region (2016–2025) (Annexure 1) is submitted for consideration of its endorsement and further guidance.

Annexure-1 STRATEGIC ACTION PLAN TO REDUCE THE DOUBLE BURDEN OF MALNUTRITION IN SOUTH-EAST ASIA REGION, 2016–2025

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

1

Table of Contents Abbreviations ........................................................................................................................................................................... iii Executive summary ............................................................................................................................................................... iv 1. Introduction .......................................................................................................................................................................... 1 1.1 Suboptimal diets .......................................................................................................................................................... 1 1.2 Consequences of malnutrition ............................................................................................................................... 2 1.3 Addressing the determinants of the double burden of malnutrition .................................................... 2 1.4 Emerging challenges in nutrition ......................................................................................................................... 3 2. Profile of nutritional status in the WHO South-East Asia Region ................................................................... 5 2.1 Nutritional status of children aged 0–5 years ................................................................................................. 6 2.1.1 Stunting and overweight in children < 5 years ...................................................................................... 6 2.1.2 Wasting in children < 5 years of age ........................................................................................................... 7 2.1.3 Underweight in children < 5 years .............................................................................................................. 7 2.1.4 Low birth weight (LBW) .................................................................................................................................. 8 2.2 Nutritional status of adolescents .......................................................................................................................... 9 2.3 Nutritional status of adult population ................................................................................................................ 9 2.4 Nutrition in older persons ..................................................................................................................................... 10 2.5 Micronutrient Deficiencies in the South-East Asia Region ...................................................................... 11 2.5.2 Status of other micronutrient deficiencies ............................................................................................. 13 2.6 Diets in the WHO South-East Asia Region....................................................................................................... 13 2.6.1Consumption of minimum acceptable diets by young children ..................................................... 13 2.6.2 Dietary risk factors for noncommunicable disease risk ................................................................... 14 2.6.3 Fruit and vegetable consumption .............................................................................................................. 14 3. The Strategic Framework and Action Plan............................................................................................................. 15 3.1 Goal.................................................................................................................................................................................. 15 3.2 Objectives ..................................................................................................................................................................... 15 3.3 Scope and purpose .................................................................................................................................................... 15 3.4 Policy context .............................................................................................................................................................. 15 3.5 Time frame ................................................................................................................................................................... 16 3.6 Monitoring.................................................................................................................................................................... 16 3.7 Guiding principles ..................................................................................................................................................... 16 3.8 Strategic directions and outcomes of the action plan are set out in the following theory of change ......................................................................................................................................................................... 17 3.9 Role of the WHO ......................................................................................................................................................... 17 3.10 Nutrition and diet-related noncommunicable diseases risk targets ................................................. 18 4. The Action Plan .................................................................................................................................................................. 20 5. References ........................................................................................................................................................................... 25

i

List of tables Table 1: Level of public health burden caused by anaemia among nonpregnant women, children and pregnant women. ................................................................................................................................................................... 12

List of figures Figure 1: The double burden of malnutrition across the life course. ...................................................... 2 Figure 3: Prevalence of stunted children and overweight children aged < 5 years (-2SD Height-forage Z scores) in SEAR. ................................................................................................................................. 6 Figure 4: Prevalence of wasting in children aged <5 years (-2SD Weight-for-height Z scores) in SEAR. ............................................................................................................................................................ 7 Figure 5: Prevalence of underweight (-2SD Weight-for-age Z scores) in children <5 years in SEAR. . 7 Figure 6: Prevalence of low birth weight children in SEAR. .................................................................... 8 Figure 7: Proportion of stunted, underweight and overweight/obese female adolescents aged 15–19 years in selected countries of SEAR. ..................................................................................................... 9 Figure 8: Trend in prevalence of overweight (mean BMI ≥25 kg/m2) in adults (both sexes) in 2010 and 2014 in SEAR. ..................................................................................................................................... 10 Figure 9: Proportion of older persons (aged 60 years and over) in SEAR. ........................................... 10 Figure 10: Prevalence of anaemia among children aged < 5 years and non-pregnant women in SEAR. .................................................................................................................................................................... 12 Figure 11: Consumption of minimum acceptable diets by 6–23 month old children in SEAR. .......... 13 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 Region. ..................................................... 14 Figure 13: Percentage of adults who ate < 5 servings of fruits and vegetables per day. ..................... 14 Figure 14: Strategic directions and outcomes of the action plan. ......................................................... 17 Figure 15: Global nutrition and diet-related noncommunicable disease targets................................. 19 List of annexes Annex 1. Supporting global and regional resolutions/mandates and content analysis of technical areas covered. ............................................................................................................................................ 27 Annex 2. Regional monitoring framework for policy, capacity and legislative indicators. ................ 28 Annex 3. Selected evidence-based interventions (e-Library of Evidence Based Nutrition Actions) to reduce the double burden of malnutrition. ............................................................................................. 29 Annex 4. Indicator definitions for Global Nutrition and diet related Noncommunicable Diseases targets. ........................................................................................................................................................ 32 Annex 5. 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). ........................................................................................................................................ 33 Annex 6. Example of cross-sectoral Government engagement and potential multisectoral action. .. 48

ii

Abbreviations BMI BMS CIP DHS eLENA FAO GDP GHI GNP HDI ICN 2 IDD USI IYCF IMR LBW MICS MDG NCD REACH SAM SD SEAR SUN SDG U5MR UNICEF WASH WHA WHO WIFS IDA IEC IFA IYCF LMICs Body Mass Index breast milk substitutes Comprehensive Implementation Plan Demographic and Health Survey Electronic Library of Evidence for Nutrition Actions Food and Agriculture Organization Gross Domestic Product Global Hunger Index Gross National Product Human Development Index Second International Conference on Nutrition Iodine Deficiency Disorder Universal Salt Iodization Infant and Young Child Feeding Practices Infant Mortality Rate Low Birth Weight Multiple Indicator Cluster Survey Millennium Development Goal Noncommunicable Diseases Renewed Efforts Against Child Hunger and Undernutrition Severe Acute Malnutrition standard deviation South-East Asia Region Scaling Up Nutrition Sustainable Development Goal Under Five Mortality Rate United Nations Children’s Fund Water, Sanitation and Hygiene World Health Assembly World Health Organization Weekly Iron and Folate Supplementation Iron Deficiency Anaemia Information, Education and Communication Iron Folic Acid Infant and Young Children Feeding Low and Middle-Income Countries

iii

Executive summary Economic growth accompanied by investments in social development and health have resulted in improvements in the nutritional status of the populace in the WHO South-East Asia Region. However, despite progress on the Millennium Development Goals (MDGs), targets of halving poverty and hunger, reducing child mortality and underweight, malnutrition continues to persist. The ongoing nutrition transition in the Region is characterized by persistent undernutrition, which includes micronutrient deficiencies, and concomitant overweight and obesity (the double burden), and associated risk of noncommunicable diseases (NCDs). In South-East Asia Region, an estimated 60 million children in the 0–5 year age group are stunted, 45 million are underweight and 8.8 million are overweight. Anaemia and other micronutrient deficiencies are a significant public health problem in many Member States. Undernutrition contributes to about 45 % of preventable deaths of children under 5 years annually. Increased overweight and obesity underpin the high rates of NCDs in Member States, with 55 % of all deaths attributed to NCDs. Maternal undernutrition, as well as overweight and obesity have a transgenerational impact. Poor maternal nutrition is a determinant of low birth weight, associated with stunting. Both low birth weight and stunting in turn increase risk of overweight, obesity and noncommunicable diseases in later life. Maternal overweight and obesity are also related to child overweight. Poverty and inequity, inadequate nutrition, want of access to health and nutrition services, infections and lack of clean water and sanitation are some determinants of undernutrition. Changing dietary habits fuelled by globalization of markets with increased availability of energy dense, nutrient-poor foods, and inadequate physical activity lead to overweight and obesity. The double burden of malnutrition affects Member States to varying degrees, and urgent and sustained efforts are needed to address the problem. 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 between Member States, experts and the WHO secretariat. It advances efforts established under the previous regional strategy, and brings together guidance from global and regional policy platforms on promoting integrated approaches to address all forms of malnutrition concurrently. Policy actions from the Global Strategy on infant and young child feeding; the Comprehensive Implementation Plan for Maternal, Infant and Young Child Nutrition; the framework for action of the 2nd International Conference on Nutrition (ICN2); the Ending Childhood Obesity Commission report; and the post 2015 development agenda have informed the action plan. The emphasis of the action plan is on improving nutrition governance, adopting global guidance and institution of legislation, improving capacity, multisectoral engagement and community empowerment to ensure sustainable solutions to nutrition problems. These aspects are articulated through four strategic directions. This plan will serve Member States as an advocacy and reference tool, to ensure that interventions covering the double burden of malnutrition are addressed comprehensively and simultaneously in Member State policies, strategies and actions. The plan also provides direction to the Regional Office and country offices on the pertinent areas of support for Member States.

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1. Introduction Malnutrition,1 in all its forms, threatens human health and development. Today, most low and middle-income countries face an increasing 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)2 such as cardiovascular disease, diabetes mellitus and cancer is threatening already stretched and under-resourced health systems and economies.(2) By 2030, NCDs are expected to contribute to two thirds of the disease burden in low and middle-income countries.(2) The South-East Asia Region has historically carried a high burden of child undernutrition, caused by socioeconomic disadvantages, and other biological and social determinants. The picture is now changing with a concomitant rise in both child and adult overweight and obesity. Evidence indicates that 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. (3) As indicated in Figure 1, the behavioural and biological responses of a child to the obesogenic environment is shaped partly in utero, placing many on the pathway to obesity when faced with an unhealthy diet and low physical activity, as seen in today’s transitioning societies.(4) Low birth weight and stunted children who experience rapid weight gain during childhood and adolescence are at greater risk to develop NCDs. (5) For South-East Asia, and especially for its stunted populations, the risks of a mismatch between their genetic programming (in preparation for a resource-poor environment after birth) and the unhealthy diet environment after birth are greatly increasing NCD risk. (6) 1.1 Suboptimal diets The predominant dietary patterns in the South-East Asia Region are plant based, often inadequate in energy, protein, and micronutrients, and low in diversity giving rise to stunting, wasting and anaemia in young children. (7) Significant protein-energy deficits are common (8). At the same time, particularly in urban areas, diets higher in refined grains and sugars, and fats are getting more common. Healthy diets where adequate energy should be obtained mostly from unrefined carbohydrates, protein from plant and animal sources, are shifting away from saturated fats to unsaturated fats, and elimination of trans fatty acids; limiting intake of free sugars, sodium and increasing fruits, legumes, whole grains and nut consumption needs to be advocated. Intrauterine life, infancy and the preschool period have all been considered as critical periods where long-term regulation of energy balance is programmed. Therefore, a life-course perspective (Figure 1) along with measures to reduce the obesogenic environment3 has the greatest potential to address both undernutrition and overweight and obesity (4, 9), with an emphasis on prevention in children under five years of age, school aged children,4 adolescents5 and pregnant women. 1 2

Malnutrition is defined as nutritional excesses of macronutrients and micronutrients as well as deficiencies (WHO 1995). World Health Organization. Noncommunicable diseases. http://www.who.int/mediacentre/factsheets/fs355/en/ -accessed 1 August 2017. 3 An environment that promotes high energy intake and sedentary behaviour. 4 Children between ages 6 and 11 years.

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 Consequences of malnutrition Worldwide, more than one third of child deaths and one fifth of the total disease burden are due to maternal and child undernutrition. (10) Final adult height, which is largely determined in childhood, reflects the nutrition quality during early life. (11) Stunting during the prenatal period and infancy impairs cognitive development, with reduced school performance. In adult life, work performance is reduced, and stunting is associated with an increased risk of noncommunicable diseases. (10, 12) Loss of attainment of height causes an annual loss of two to three percent of GDP, undermining efforts to eradicate poverty. (13) Micronutrient deficiencies add to the social and economic burden, compromising the immune system, diminishing cognitive functions and intellect, causing anaemia and other illnesses. (1) Of a total 13.7 million deaths in the South-East Asia Region during 2012, 6.8 million were due to NCDs, principally cardiovascular diseases, diabetes, cancer and chronic respiratory diseases (14). By 2030, an estimated 32 percent of the total proportion of diabetes cases will be from the South-East Asia Region. (15) Together, both undernutrition and NCDs represent a significant economic and social cost to countries with an estimated cost of more than US$ 30 trillion globally over the next 20 years. (15) 1.3 Addressing the 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) Poor diets, physical inactivity and infections contribute to immediate causes of malnutrition. Inadequate care, suboptimal and unhealthy diets, poor water and sanitation, lack of food safety, inadequate health care and sedentary behaviours underlie the double burden of malnutrition. Finally, basic causes of malnutrition at the societal level include inadequate access to food supply, maternal education, 5

Boys and girls between ages 11 and 19 years.

2

inadequate investments in health services, social protection schemes and poverty. Such determinants should be examined and addressed through a nutrition lens that considers both aspects of the double burden of malnutrition that also considers country specific contexts. Figure 2: Conceptual framework of malnutrition.

Basic, underlying and immediate causes are included in this figure, as well as outcomes of malnutrition. ASEAN/UNICEF/WHO (2016) Regional Report on Nutrition Security in ASEAN, Volume 2, Bangkok, UNICEF.

1.4 Emerging challenges in nutrition 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.6 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 could play a part in the prevention of degenerative conditions of the elderly and an improvement in quality of life.

6

National Institute on Aging, National Institutes of Health. Global Health and Ageing. United States: NIH Publication, 2011.

3

Climate change Climate change increases the incidence and severity of extreme weather events and magnifies the risk of disasters globally.7 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, stability and utilization, thereby exacerbating current states of malnutrition. It is the poorest and vulnerable groups such as young children and women with inadequate resilience to cope that would be most affected. Obesogenic environment Mechanization and urban lifestyles that promote increased screen time and other sedentary behaviours are becoming more common in the South-East Asian Region, along with an abundance of low-cost, high-energy foods due to globalization and aggressive marketing by industry.

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. 7

4

2. Profile of nutritional status in the WHO South-East Asia Region The WHO South-East Asia (SEA) Region represents a diverse range of 11 low- and middle-income countries, with wide variations in geography, culture, social development and nutrition transition. Over the past two to three decades, the Region has seen significant social, economic and demographic changes that have greatly influenced the nature of nutrition issues currently faced by countries. Of the world’s population, 26% lives in the South-East Asia Region, with more than 90 percent of the Regional population being in Bangladesh, India and Indonesia. (17). The rate of urbanization in Asia (1.5% per annum) is the highest in 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 the population is rural. (19) The Region has the Bangladesh largest working age population in the world, representing enormous human Bhutan resource potential. Literacy rates, especially among women, are rising consistently, contributing to human and social capital. In Thailand, Sri Lanka, Indonesia 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) Democratic People’s Republic of Korea India

Robust economic growth accompanied by intensive efforts for social development Indonesia have resulted in declining poverty and improvements in the Human Development Maldives 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 Myanmar declined significantly from 34 deaths per 1000 live births in 2000 to an estimated Nepal 26 deaths in 2015.8 Significant progress has been made in reducing undernutrition. Sri Lanka Bangladesh (21) reported a 35–40% decline in child stunting and underweight between 2004 and 2014. Similarly, a 60% reduction in stunting prevalence and 70% Thailand reduction in underweight among under-five children was reported from Bhutan Timor- Leste 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 years9 and a significant increase in exclusive breastfeeding rates. (23) However, while undernutrition is declining, micronutrient deficiencies, particularly anaemia, remains a significant problem, and child, adolescent and adult overweight and obesity is increasing in prevalence.



Data not available for Democratic People’s Republic of Korea and for Bhutan. 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. 9 International institute for population sciences. National family health survey, India. http://rchiips.org/NFHS/factsheet_NFHS-4.shtml – accessed 1 August 2016. 8

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2.1 Nutritional status of children aged 0–5 years10,11 2.1.1 Stunting and overweight in children < 5 years: Stunting12 is the cumulative result of chronic malnutrition and deprivations from the prenatal period and childhood. Overweight may or may not be superimposed on stunting and results from diets excessive in energy, together with reduced physical activity. Figure 3 indicates the prevalence of both stunting as well as overweight in young children.13 The double burden varies between countries with over 10% of children in under-five age group estimated to be overweight in India, Indonesia and Thailand and less than 3% in Bangladesh, Myanmar, Nepal and Sri Lanka. The regional prevalence of overweight in children under five years was 3.3% in 2005 and 4.9% in 2014.14 Prevalence of stunting is declining across all countries in the Region. The overall Annual Average Rate of Reduction of 1 percentage point per year is much slower than the estimated 3.9% needed to meet Global nutrition targets. Although the overall prevalence of stunting in SEAR countries has been reduced from 59% in 1990 to 32.9% in 2013, it translates to 60.8 million stunted children at present. (24) Figure 2: Prevalence of stunted children and overweight children aged < 5 years (-2SD Height-forage Z scores) in SEAR15. 100 90 80 70 60 50 40 30 20 10 0

Percentage of under five children (%)

50.2 36.1 33.6 38.7 27.9 20.3 36.4 35.1 37.4 14.7 16.3 32.9

Stunting Overweight

Source: WHO/UNICEF/World Bank joint monitoring estimates 2015. 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 noted that the prevalence of stunting is low. The most recent data

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. 11 For the purpose of uniformity, the data for nutrition profile 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. 12 Defined as height that is more than two standard deviations below the World Health Organization Child Growth Standards median. 13 Defined as weight for age more than 2 standard deviations above the WHO growth standards median (birth to less than 5 years of age). 14 WHO/UNICEF/World Bank joint monitoring estimates 2015. http://www.wssinfo.org/ - accessed 1 August 2016. 15 National Nutrition Survey 2015 of Bhutan showed that 21.2% of children are stunted. 10

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from MICS indicate that the prevalence of stunting is 10.5% for children under 5 years of age and the prevalence of overweight is 8.2% in children under 5 years of age.16

2.1.2 Wasting in children < 5 years of age17: Wasting is the result of recurrent acute deprivations of nutrition. In 2014, in the SEA Region, 14.5% of the children were wasted (25.9 million children wasted and 8.1 million severely wasted) as indicated in Figure 4. (24) Figure 3: Prevalence of wasting in children aged <5 years (-2SD Weight-for-height Z scores) in SEAR18. Precentage of under five children (%) 100 90 80 70 60 50 40 30 20 10 0

14.3

5.9

15.1 4

13.5

21.4 10.2 7.9 11.3 6.7 11

Data updated by October 2015. The specific year when the data was obtained in each country is given in parenthesis. National data is mainly originated from various household surveys included in the WHO/UNICEF/World Bank joint monitoring estimates 2015.Threshold of public health significance >5 percent (green), high severity (>10 percent , yellow). Thailand noted that the prevalence of stunting is low. The most recent data from MICS indicates that prevalence of wasting is 5.4 percent in children under 5 years of age.

2.1.3 Underweight in children < 5 years: Most of the countries of the Region show a significant decline in prevalence of underweight (figure 5). Despite this decline, in 2014, 46 million children in the Region were estimated to have low weight for age (24). Figure 4: Prevalence of underweight (-2SD Weight-for-age Z scores) in children <5 years in SEAR19.

UNICEF, MICS. Multiple Indicator Cluster Survey (MICS) 2015/16: Thailand. http://mics.unicef.org/surveys - accessed 1 August 2016. Defined as more than two standard deviations below the median weight-for-height of the WHO Child Growth Standards median and below minus three standard deviations (-3 SD) are considered to be severely wasted. 18 National Nutrition Survey 2015 of Bhutan reported prevalence of 4.4% wasting and 9% underweight among children age 0-59 months 19 Defined as weight for age less than 2 standard deviations below the WHO growth standards median (birth to less than 5 years of age). 16 17

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Precentage of children under five (%)

100 90 80 70 60 50 40 30 20 10 0

32.6 12.8 15.2

29.4 19.9 17.8

22.6

30.1

37.7 26.3 9.2

Data updated by October 2015. The specific year when data were obtained in each country is given in parenthesis. National data are mainly originated from various household surveys included in the WHO/UNICEF/World Bank joint monitoring estimates 2015. Threshold of public health significance >30% (very high severity), high severity (>20%); <1 % (low severity).

2.1.4 Low birth weight (LBW): LBW (birth weight < 2500 g) is associated with higher morbidity and mortality especially in the neonatal period. The prevalence of LBW is the highest in India, followed by Bangladesh, Nepal and Sri Lanka (Figure 6). However, birth weight figures are likely to be underreported due to home deliveries. Figure 5: Prevalence of low birth weight children in SEAR. Percentage of children born with weight <2500g (%) 100 90 80 70 60 50 40 30 20 10 0

22 10 6

28 9 11 18 9 17 11 12

Source: State of World’s Children 2015: Reimagine the Future (UNICEF 2015).

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2.2 Nutritional status of adolescents Stunting 20. 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 for stunting (145 cm of height). (Fig. 10) Thinness 21.The DHS data from six countries of the Region show that thinness among adolescent girls is in the range of 24–47%, indicating significant energy deficits in diet. Overweight and obesity 22 23. Often seen side by side with thinness and stunting in the same community, overweight /obesity24, caused by unhealthy diet and low physical activity is a growing concern among adolescents in the Region. (Figure 7)

Figure 6: Proportion of stunted, underweight and overweight/obese female adolescents aged 15–19 years in selected countries of SEAR.

100 90 80 70 60 50 40 30 20 10 0 Bangladesh India Maldives Nepal Sri Lanka Timor-Leste BMI ≥ 25kg/m2 BMI <18.5kg/m2 Height <145 cm

Source: Bangladesh DHS 2011; India NFHS3 2005-06; Maldives DHS 2009; Nepal DHS 2011; Sri Lanka DHS 2006; TimorLeste DHS 2009-10. BMI of > 25 kg/m2 has been taken as overweight, and BMI of 30 kg/m2 as obese.

2.3 Nutritional status of adult population More than one-fifth of adults are overweight in the Region, 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 Short stature/stunting among reproductive age women is frequently defined as height less than 145 cm, a cut-off chosen because of its association with increased obstetric risk. 21Thinness or underweight is defined as Body Mass Index (BMI) less 18.5 kg/m 2. 22 BMI-for-age more than 2 SD above the WHO growth reference median for ages less than 5 years. 23 From age 5 to less than 19 years: BMI-for-age more than 1 SD above WHO growth reference median. 20

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1.3 kg/m2/decade in Maldives between 1980 and 2008. The Global status report 2014 also shows high BMI levels in Maldives and Thailand. (25) Figure 7: Trend in prevalence of overweight (mean BMI ≥25 kg/m2) in adults (both sexes) in 2010 and 2014 in SEAR. 100 90 80 70 60 50 40 30 20 10 0

Percentage of adults (%)

18 16

24 27

19

20

2022

25 21

2730 1518

18 16

2225

2730 1315

2010 2022

2014

Source: Global Health Observatory Data Repository, WHO 2013. http://www.who.int/gho/en

2.4 Nutrition in older persons Figure 9 provides the population projection estimates of older persons 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 8: Proportion of older persons (aged 60 years and over) in SEAR.

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100 Percentage of older persons (%) 90 80 70 60 50 40 30 20 10 0 26.9 19.4 12.0 12.4 11.5 7.0 7.0 21.0 13.0 12.4 8.0 6.0 12.0 7.0 13.0 9.0 11.0 10.6 8.0 15.7 4.4 6.7

2015

2030

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.

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). 2.5.1Anaemia Anaemia prevalence across all countries is mainly nutritional in nature and primarily attributed to iron deficiency and partly to folic acid and vitamin B12 deficiencies. Iron deficiency is the most prevalent micronutrient deficiency across all age groups and affects physical, cognitive and social health.(28) Adolescents 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%) show that adolescent anaemia is a moderate to severe public health problem. 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 among children as indicated in Table 1.

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Figure 9: Prevalence of anaemia among children aged < 5 years and non-pregnant women in SEAR25. 100 90 80 70 60 50 40 30 20 10 0

Percentage (%)

56 43

55 44 34 25

59 48 32 22 30 37 40 30

51 36 36 26 29 24

Children <5 years 45 22

Nonpregnant women Severe public health problem Moderate public health problem

Data are based on WHO’s modelled estimates (from 1995 to 2011) in national estimates of anaemia for the year 2011, WHO. The global prevalence of anaemia in 2011. Geneva: World Health Organization; 2015. 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).26

Table 1: Level of public health burden caused by anaemia among children, non-pregnant women, and pregnant women.

Children aged 6–59 months Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Anaemic Public Health children27 Significance 56% 55% 34% 59% 32% 30% 40% 51% 36% 29% Severe Severe Moderate Severe Moderate Moderate Severe Severe Moderate Moderate

Women 15–49 years (nonpregnant) Anaemic Public nonHealth pregnant28 Significance 43% Severe 44% Severe 25% Moderate 48% Severe 22% 37% 30% 36% 26% 24% Moderate Moderate Moderate Moderate Moderate Moderate

Women 15–49 years – (pregnant) Anaemic Public Health pregnant2 Significance 48% 46% 27% 54% 30% 39% 33% 44% 25% 30% Severe Severe Moderate Severe Moderate Moderate Moderate Severe Moderate Moderate

25

Bhutan and Timor-Leste recent nutrition survey reported that 44% of children in Bhutan and 62.5% in Timor- Leste suffer from anaemia. (22, 31) 26 27

National Health Exam Survey. Thailand. Percentage with blood haemoglobin concentration <110 g/L (for children 6-59 months and pregnant women). 28 Percentage of non-pregnant women with blood haemoglobin concentration <120 g/L.

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Timor-Leste

45%

Severe

22%

Moderate

24%

Moderate

Adapted from Annex 3. 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). WHO Worldwide prevalence of anaemia 1993–2005: WHO global database on anaemia. WHO, Geneva, 2008 (De Benoist B, McLean E, Egli I, Cogswell M, editors).

2.5.2 Status of other micronutrient deficiencies Vitamin A: Among young children< 5 years the estimated prevalence of night blindness in SouthEast 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 South-East Asia 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 the WHO South-East Asia Region 2.6.1Consumption of minimum acceptable diets by young children Breastfeeding and complementary feeding practices determine the nutritional status of young children. Figure 11 indicates that 6–23 month old breastfed children are consuming minimum acceptable diets, a composite indicator of dietary diversity (consuming foods from 3 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) Figure 10: Consumption of minimum acceptable diets by 6–23 month old children in SEAR.

100 90 80 70 60 50 40 30 20 10 0

Percentage of 6-23 month old children (%)

83 63

41 34 21 22 25

Bangladesh India 2005- Indonesia 2011* 2006 2012

Maldives 2009

Nepal 2011

Sri Lanka Timor- Leste 2006-2007 2009-2010

* Children consuming foods from 4+ food groups.

Source: Country Demographic and Health surveys.

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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 11: 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 Region. Estimated sodium intake (g/d) 10 9 8 7 6 5 4 3 2 1 0

3.54

3.64

3.79

4.49 3.72 3.36 3.31

5.31 3.89 3.87

4.47

All data have been obtained from the publication from Powles et al. (35) For comparability reasons, data from the most recent surveys for each country have not been included.

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 12: Percentage of adults who ate < 5 servings of fruits and vegetables per day.

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100 90 80 70 60 50 40 30 20 10 0

96 98 94 83 83 84 67 65 70

94 93 95

99 99 99 87 85 88

97 97 97 90 78 71

Percentage of adults (%)

Total Men Women

Bangladesh 2010

Bhutan 2014

Indonesia 2006

Maldives 2011

Myanmar 2014

Nepal 2012-13

Sri Lanka Timor2003 Leste 2014

Source: STEPs country fact sheets, http://www.who.int/chp/steps/reports/en/

3. The Strategic Framework and Action Plan 3.1 Goal Reduce the double burden of malnutrition in the South-East Asia Region. 3.2 Objectives   To promote and sustain an enabling environment for the implementation of nutrition interventions. To promote effective implementation and scaling up of evidence-based, cost-effective direct and indirect nutrition interventions through the life course 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 and decision-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. It provides overarching guidance/directions on policy actions to countries to ensure that interventions covering the double burden of malnutrition are addressed comprehensively through programmes, while taking into account the country context. This plan does not focus on physical activity, which is an integral component of healthy lifestyles, since it is addressed comprehensively in other regional plans. 3.4 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 1) and the objectives of policy

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platforms including the Scaling Up Nutrition (SUN) Movement and UN Secretary-General’s Zero Hunger Challenge. 3.5 Time frame The action plan spans the period of 10 years (2016–2025), in line with the Global Nutrition and NCD targets,29,30 and the Decade of Action for Nutrition 2016–2025. 3.6 Monitoring The Regional office will track progress of implementation of the action plan in the medium (2021) and long term (2025) through monitoring of key selected indicators that reflect the double burden of malnutrition (Annex 2). The plan will be reviewed in 2021 and revised as needed and an endterm assessment will be conducted in 2025. 3.7 Guiding principles The following guiding principles underpin the action plan: Life-course approach: A continuum of interventions across the life course is essential for improvement in nutrition. A special focus will be on the “window of opportunity,” from conception to two years (first 1000 days), which is the best opportunity to pause the intergenerational cycle of malnutrition. The action plan will also focus on nutrition of the school-aged child and adolescent. Schools offer the opportunity to promote healthy diets and provide life skills on nutrition and health that are the foundation for good nutrition. Ensuring human rights and the right to food: A human rights approach to policies, strategies and programmes designed to address equity, availability, accessibility, acceptability, quality and universality. The right to food is a human right, protecting the right for people to feed themselves in dignity, and have sufficient, accessible food that can adequately meet their dietary needs. Commitment and accountability: Political will and commitment to good governance is needed to address double burden of malnutrition. Robust mechanisms are needed to monitor policy development and implementation, thus facilitating the accountability of governments, civil society and the private sector on commitments. Sustainable solutions that build self-reliance and empowerment: Strengthening and reorienting strategies for food systems so that they become health promoting and are economically and environmentally sustainable. This would be done through a focus on policy coherence between nutrition and agriculture. Multisectoral approach: Collaboration and coordination with various sectors, e.g. health, education, environment, social protection, labour, water and sanitation, agriculture, transport, etc., through joint strategies with common goals are essential to address the multiple underlying causes of malnutrition.

29

World Health Organisation. Nutrition: Global targets 2025. Geneva. http://www.who.int/nutrition/global-target-2025/en/ -accessed 1 August 2016. 30World Health Organziation. Noncommunicable diseases and mental health. Geneva http://www.who.int/nmh/ncd-tools/definition-targets/en/ accessed 1 August 2016.

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Equity: Equitable coverage of interventions, particularly for disadvantaged or otherwise vulnerable population groups, who are at high risk for all forms of malnutrition are promoted.

3.8 Strategic directions and outcomes of the action plan are set out in the following theory of change. Figure 13: Strategic directions and outcomes of the action plan.

INPUTS/PROCESSES Strategic directions to create an enabling environment for effective implementation of interventions 1. Improve nutrition governance through enhanced political commitment and evidence informed, context-specific sectoral policies. 2. Develop, adopt/adapt relevant guidelines, legislation and regulatory frameworks needed to implement evidence-based interventions. 3. Strengthen health systems to address the double burden of malnutrition with adequate resources, capacity strengthening and comprehensive monitoring. 4. Empower communities, support and strengthen academia and civil society to promote healthy diets and form strategic alliances with other stakeholders. OUTPUTS Evidence based interventions contextual to country context implemented and scaled up* OUTCOMES Global nutrition and diet related NCD targets IMPACT Reduced double burden of malnutrition in the SouthEast Asia Region

*Evidence-informed guidance for nutrition interventions is available through the eLibrary of evidence for nutrition actions (eLENA) and other guidance documents. Selected direct and indirect interventions are provided in Annex 3.

3.9 Role of the WHO The Regional and country offices will be engaged in a variety of roles to support, facilitate and strengthen Member States to implement policy actions to reduce the double burden of malnutrition.

17

Policy advocacy and planning   Support in setting targets and developing national policies, strategies and action plans to reduce the double burden of malnutrition. Advocate for resources to nutrition, support the establishment of partnerships and coordination mechanisms within health and other sectors to promote healthy diets and 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.



Technical guidance and policy support to  Access normative products and tools.  Translate and establish global and regional guidance into effective interventions.  Monitor nutrition outcomes and implement national action plans.  Build additional capacity needed in special areas, such as legislation, standards and specifications for the promotion of healthy diets, food labelling and fortification of food with micronutrients.  Strengthen human resource capacity in countries for effective and sustainable implementation of relevant interventions. 3.10 Nutrition and diet-related noncommunicable diseases risk targets31 The policy actions and interventions stated in the plan will contribute to achieving the voluntary Global nutrition targets (Figure 15) in the Comprehensive Implementation Plan on Maternal, Infant and Young Child nutrition (WHA 2012), and the diet-related NCD targets of the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases (WHA 66.10). Annex 4 provides indicator definitions.

31

Definitions provided in annex.

18

Figure 14: Global nutrition and diet-related noncommunicable disease targets. Global nutrition targets 2025 40% reduction in the number of children under five who are stunted 50% reduction of anaemia in women of reproductive age 30% reduction in low birth weight No increase in childhood over weight Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50% Reduce and maintain childhood wasting to less than 5% The WHO Global Action Plan for the Prevention and Control of NCDs includes two further nutritionrelated targets. A 30 % relative reduction in mean population intake of salt/sodium

Halt the rise in diabetes and obesity

19

4. The Action Plan The framework for implementing the strategic directions to create an enabling environment for implementation of nutrition interventions is given below. Annex 5 provides a mapping of associations between policy actions, 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 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. Policy development needs 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 policy actions should be promoted. Policy actions Establish a high-level coordination mechanism to guide multisectoral nutrition actions Ensure policies that provide adequate financing for nutrition Develop/update national policies and plans in nutrition and related sectors to reflect the double burden of malnutrition Policy indicators Higher-level coordination mechanism established with specific terms of reference Adequate resources (as identified by costing analysis) are earmarked and available for implementation of nutrition action plans National nutrition and/or related health policies and plans have addressed the double burden of malnutrition32 Multisectoral nutrition action plans with operational mechanisms are updated with identified budget lines Multisectoral nutrition action plans are implemented and monitored At least three key nonhealth policies address the double burden of malnutrition 33 Policy coherence ensured between nutrition and agriculture National nutrition targets and diet-related NCD targets identified and indicators based on the global monitoring framework are included in monitoring mechanism Country frameworks are developed and implemented to protect food policies and dietary guidance from conflict of interest Nutrition is addressed in policies, strategies and plans on healthy ageing

Identify national targets and indicators for nutrition and dietrelated NCD risk factors that address country priorities Ensure policy actions to insulate nutrition policy-making from conflict of interest to safeguard public good Build on existing WHO policy frameworks relevant to healthy and 32

Annex 6 provides an example of multi sectoral actions.

33

Education, social protection, sports (or relevant policies) identified as important in the country context.

20

active ageing to include nutrition Ensure that emerging challenges such as climate change and natural disasters address nutrition in related policies and plans

Country health emergency /disaster preparedness plans explicitly address the double burden of malnutrition

Strategic direction 2 Develop, adopt /adapt relevant guidelines, legislation and regulatory frameworks needed to implement evidence-based interventions. Development and adaptation of guidelines and legislation and regulatory frameworks are vital in reducing the double burden of malnutrition. Evidence-based guidance is available at the global level and should be adopted by countries to enable successful implementation of nutrition actions. Policy actions Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet-related risk of NCDs Policy indicators Country food-based dietary guidelines that promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized Strategies and roadmap developed for population reduction of salt, sugar and fat intake Country develops a national nutrition plan that includes WASH (Water, Sanitation, and Hygiene) Fiscal policies are developed and enacted for food products that are high in sugar , fat and salt Policies for subsidizing local fruits and vegetables are enacted Micronutrient (supplementation) guidelines within the country are updated regularly Food fortification legislation for iodization of salt and other relevant-identified micronutrients are developed and implemented Legislation enacted and implemented to ensure mandatory labelling of food products for both front of pack and back of pack labelling of nutrients A watchdog mechanism established in a country to ensure that health and nutrition claims are based on codex guidelines and adequate scientific evidence Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated

Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruits and vegetables Ensure that regulations and guidelines are in place for supplementation and fortification of products as suitable for the country context Enact legislation and its implementation on appropriate nutritional information for processed , pre-packaged food products

Promote healthy and safe foods for informal sector to enable the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and

21

Policy actions management of nutrition emergencies Promote, protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms

Policy indicators International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions are legislated and implemented Maternity protection measures 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 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 to implement WHO’s Recommendations on Marketing of unhealthy foods and beverages to children School guidelines and standards ensuring a healthy food environment are developed and implemented Guidance provided on food supplementation for pregnant and lactating women and young children

Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet-related risks of NCDs Develop guidelines for supplementary food assistance to vulnerable groups for improving 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. Availability, access and affordability of nutrition services is critical to achieving the Global Nutrition and diet related NCD targets. A comprehensive, evidence-based capacity development process that will integrate latest research, learning tools and technology to enhance leadership and workforce capacity are essential. Policy actions Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary health-care packages Ensure adequate financing for nutrition through separate budget line for nutritionrelated activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population-based nutrition services Policy indicators Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions. Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population Proportion of health-care facilities that offer prevention/treatment counselling and other

Promote nutrition services in clinical conditions and settings for prevention and

22

Policy actions treatment of severe acute malnutrition, obesity and other nutrition-related conditions

Health infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition

Policy indicators nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition-related conditions Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation Established management of safe water and the accessibility of sanitation facilities at community settings is supported Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized

Strategic direction 4 Empower communities, support and strengthen academia and civil society to promote healthy diets and form strategic alliances with other stakeholders. Policy action to promote empowerment through strengthening civil society organizations is key to promoting community empowerment. Support for academia to promote country-based research would ensure selection and implementation of actions based on country context. Forming strategic partnerships with the food sector is also important in promoting healthy diets to reduce the double burden of malnutrition. Policy actions Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require childcare settings, pre-schools, schools, children’s and youth sports facilities and events to create healthy food environment Engage with private sector to reduce the Policy indicators Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available Policy measures that appropriately engage

23

obesogenic environment Promote healthy diets and lifestyle at the workplace

relevant private sector, to implement actions, aimed at reducing overweight, obesity and dietary risk of NCDs are instituted Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces

24

5. References 1. 2. 3. 4. 5. 6. 7. Shrimpton R, Rokx C. The double burden of malnutrition: a review of global evidence. Health, Nutrition and Population (HNP) Discussion Paper. 2012. World Health Organization. Global status report on non communicable diseases 2014. Geneva: WHO, 2014. Barker DJP. Mothers, babies and health in later life. 2nd edn. Edinburgh: Churchill Livingstone, 1998. World Health Organization. Report of the commission on ending childhood obesity. Geneva: WHO, 2016. Darnton-Hill I, Nishida C, James WPT. A life course approach to diet, nutrition and the prevention of chronic diseases. Public Health Nutrition. 2004 Feb;7(1A):101-21. Deurenberg P, Yap M, van Staveren WA. Body mass index and percent body fat: a meta analysis among different ethnic groups. Int J Obes Relat Metab Disord. 1998 Dec;22(12):1164-71. Food and Agriculture Organization, Regional office for Asia and the Pacific. The state of food and agriculture in Asia and the Pacific region. Bangkok. http://www.fao.org/docrep/010/ai411e/AI411E02.htm - accessed 2 August 2016. 8. Lee Da Eun Rachel. Children's protein consumption in Southeast Asia: consideration of quality as well as quantity of children's protein consumption in Southeast Asia. Wharton Research Scholars Journal. Paper 115. 2014. http://repository.upenn.edu/wharton_research_scholars/115 - accessed 2 August 2016. World Health Organization. Diet, nutrition and the prevention of chronic diseases. Report of a joint WHO/FAO expert consultation. WHO Technical Report Series 916. Geneva: WHO, 2003. http://whqlibdoc.who.int/trs/who_trs_916.pdf - accessed 2 August 2016.

9.

10. Scaling up nutrition. http://scalingupnutrition.org/about/why-nutrition - accessed 2 August 2016. 11. Victora C. G., M. de Onis, P. C. Hallal, M. Blössner, R. Shrimpton. 2010. Worldwide timing of growth faltering: revisiting implications for interventions. Pediatrics. 2010 Mar;125(3):e473-80. 12. Prendergast AJ, Humphrey JH. The stunting syndrome in developing countries. Paediatr Int Child Health. 2014 Nov;34(4):250-65. 13. Horton S, Steckel RH. Malnutrition: global economic losses attributable to malnutrition 1990-2000 and projections to 2050. 2011. http://www.copenhagenconsensus.com/sites/default/files/malnutrition.pdf - accessed 2 August 2016. 14. Global status report on noncommunicable diseases. World Health Organization 2014. 15. World Health Organization. Global health estimates. 2014. http://www.who.int/healthinfo/global_burden_disease/en/ - accessed 2 August 2016. 16. ASEAN, UNICEF, WHO . Regional report on nutrition security in ASEAN. Volume 2. Bangkok; UNICEF, 2016. 17. The World Bank: http://data.worldbank.org/indicator/SP.POP.TOTL - accessed 2 August 2016. 18. United Nations. World urbanization prospects: 201 revision. New York: United Nations, 2014. http://esa.un.org/unpd/wup/Highlights/WUP2014-Highlights.pdf - accessed 2 August 2016.

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19. The World Bank. http://data.worldbank.org/indicator/SE.ADT.LITR.ZS/countries - accessed 2 August 2016. 20. United Nations Development Programme. Human development reports. New York. http://hdr.undp.org/en/content/table-2-human-development-index-trends-1980-2013 - accessed 2 August 2016. 21. Ministry of Health and Family Welfare, Bangladesh. Bangladesh demographic and health survey 2014. Dhaka, 2016. https://dhsprogram.com/pubs/pdf/FR311/FR311.pdf - accessed 2 August 2016. 22. Ministry of Health, Bhutan. 2015 National Nutrition Survey (NNS). Thimphu. 23. Ministry of Health, India. India National Family Health Survey 2015. New Delhi. 24. WHO, UNICEF, World Bank, Joint child malnutrition estimates (UNICEF-WHO-WB). 25. Compare regional trends in numbers of children affected by malnutrition (1990-2014). Geneva: WHO. http://apps.who.int/gho/data/view.wrapper.nutrition-1-3?lang=en&showonly=nutrition – accessed 3 August 2016. 26. Finucane MM, Stevens GA, Cowan MJ, Danaei G, Lin JK, Paciorek CJ, et al. National, regional, and global trends in body mass index since 1980: Systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet. 2011 Feb 12; 377(9765): 557–567. 27. United Nations, Department of Economic and Social Affairs, Population Division. World Population Ageing 2015. Highlights (ST/ESA/SER.A/368). New York, 2015. 28. World Health Organization, UNICEF. Joint statement by the World Health Organization, the World Food Programme and the United Nations Children’s Fund. Preventing and controlling micronutrient deficiencies in populations affected by an emergency. Geneva. http://www.who.int/nutrition/publications/WHO_WFP_UNICEFstatement.pdf - accessed 3 August 2016. 29. World Health Organization. Iron deficiency anaemia: assessment, prevention and control- a guide for programme managers. Geneva: WHO, 2001. 30. World Health Organization. Global prevalence of vitamin A deficiency in populations at risk 1995– 2005: WHO global database on Vitamin A Deficiency. Geneva: WHO, 2009. 31. Bleichrodt N, Born MP. A meta-analysis of research on iodine and its relationship to cognitive development. In: Stanbury JB, ed. The damaged brain of iodine deficiency. New York, Cognizant Communication, 1994. Pp. 195–200. 32. Global Iodine Nutrition Scorecard 2015. http://www.ign.org/cm_data/Scorecard_2015_August_26_new.pdf - accessed 3 August 2016. 33. World Health Organization. Nutrition Landscape Information System. Geneva: WHO. http://www.who.int/nutrition/nlis/en/ - accessed 3 August 2016. 34. World Health Organization. From burden to “Best Buys”: reducing the economic impact of non communicable diseases in low-and Middle-Income Countries. Geneva: WHO, 2011. http://www.who.int/nmh/publications/best_buys_summary.pdf - accessed 3 August 2016. 35. Powles J, Fahimi S, Micha R, Khatibzadeh S, Shi P, Ezzati M, et al. Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open. 2013 Dec 23; 3(12):e003733.

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Annexes Annex 1. Supporting global and regional resolutions/mandates and content analysis of technical areas covered. Targets Technical areas NCDs (salt/sweet/fat) Infant + Young child Children + adolescent General population (adult) Undernutrition (stunting, wasting underweight) and nutrient Micro + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Global Global Strategy on infant and young child feeding 2003 Global Strategy on Diet, Physical Activity and Health 2004 Comprehensive Implementation Plan on Maternal Infant and Young Child Nutrition (WHO, 2014) and 2025 Global Nutrition targets (WHA65.6) Rome Declaration and 2nd International Conference on Nutrition and the framework for actions 2014, adopted by the WHA in 2015 Report of the Commission on ending Childhood Obesity 2016 Global Action Plan for prevention and control of NCD’s 2013–2020 Sustainable Development Goal 2 targets at 2025, 2030 UN Decade of Action on Nutrition. 2016– 2025 Regional Regional Nutrition Strategy; Addressing malnutrition and micronutrient deficiencies 2011–2015 Action plan for the prevention and control of noncommunicable diseases in South-East Asia 2013–2020 South-East Asia Regional Strategic Framework for Improving Neonatal and Child Health and Development 2012 Strategic Action Plan to reduce the double burden of malnutrition in South- East Asia Region 2016–2025

+ + + + + + +

+

+

+

+

+

+

+

+

(+ ) +

+

+ +

+ +

+

+ + (+)

+ +

+ + + + +

+

+

+

Healthy systems + + + +

Overweight and Obesity

Breastfeeding

Maternal

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Annex 2. Regional monitoring framework for policy, capacity and legislative indicators. These indicators will be assessed in 2016 (baseline), 2021 (mid- term) and 2025 (end term). Policy and progress Indicator definitions indicators for monitoring by WHO SEARO

1

2 3

4 5.

National nutrition policies, strategies or action plans with explicit reference to both undernutrition and overweight and obesity are available Government has a functioning a multistakeholder coordination process for nutrition Countries have identified time-bound nutrition targets based on global nutrition targets and diet related noncommunicable diseases (NCD) targets. Appropriately skilled personnel with competencies to deliver nutrition services are available Countries have conducted regular national level nutrition surveys

National nutrition policies, strategies or action plans with explicit reference to implementing actions to reduce undernutrition and overweight and obesity are available34. Yes=2, In process= 1, No=0 A multi-stakeholder coordination mechanism for nutrition is established and functional 35 Yes=2 In process=1, No=0 Country has identified time-bound nutrition targets and diet-related NCD targets in public policy documents. Yes=2, In process= 1, No=0 No. of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population32 Country has conducted a Demographic and Health Survey / 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) new surveys undertaken33 Country has food-based dietary guidelines that promote healthy diets are developed and used for nutrition promotion. Yes=2, In process= 1, No=0 Country has a comprehensive legislation for effective implementation of the International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions 32 Yes=2, In process= 1, No=0 Country has legislation enacted to implement WHO’s Recommendations on Marketing of unhealthy foods and nonalcoholic beverages to children32 Yes=2, In process= 1, No=0 Country has developed and implemented a mechanism for promoting healthy diets for the informal food sector. Yes=2, In process= 1, No=0 Country has developed/implemented the following 36  Meals provided in schools adhere to minimum nutrition

6

7

8

9

10 34

Country food-based dietary guidelines that promote healthy diets are developed and used for nutrition promotion Government has adopted legislation for effective national implementation and monitoring of the International Code of Marketing of Breast milk Substitutes (ICBMS) and subsequent relevant WHA resolutions Legislation or regulations enacted to implement WHO’s Recommendations on Marketing of unhealthy foods and non-alcoholic beverages to children. Country has developed and implemented a mechanism for promoting health diets in the informal food sector Countries have developed and implemented processes to promote

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. 35 HANCI: Hunger and Nutrition Commitment Index. http://www.hancindex.org/explore-the-data/understanding-theindicators/ - accessed 1 August 2016. 36 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.

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healthy dietary environments in schools to reduce the double burden of malnutrition



standards based on national or regional dietary guidelines (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,)

Annex 3. Selected evidence-based interventions (e-Library of Evidence Based Nutrition Actions) to reduce the double burden of malnutrition. Direct Nutrition Interventions Breastfeeding Breastfeeding: continued breastfeeding Breastfeeding education for increased breastfeeding duration Breastfeeding: early initiation Breastfeeding: exclusive breastfeeding Breastfeeding: implementation of the Baby-friendly Hospital Initiative Breastfeeding: regulation of marketing breast-milk substitutes Complementary feeding Supplementary feeding in community settings for promoting child growth Deworming to combat the health and nutritional impact of helminth infections Anaemia/iron deficiency Optimal timing of cord clamping for the prevention of iron deficiency anaemia in infants 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 children in malaria-endemic areas Iron: intermittent supplementation in preschool and school-age children Deworming to combat the health and nutritional impact of helminth infections*37 Intermittent iron and folic acid supplementation in menstruating women Intermittent iron and folic acid supplementation in menstruating women in malaria-endemic areas Low birth weight Low birth weight: breastfeeding of low-birth-weight infants Low birth weight: cup-feeding for low-birth-weight infants unable to fully breastfeed Low birth weight: demand feeding for low-birth-weight infants Low birth weight: donor human milk for low-birth-weight infants Low birth weight: feeding of very-low-birth-weight infants Low birth weight: kangaroo mother care to reduce morbidity and mortality in low-birth-weight infants Low birth weight: micronutrient supplementation in low-birth-weight and very-low-birth-weight infants Low birth weight: mother’s milk for low-birth-weight infants Low birth weight: standard formula for low-birth-weight infants following hospital discharge Moderate acute malnutrition Moderate acute malnutrition: supplementary foods for the management of moderate acute malnutrition in children Severe Acute Malnutrition Severe acute malnutrition: identification of severe acute malnutrition in children 6–59 months of age Severe acute malnutrition: identification of severe acute malnutrition requiring inpatient care in children 6–59 months of age Severe acute malnutrition: management of infants under 6 months of age with severe acute malnutrition 37

Also relevant to growth

29

Severe acute malnutrition: management of severe acute malnutrition in children 6–59 months of age with oedema Severe acute malnutrition: micronutrient intake in children with severe acute malnutrition Childhood Obesity Exclusive breastfeeding to reduce the risk of childhood overweight and obesity 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 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 Vitamin D supplementation in children with respiratory infections Water, sanitation and hygiene interventions to prevent diarrhoea Zinc supplementation in the management of diarrhoea 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 Noncommunicable diseases Noncommunicable diseases: increasing fruit and vegetable consumption to reduce the risk of noncommunicable diseases Potassium: increasing intake to control blood pressure in children Sodium: reducing sodium intake to control blood pressure in children 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 Pregnancy and post-partum women Maternal nutrition; balanced energy and protein supplementation during pregnancy 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: periconceptional 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

30

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 Other guidance and recommendations selected from the Ending Childhood Obesity Commission Report Appropriate and context-specific nutrition information and guidelines for both adults and children are developed and disseminated in a simple, understandable and accessible manner to all groups in society. Implement an effective tax on sugar-sweetened beverages. Develop nutrient-profiles to identify unhealthy foods and beverages. Establish cooperation between Member States to reduce the impact of cross-border marketing of unhealthy foods and beverages. Implement interpretive front-of-pack labelling, supported by public education of both adults and children for nutrition literacy. Require settings such as schools, child-care settings, children’s sports facilities and events to create healthy food environments. Monitor and manage appropriate gestational weight gain. Provide clear guidance and support to caregivers to encourage the consumption of a wide variety of healthy foods for children. Establish standards for meals provided in schools, or foods and beverages sold in schools and other child-care settings meet healthy nutrition guidelines. Require inclusion of nutrition and health education within the core curriculum of schools . Improve the nutrition literacy and skills of parents and caregivers Develop and support appropriate multicomponent weight management services for children and adolescents who are overweight or obese as part of universal health coverage. Indirect Nutrition Interventions Supporting women's empowerment and changes to intra household food allocation. Promoting agriculture and nutrition friendly healthy food systems. In-kind household food distributions Early Child development interventions Classroom education for girls Social protection and safety nets including cash transfers: Water and sanitation initiatives: the critical importance of water, sanitation and hygiene (WASH) for nutrition status children have been demonstrated. Along with several other factors, poor hygiene and sanitation cause high levels of maternal and child undernutrition38

38

Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Ruel MT & Alderman H.the Maternal and Child Nutrition Study Group. Lancet, Volume 382, Issue 9891, 10–16 August 2013, Pages 536–551.

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Annex 4. Indicator definitions for Global Nutrition and diet related Noncommunicable Diseases targets. Indicator Indicator definition (assessment method) Stunting Prevalence of low height-for-age in children under five years of age Wasting Prevalence of weight-for-height <2 SD in children under five years of age Low birth weight Prevalence of infants born <2500 g Overweight Prevalence of weight-for-height >2 SD in children under five years of age Anaemia among pregnant women Prevalence of haemoglobin<11 g/dL in pregnant women Anaemia among nonpregnant women Prevalence of haemoglobin<12 g/dL in nonpregnant women Exclusively breastfed children Prevalence of exclusive breastfeeding in infants aged six months or less Salt intake Age standard mean population intake of salt (sodium Chloride) per day in grams in persons aged 18+ years Diabetes Age standard prevalence of raised blood glucose/diabetes among persons aged 18+ years or on medication for raised blood glucose Underweight women The prevalence of underweight in women of reproductive age Numerator: Number of children under five with height-for age below -2SD Denominators: Total number of children under five measured Numerator: Number of children under five with weight for height below -2SD Denominators: Total number of children under five measured Numerator: Number of LBW singleton live births to women <2500g Denominator: Total number of singleton live births to women Numerator: Number of children under five with weight for height above+2SD Denominators: Total number of children under five measured Numerator: Number of pregnant women aged 15-49 years who had haemoglobin concentration <11g/dl Denominator: Total number of pregnant women 15-49 years old Numerator: Number of non-pregnant women aged 15-49 years who had haemoglobin concentration <12g/dl Denominator: Total number of nonpregnant women 15-49 years old Numerator: Infants 0–5 months of age who received only breast milk during the previous day Denominator: Infants 0-5 months of age Numerator: Sum of sodium excretion in urine samples from all respondents aged 18+years Denominator: Number of survey respondents aged 18+ years Numerator: Number of respondents aged 18+ years with fasting plasma glucose value ≥126 mg/dl or on medication for raised blood glucose Denominator: Number of survey respondents aged 18+ years

Numerator: Number of women aged 15–49 years in the sample with BMI<18.5 kg/m² Denominator: Total number of women aged 15–49 years in the sample Overweight women Numerator: Number of women aged 15–49 years in the The prevalence of overweight in women of sample with BMI≥25 kg/m² reproductive age Denominator: Total number of women aged 15–49 years in the sample 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. World Health Organization. Noncommunicable diseases global monitoring framework: indicator definitions and specifications. Geneva: WHO, 2014. http://www.who.int/nmh/ncdtools/indicators/GMF_Indicator_Definitions_Version_NOV2014.pdf - accessed 1 August 2016.

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Annex 5. 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 direction 1 Strategic direction 2 Strategic direction 3 Strategic 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 measure(s) Intermediate outcomes Proportion of women aged 15-49 years with low body mass index (<18.5 kg/m2) a Number of births during a given reference period to women aged 15-19 years /1000 females aged 15-19 years *a Prevalence of diarrhea in children under 5 years of age a

40% reduction in the number of children under five who are stunted The change in the number of heightfor-age < (-)2 SD in children under five years of age between 2010 and 2025

Process indicators Proportion of children aged 6-23 months receiving a minimum acceptable diet a Percentage of births in baby friendly facilities a Proportion of mothers of children 0-23 months receiving counselling, support or messages on optimal breastfeeding at least once in the last year a

Policy indicators --Strategic direction 1—

Policy actions --Strategic direction 1--

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized Country develops a national nutrition plan that includes WASH (Water, Sanitation, and Hygiene (WASH)

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs

Reduce and maintain childhood wasting to less than 5% The prevalence of weight-for-height <(-)2 SD in children under five years of age between 2010 and 2025

Policies for subsidizing local fruit and vegetable are enacted

Proportion of stunted women of reproductive age (15-49 years) a

Proportion women aged 15-49 years receiving counselling /treatment on appropriate weight gain Proportion of population using a safely managed drinking service a Proportion of

Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables Ensure that regulations and guidelines are in place for supplementation and fortification of products as suitable for the country context Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases

Micronutrient (supplementation) guidelines within the country are updated regularly Food fortification legislation for iodization of salt and other relevant identified micronutrients are developed and implemented Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity

33

Targets and its measure(s)

Intermediate outcomes

Process indicators population using a safely managed sanitation service a Proportion of children with severe acute malnutrition having access to appropriate treatment including therapeutic foods and nutrition counselling a Proportion of children aged 12-59 months receiving at least one dose of deworming medication a Percentage of pregnant women aged 15-49 years receiving 1+ ANC visit (including nutrition counselling) b Percentage of pregnant women aged 15-49 years receiving 4+ ANC visit (including nutrition counselling) b Proportion of children under five years old with diarrhea (in last two weeks) receiving oral dehydration salts (ORS packets or pre-packaged ORS fluids) a

Policy indicators Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions are legislated and implemented Maternity protection measures 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 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 School guidelines and standards ensuring a healthy food environment are developed and implemented

Policy actions Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Promote protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms

Guidance provided on food supplementation for pregnant and lactating women and young children Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available

Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary health-care packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions

Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track

34

Targets and its measure(s)

Intermediate outcomes

Process indicators and utilized

Policy indicators

Policy actions data on double burden of malnutrition Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require child-care settings, preschools, schools, children’s and youth sports facilities and events to create healthy food environments Policy actions --Strategic direction 1--

Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available

Targets and its measure(s)

50% reduction of anaemia in women of reproductive age The change of number of haemoglobin<11 g/dL in pregnant women aged 1549 years between (period of 1993-2005) and 2025 The change of number of haemoglobin<12 g/dL in nonpregnant women aged 15-49 years between (period of 1993-2005) and 2025

Intermediate outcomes Proportion of women aged 15-49 years with low body mass index (<18.5 kg/m2) a Number of births during a given reference period to women aged 15-19 years /1000 females aged 15-19 years a

Process indicators Proportion of pregnant women aged 15-49 years receiving weekly iron-folic acid supplementation a Proportion of nonpregnant women aged 15-49 years receiving weekly ironfolic acid supplementation a Proportion women aged 15-49 years receiving counselling/treatment on appropriate weight gain Proportion of population using a safely managed drinking service a Proportion of population using a safely managed sanitation service a Percentage of pregnant women aged 15-49 years receiving 1+ ANC visit (including nutrition

Policy indicators --Strategic direction 1--

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs

Country develops a national nutrition plan that includes WASH (Water, Sanitation, and Hygiene (WASH)

Policies for subsidizing local fruit and vegetable are enacted

Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables

35

counselling) b Percentage of pregnant women aged 15-49 years receiving 4+ ANC visit (including nutrition counselling) b

Micronutrient (supplementation) guidelines within the country are updated regularly Food fortification legislation for iodization of salt and other relevant identified micronutrients are developed and implemented Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated School guidelines and standards ensuring a healthy food environment are developed and implemented Guidance provided on food supplementation for pregnant and lactating women and young children Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation Efficient and effective nutrition surveillance actions suitable for tracking the double burden of

Ensure that regulations and guidelines are in place for supplementation and fortification of products as suitable for the country context

Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary healthcare packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions

Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and

36

malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skillsbased nutrition education in schools is available Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces Targets and its measure(s) Intermediate outcomes Proportion of women aged 15-49 years with low body mass index (<18.5 kg/m2) a Process indicators Proportion of pregnant women aged 15-49 years receiving weekly iron and folic acid supplements a Percentage of births in baby friendly facilities a Proportion women aged 15-49 years receiving counselling/treatment on appropriate weight gain Percentage of pregnant women aged 15-49 years receiving 1+ ANC visit (including nutrition counselling) b Percentage of pregnant women aged 15-49 years receiving 4+ ANC visit (including nutrition Policy indicators --Strategic direction 1--

identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition Recognize the importance of professional and civil society organizations to promote and support healthy diets

Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition

Require child-care settings, preschools, schools, children’s and youth sports facilities and events to create healthy food environments Promote healthy diets and lifestyle at the workplaces

Policy actions --Strategic direction 1--

30% reduction in low birth weight The change of number of infants born <2500 g between (period of 2006-2010) and 2025

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs

Policies for subsidizing local fruit and vegetable are enacted

Micronutrient (supplementation) guidelines within the country are updated regularly Food fortification legislation for iodization of salt and other relevant identified micronutrients are developed and implemented Healthy and safe food guidelines

Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables Ensure that regulations and guidelines are in place for supplementation and fortification of products as suitable for the country context

Promote healthy and safe foods for

37

counselling) b

are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated Maternity protection measures enacted and aligned with ILO Convention 183 School guidelines and standards ensuring a healthy food environment are developed and implemented Guidance provided on food supplementation for pregnant and lactating women and young children Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Established management of safe water and the accessibility of sanitation facilities at community settings is supported Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil

informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Promote protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary health-care packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions

Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition Recognize the importance of

38

society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available Targets and its measure(s) Intermediate outcomes Proportion of overweight and obese women 1849 years of age (body mass index ≥25 kg/m2) a Proportion of overweight in schoolage children and adolescents 5-18 years (BMI-for-age >+1 SD) a Process indicators Proportion of children 6-23 months of age receiving a minimum acceptable diet a Percentage of births in baby friendly facilities a Proportion of mothers of children 0-23 months receiving counselling, support or messages on optimal breastfeeding at least once in the last year a Proportion women who received counselling/treatment of appropriate body weight Proportion of schoolage children and adolescents 5-18 years receiving counselling/treatment on appropriate weight gain Proportion of children and adolescent diagnosed as overweight or obese who received appropriate weight management service d Policy indicators --Strategic direction 1--

professional and civil society organizations to promote and support healthy diets

Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require child-care settings, pre-schools, schools, children’s and youth sports facilities and events to create healthy food environments Policy actions --Strategic direction 1--

No increase in childhood overweight The change of prevalence of weight-forheight >2 SD in children under five years of age between 2010 and 2025

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs

Strategies and roadmap developed for population reduction of salt, sugar, and fat intake Fiscal-policies are developed and enacted for food products that high in sugar , fat, and salt Policies for subsidizing local fruit and vegetable are enacted Legislation enacted and implemented to ensure mandatory labelling of food products for both front of pack and back of pack nutrient labelling A watchdog mechanism established in country to ensure that health and nutrition claims are based on codex guidelines and adequate scientific evidence Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables Enact legislation and its implementation on appropriate nutritional information for processed, pre-packaged food products

Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the

39

Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions are legislated and implemented Maternity protection measures 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 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 to implement WHO’s Recommendations on Marketing of unhealthy foods and beverages to children School guidelines and standards ensuring a healthy food environment are developed and implemented Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation

management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Promote protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms

Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary health-care packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions

Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established

Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of

40

malnutrition Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition

Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require child-care settings, pre-schools, schools, children’s and youth sports facilities and events to create healthy food environments Engage with private sector to reduce the obesogenic environment Promote healthy diets and lifestyle at the workplaces

Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available Policy measures that appropriately engage relevant private sector, to implement actions, aimed at reducing overweight, obesity and dietary risk of NCDs are instituted Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces Targets and its measure(s) Intermediate outcomes Proportion of children born in the last 24 months who were put to the breast within one hour of birth a

Process indicators Percentage of births in baby friendly facilities a Proportion of mothers of children 0-23 months receiving counselling, support or messages on optimal breastfeeding at least once in the last year a

Policy indicators --Strategic direction 1--

Policy actions --Strategic direction 1--

Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50% The prevalence of infants aged 0-5 months received only breast milk during the previous day between (period of 2006-2010) and 2025

Number of births during a given reference period to women aged 15-19 years/1000 females aged 15-19 years a

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCD’s

Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated

Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies

41

International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions are legislated and implemented Maternity protection measures 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 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 food supplementation for pregnant and lactating women and young children Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutritionpromoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces

Promote protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms

Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary healthcare packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Promote healthy diets and lifestyle at the workplaces

42

Targets and its measure(s)

Intermediate outcomes

A 30% relative reduction in mean population intake of salt/sodium The change of agestandardized mean population intake of salt (sodium Chloride) per day in grams in persons aged 18+ years between 2010 and 2025

Process indicators Agestandardized mean population intake of salt (sodium Chloride) per day in grams in persons aged 18+ years c Percentage of households that have adequately iodized salt (>15 ppm) a

Policy indicators --Strategic direction 1--

Policy actions --Strategic direction 1--

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs

Strategies and roadmap developed for population reduction of salt, sugar, and fat intake Fiscal-policies are developed and enacted for food products that high in sugar , fat, and salt Policies for subsidizing local fruit and vegetable are enacted Micronutrient (supplementation) guidelines within the country are updated regularly Food fortification legislation for iodization of salt and other relevant identified micronutrients are developed and implemented Legislation enacted and implemented to ensure mandatory labelling of food products for both front of pack and back of pack nutrient labelling A watchdog mechanism established in country to ensure that health and nutrition claims are based on codex guidelines and adequate scientific evidence Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated Legislation enacted to implement WHO’s Recommendations on Marketing of unhealthy foods and beverages to children School guidelines and standards ensuring a healthy food environment are developed and Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables Ensure that regulations and guidelines are in place for supplementation and fortification of products as suitable for the country context Enact legislation and its implementation on appropriate nutritional information for processed, pre-packaged food products

Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs

43

implemented Guidance provided on food supplementation for pregnant and lactating women and young children Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutritionpromoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available Policy measures that appropriately engage relevant private sector, to implement actions, aimed at reducing overweight, obesity and dietary risk of NCDs are instituted Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces

Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require child-care settings, preschools, schools, children’s and youth sports facilities and events to create healthy food environments Engage with private sector to reduce the obesogenic environment Promote healthy diets and lifestyle at the workplaces

44

Targets and its measure(s)

Halt the rise in diabetes and obesity The change of agestandardized prevalence of raised blood glucose/diabetes among persons aged 18+ years(defined as fasting plasma glucose concentration ≥ 7.0 mmol/l (126 mg/dl) or on medication for raised blood glucose) between 2010 and 2025 The change of prevalence of overweight and obesity in adolescents (defined according to the WHO growth reference for school-aged children and adolescents, overweight – BMI for age and sex >1 SD, and obese – BMI for age and sex >2 SD) between 2010 and 2025 The change of agestandardized prevalence of overweight and obesity in persons aged 18+ years (defined as body mass index ≥ 25 kg/m2 for overweight and body mass index ≥ 30 kg/m² for obesity) between 2010 and 2025

Intermediate outcomes Agestandardized prevalence of raised total cholesterol among persons aged 18+ years (defined as total cholesterol ≥5.0 mmol/l or 190 mg/dl); and mean total cholesterol concentration c

Process indicators Age-standardized prevalence of persons (aged 18+ years) consuming less than five total servings (400 grams) of fruit and vegetables per day c Age-standardized mean proportion of total energy intake from saturated fatty acids in persons aged 18+ years c Age-standardized mean proportion of persons aged 18+ years receiving counselling/treatment on appropriate weight gain Proportion of adolescents receiving counselling/treatment on appropriate weight gain Proportion of children and adolescent diagnosed as overweight or obese who received appropriate weight management service d

Policy indicators --Strategic direction 1--

Policy actions --Strategic direction 1--

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized Strategies and roadmap developed for population reduction of salt, sugar, and fat intake Fiscal-policies are developed and enacted for food products that high in sugar , fat, and salt Policies for subsidizing local fruit and vegetable are enacted Legislation enacted and implemented to ensure mandatory labelling of food products for both front of pack and back of pack nutrient labelling A watchdog mechanism established in country to ensure that health and nutrition claims are based on codex guidelines and adequate scientific evidence Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables Enact legislation and its implementation on appropriate nutritional information for processed, pre-packaged food products

Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions are legislated and implemented Maternity protection measures 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 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 to implement WHO’s Recommendations on Marketing of unhealthy foods and beverages to children School guidelines and standards ensuring

Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Promote protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms

Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and

45

a healthy food environment are developed and implemented Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation

overweight and obesity and diet related risks of NCDs Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary health-care packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require child-care settings, pre-schools, schools, children’s and youth sports

Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized

Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition

Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available

46

Policy measures that appropriately engage relevant private sector, to implement actions, aimed at reducing overweight, obesity and dietary risk of NCDs are instituted Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces

facilities and events to create healthy food environments Engage with private sector to reduce the obesogenic environment Promote healthy diets and lifestyle at the workplaces

47

Annex 6. Example of cross-sectoral Government engagement and potential multisectoral action. Sector Health Nutrition Areas Food security Food safety Food safety and hygiene regulations Food inspections Food standards

Healthy lifestyle Promoting healthy diets Promotion of exercise Infection control Family Planning

Nutrition Micronutrient supplementation Management of SAM Dietary guidelines Baby friendly hospitals Breast and complementary feeding promotion

Public works/Urban development

Rural roads Irrigation

Water and sanitation improvement

Urban bike lanes Pedestrian walk ways Road safety Smoke free environment Bio-fortification to improve nutrition density Nutrition oriented agriculture research Nutrient promoting farming systems, agronomic practices and crops Nutrition education Anaemia control

Agriculture

Food and agriculture policies to promote availability, affordability and quality Sustainable intensification of production Promotion of home gardens

Regulation to improve food safety in processing, transport and storage

Education

Promotion of gardens School meals

school

Food safety and hygiene education

Physical exercise Life skills and sex education Gender equality

Industry/trade/commerce

Food availability (manufacturing marketing)

Food standards and

Food regulations

safety

Product formulation to reduce saturated and trans fats, sodium and sugar content Food fortification Nutrition labelling Code of breast milk substitutes Nutrition information campaigns Nutrition labelling Food taxes

Public information

Marketing of foods to children

Finance and economy

Food subsidies

Source: Adapted from Shrimpton and Rokx, 2012 (1).

48



REGIONAL COMMITTEE Sixty-ninth Session Colombo, Sri Lanka 5–9 September 2016

Provisional Agenda item 9.8 SEA/RC69/16 Rev.3 23 August 2016

Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016-2025 Malnutrition in all its forms threatens human development. Both undernutrition and overweight and obesity throughout the life course are public health problems in the WHO South-East Asia Region, affecting Member States to varying degrees. Undernutrition, including micronutrient deficiencies, contributes to about 45% of preventable deaths of children under five years of age annually, while overweight resulting from unhealthy diets and sedentary lifestyle underpins high rates of noncommunicable diseases (NCDs) in Member States. Therefore, urgent attention is needed to reduce malnutrition. While the previous Regional Nutrition Strategy, “Addressing malnutrition and micronutrient deficiencies (2011–2015)”, emphasized a multisectoral approach (SEA/RC64/R4), it cannot adequately address the current need in the Region to tackle both undernutrition and overweight and obesity. Many global actions and policies have focused attention on the rise of overweight and obesity, including the recent Sustainable Development Goals agenda, which calls for an end to all forms of malnutrition. In response, the WHO Regional Office, in consultation with Member States, has developed a Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016–2025, through extensive consultation with Member States, technical experts and WHO country offices and headquarters. The Plan focuses on creating an enabling environment that will facilitate the implementation of interventions focused towards both undernutrition and overweight and obesity. The attached Working Paper was presented to the High-Level Preparatory (HLP) Meeting for its review and recommendations. It was discussed that the title of the Regional Committee agenda item may be reflected as “Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016–2025”. The recommendations made by the HLP Meeting for consideration to the Sixty-ninth Session of the Regional Committee are as follows: Actions by Member States (1) Propose a resolution based on the Draft Strategic Action Plan to reduce the Double Burden of Malnutrition in the South-East Asia Region 2016-2025 at the Sixty-ninth Session of the Regional Committee for South-East Asia in September 2016.

(2) Use the draft plan – based on the national context in each country – as an advocacy and reference tool to guide the process of updating national plans and strategies to address the double burden of malnutrition. Actions by WHO (1) Provide technical guidance and support to Member States for adapting and revising their policies and plans on nutrition to address the double burden. (2) Support operationalizing of actions to address the double burden of malnutrition through technical support to mobilize resources, develop capacity, and frame and enact new legislations and regulations based on country-level contexts and specificities. (3) Adapt and develop region-specific tools and frameworks to support development of an enabling environment for implementation of evidence-based nutrition interventions. This Working Paper and the HLP Meeting recommendations are submitted to the Sixty-ninth Session of the WHO Regional Committee for South-East Asia for its consideration and decision.

SEA/RC69/16 Rev.3

Introduction 1. Economic growth and investments, demographic changes, globalization and social and health development have altered the nutrition profile and its determinants across the WHO South-East Asia Region. Despite progress in reducing hunger and undernutrition, malnutrition continues to undermine the health of populations. The current nutrition landscape in the Region is characterized by persistent undernutrition and emerging overweight and obesity existing side by side, often within the same community; i.e. the double burden. The extent of the double burden varies across Member States, and urgent and sustained efforts are needed in improving nutrition status. 2. Undernutrition contributes to about 45% of preventable deaths of children under five years of age annually. Meanwhile, increased rates of overweight and obesity mainly resulting from unhealthy diets and sedentary lifestyle have led to unprecedented rates of noncommunicable diseases (NCDs) in Member States, with 55% of all deaths attributed to NCDs. Regionally, an estimated 60 million children in the 0–5-year age group are stunted, 45 million are underweight and 8.8 million are overweight. Thinness in adolescent girls aged 15–19 years ranges from 24% to 47%, and overweight between 2% and 24%. Among adult women, prevalence of overweight is greater than underweight and ranges from 18% to 34% across Member States. Anaemia and other micronutrient deficiencies affect both the undernourished and overweight and obese, and is of a magnitude to be recognized as a public health problem in all Member States. High salt intake in all Member States compounds the rise in NCDs and hypertension rates, with one in three adults estimated to have high blood pressure.

Current responses and challenges 3. Previous nutrition policy initiatives of the SEA Region have not comprehensively addressed both aspects of malnutrition. The Regional Nutrition Strategy, “Addressing malnutrition and micronutrient deficiencies (2011–2015)”, emphasized a multisectoral approach and the identification of core nutrition interventions (SEA/RC64/R4). WHO has supported Member States to review national nutrition policies and plans and strengthen multisectoral collaboration. WHO has also facilitated initial policy dialogue and advocated Member States to focus on the double burden of malnutrition. 4. Maternal undernutrition, as well as overweight and obesity, have a transgenerational impact with significant repercussions for future generations. Undernutrition and overweight and obesity result from suboptimum dietary practices through the life cycle, with low physical activity exacerbating effects of unhealthy diets. In addition to the traditional determinants of malnutrition, which include inequity, inadequate nutrition and inadequate care, newer drivers of the epidemic of overweight and obesity are the obesogenic environment caused by urbanization and changing lifestyles, unhealthy food systems and globalization of markets resulting in the increasing availability of energy-dense, nutrient-poor foods high in sugar, salt and fat, aggressive marketing of unhealthy foods and low physical activity. Emerging challenges such as climate change and migration compound the problem.

SEA/RC69/16 Rev.3 Page 2

5. Due to the historic and the significant burden of undernutrition in the past decades, most health systems in Member States are geared towards reducing undernutrition. Therefore, countries in this Region are challenged to concurrently develop systematic multisectoral policy actions and implement interventions for reducing overweight and obesity, and dietary risk factors for NCDs, in addition to the current focus on undernutrition. 6. Many global actions and policies have focused attention on the double burden of Malnutrition. These include: • • • • • WHO Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition (resolution WHA65.6) and Global Nutrition Targets 2025; The Outcome of the Second International Conference on Nutrition (resolution WHA68.19); The United Nations Decade of Action on Nutrition (2016 –2025) (UNGA A/70/L.42 and resolution WHA69.7); Nutrition-related SDGs, including SDG2 which calls for an end to all forms of malnutrition by 2030 and reaffirms attaining the global nutrition targets by 2025; Sixty-ninth World Health Assembly resolution and decision (the guidance on ending inappropriate promotion of foods for infants and young children (resolution WHA69.9) and the Report of the Commission on Ending Childhood Obesity (resolution WHA 69(12)).

The way forward 7. In view of the rising double burden of malnutrition reflected in the unfinished agenda of reducing undernutrition and diet-related noncommunicable diseases, a Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016–2025 has been developed. The Action Plan advances efforts established under the previous regional strategy and incorporates recent global and regional guidance in encouraging comprehensive implementation of policy actions that simultaneously deal with both undernutrition and overweight and obesity as well as new and emerging challenges such as climate change and emergencies. The draft action plan was developed through an extensive consultative process with Member States, including: the Commission on Ending Childhood Obesity—South-East Asia Regional Consultation (28–29 September 2015, New Delhi, India); an Informal Member State Consultation—Developing a regional action plan of multisectoral actions for ending childhood obesity (29 September 2015, New Delhi, India); an expert group consultation to review the draft strategic action plan for addressing the dual burden of malnutrition in South-East Asia Region (2–3 February 2016, New Delhi, India); and a regional meeting to review the Draft Strategic Acton Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region (21–22 March 2016, New Delhi, India). UN agencies and donors also participated in these consultations. 8. The Strategic Action Plan is structured in a theory-of-change model, which is based on the premise that creating an enabling environment is the key to successful implementation and scaling up of context-specific nutrition interventions to achieve the six global nutrition targets and two nutrition-related global voluntary targets for the prevention and control of NCDs (halt

SEA/RC69/16 Rev.3 Page 3

the rise in diabetes and obesity and reduction of salt intake). Moreover, it takes into account the outcomes of recent international movements on nutrition, including the Scaling Up Nutrition and Zero Hunger Challenge. 9. The Strategic Action Plan recommends that Member States examine their policies and strategies on nutrition, NCDs and any multisectoral action plans to ensure inclusion of policy actions to reduce the double burden with an emphasis on the first 1000 days, school-aged children and on adolescents. It provides guidance for Member States via key policy actions to be undertaken across four strategic areas. These include improving nutrition governance through enhanced political commitment and evidence-informed multisectoral policies; developing and adapting relevant legislation and guidelines; strengthening health workforce capacity and information systems; and tactical engagement with stakeholders including the community, academia, civil society and the private sector. The Action Plan also provides direction to the WHO Regional Office and country offices on their role in supporting Member States to deal with the double burden, while acknowledging that countries are at different stages along the double burden continuum.

Conclusions 10. The Strategic Action Plan would be an advocacy and reference tool for Member States, to ensure that interventions covering the double burden of malnutrition are addressed comprehensively through country nutrition or NCD strategies, action plans and programmes. As appropriate to the national context, countries are encouraged to prioritize actions recommended in this Action Plan. The Action Plan suggests a timeframe for review of actions through a brief monitoring framework at the regional level. The plan would be reviewed in 2021 and then revised as needed. 11. The draft Strategic Action Plan to Reduce the Double Burden of Malnutrition in the SouthEast Asia Region 2016–2025 (Annexure 1) is submitted for consideration of its endorsement and further guidance.



REGIONAL COMMITTEE Sixty-ninth Session Colombo, Sri Lanka 5–9 September 2016

Provisional Agenda item 9.8 SEA/RC69/16 Rev.3 23 August 2016

Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016-2025 Malnutrition in all its forms threatens human development. Both undernutrition and overweight and obesity throughout the life course are public health problems in the WHO South-East Asia Region, affecting Member States to varying degrees. Undernutrition, including micronutrient deficiencies, contributes to about 45% of preventable deaths of children under five years of age annually, while overweight resulting from unhealthy diets and sedentary lifestyle underpins high rates of noncommunicable diseases (NCDs) in Member States. Therefore, urgent attention is needed to reduce malnutrition. While the previous Regional Nutrition Strategy, “Addressing malnutrition and micronutrient deficiencies (2011–2015)”, emphasized a multisectoral approach (SEA/RC64/R4), it cannot adequately address the current need in the Region to tackle both undernutrition and overweight and obesity. Many global actions and policies have focused attention on the rise of overweight and obesity, including the recent Sustainable Development Goals agenda, which calls for an end to all forms of malnutrition. In response, the WHO Regional Office, in consultation with Member States, has developed a Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016–2025, through extensive consultation with Member States, technical experts and WHO country offices and headquarters. The Plan focuses on creating an enabling environment that will facilitate the implementation of interventions focused towards both undernutrition and overweight and obesity. The attached Working Paper was presented to the High-Level Preparatory (HLP) Meeting for its review and recommendations. It was discussed that the title of the Regional Committee agenda item may be reflected as “Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016–2025”. The recommendations made by the HLP Meeting for consideration to the Sixty-ninth Session of the Regional Committee are as follows:

Actions by Member States (1) Propose a resolution based on the Draft Strategic Action Plan to reduce the Double Burden of Malnutrition in the South-East Asia Region 2016-2025 at the Sixty-ninth Session of the Regional Committee for South-East Asia in September 2016. (2) Use the draft plan – based on the national context in each country – as an advocacy and reference tool to guide the process of updating national plans and strategies to address the double burden of malnutrition. Actions by WHO (1) Provide technical guidance and support to Member States for adapting and revising their policies and plans on nutrition to address the double burden. (2) Support operationalizing of actions to address the double burden of malnutrition through technical support to mobilize resources, develop capacity, and frame and enact new legislations and regulations based on country-level contexts and specificities. (3) Adapt and develop region-specific tools and frameworks to support development of an enabling environment for implementation of evidencebased nutrition interventions. This Working Paper and the HLP Meeting recommendations are submitted to the Sixty-ninth Session of the WHO Regional Committee for South-East Asia for its consideration and decision.

SEA/RC69/16 Rev.3

Introduction 1. Economic growth and investments, demographic changes, globalization and social and health development have altered the nutrition profile and its determinants across the WHO South-East Asia Region. Despite progress in reducing hunger and undernutrition, malnutrition continues to undermine the health of populations. The current nutrition landscape in the Region is characterized by persistent undernutrition and emerging overweight and obesity existing side by side, often within the same community; i.e. the double burden. The extent of the double burden varies across Member States, and urgent and sustained efforts are needed in improving nutrition status. 2. Undernutrition contributes to about 45% of preventable deaths of children under five years of age annually. Meanwhile, increased rates of overweight and obesity mainly resulting from unhealthy diets and sedentary lifestyle have led to unprecedented rates of noncommunicable diseases (NCDs) in Member States, with 55% of all deaths attributed to NCDs. Regionally, an estimated 60 million children in the 0–5-year age group are stunted, 45 million are underweight and 8.8 million are overweight. Thinness in adolescent girls aged 15–19 years ranges from 24% to 47%, and overweight between 2% and 24%. Among adult women, prevalence of overweight is greater than underweight and ranges from 18% to 34% across Member States. Anaemia and other micronutrient deficiencies affect both the undernourished and overweight and obese, and is of a magnitude to be recognized as a public health problem in all Member States. High salt intake in all Member States compounds the rise in NCDs and hypertension rates, with one in three adults estimated to have high blood pressure.

Current responses and challenges 3. Previous nutrition policy initiatives of the SEA Region have not comprehensively addressed both aspects of malnutrition. The Regional Nutrition Strategy, “Addressing malnutrition and micronutrient deficiencies (2011–2015)”, emphasized a multisectoral approach and the identification of core nutrition interventions (SEA/RC64/R4). WHO has supported Member States to review national nutrition policies and plans and strengthen multisectoral collaboration. WHO has also facilitated initial policy dialogue and advocated Member States to focus on the double burden of malnutrition. 4. Maternal undernutrition, as well as overweight and obesity, have a transgenerational impact with significant repercussions for future generations. Undernutrition and overweight and obesity result from suboptimum dietary practices through the life cycle, with low physical activity exacerbating effects of unhealthy diets. In addition to the traditional determinants of malnutrition, which include inequity, inadequate nutrition and inadequate care, newer drivers of the epidemic of overweight and obesity are the obesogenic environment caused by urbanization and changing lifestyles, unhealthy food systems and globalization of markets resulting in the increasing availability of energy-dense, nutrientpoor foods high in sugar, salt and fat, aggressive marketing of unhealthy foods and low

SEA/RC69/16 Rev.3 Page 2

physical activity. Emerging challenges such as climate change and migration compound the problem. 5. Due to the historic and the significant burden of undernutrition in the past decades, most health systems in Member States are geared towards reducing undernutrition. Therefore, countries in this Region are challenged to concurrently develop systematic multisectoral policy actions and implement interventions for reducing overweight and obesity, and dietary risk factors for NCDs, in addition to the current focus on undernutrition. 6. Many global actions and policies have focused attention on the double burden of Malnutrition. These include: • • • • • WHO Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition (resolution WHA65.6) and Global Nutrition Targets 2025; The Outcome of the Second International Conference on Nutrition (resolution WHA68.19); The United Nations Decade of Action on Nutrition (2016 –2025) (UNGA A/70/L.42 and resolution WHA69.7); Nutrition-related SDGs, including SDG2 which calls for an end to all forms of malnutrition by 2030 and reaffirms attaining the global nutrition targets by 2025; Sixty-ninth World Health Assembly resolution and decision (the guidance on ending inappropriate promotion of foods for infants and young children (resolution WHA69.9) and the Report of the Commission on Ending Childhood Obesity (resolution WHA 69(12)).

The way forward 7. In view of the rising double burden of malnutrition reflected in the unfinished agenda of reducing undernutrition and diet-related noncommunicable diseases, a Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016–2025 has been developed. The Action Plan advances efforts established under the previous regional strategy and incorporates recent global and regional guidance in encouraging comprehensive implementation of policy actions that simultaneously deal with both undernutrition and overweight and obesity as well as new and emerging challenges such as climate change and emergencies. The draft action plan was developed through an extensive consultative process with Member States, including: the Commission on Ending Childhood Obesity—South-East Asia Regional Consultation (28–29 September 2015, New Delhi, India); an Informal Member State Consultation—Developing a regional action plan of multisectoral actions for ending childhood obesity (29 September 2015, New Delhi, India); an expert group consultation to review the draft strategic action plan for addressing the dual burden of malnutrition in South-East Asia Region (2–3 February 2016, New Delhi, India); and a regional meeting to review the Draft Strategic Acton Plan to Reduce the Double Burden of

SEA/RC69/16 Rev.3 Page 3

Malnutrition in the South-East Asia Region (21–22 March 2016, New Delhi, India). agencies and donors also participated in these consultations.

UN

8. The Action Plan is structured in a theory-of-change model, which is based on the premise that creating an enabling environment is the key to successful implementation and scaling up of context-specific nutrition interventions to achieve the six global nutrition targets and two nutrition-related global voluntary targets for the prevention and control of NCDs (halt the rise in diabetes and obesity and reduction of salt intake). Moreover, it takes into account the outcomes of recent international movements on nutrition, including the Scaling Up Nutrition and Zero Hunger Challenge. 9. The Action Plan recommends that Member States examine their policies and strategies on nutrition, NCDs and any multisectoral action plans to ensure inclusion of policy actions to reduce the double burden with an emphasis on the first 1000 days, school-aged children and on adolescents. It provides guidance for Member States via key policy actions to be undertaken across four strategic areas. These include improving nutrition governance through enhanced political commitment and evidence-informed multisectoral policies; developing and adapting relevant legislation and guidelines; strengthening health workforce capacity and information systems; and tactical engagement with stakeholders including the community, academia, civil society and the private sector. The Action Plan also provides direction to the WHO Regional Office and country offices on their role in supporting Member States to deal with the double burden, while acknowledging that countries are at different stages along the double burden continuum.

Conclusions 10. The Action Plan would be an advocacy and reference tool for Member States, to ensure that interventions covering the double burden of malnutrition are addressed comprehensively through country nutrition or NCD strategies, action plans and programmes. As appropriate to the national context, countries are encouraged to prioritize actions recommended in this Action Plan. The Action Plan suggests a timeframe for review of actions through a brief monitoring framework at the regional level. The plan would be reviewed in 2021 and then revised as needed. 11. The draft Strategic Action Plan to Reduce the Double Burden of Malnutrition in the South-East Asia Region 2016–2025 (Annexure 1) is submitted for consideration of its endorsement and further guidance.

Annexure-1 STRATEGIC ACTION PLAN TO REDUCE THE DOUBLE BURDEN OF MALNUTRITION IN THE SOUTH-EAST ASIA REGION 2016–2025

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

1

Table of Contents Abbreviations..................................................................................................................................................................................... iii Executive summary ........................................................................................................................................................................ iv 1. Introduction.................................................................................................................................................................................... 1 1.1 Suboptimal diets................................................................................................................................................................... 1 1.2 Consequences of malnutrition ...................................................................................................................................... 2 1.3 Addressing the determinants of the double burden of malnutrition ....................................................... 2 1.4 Emerging challenges in nutrition ................................................................................................................................ 3 2. Profile of nutritional status in the WHO South-East Asia Region ....................................................................... 5 2.1 Nutritional status of children aged 0–5 years....................................................................................................... 6 2.1.1 Stunting and overweight in children < 5 years ........................................................................................... 6 2.1.2 Wasting in children < 5 years of age ................................................................................................................. 7 2.1.3 Underweight in children < 5 years .................................................................................................................... 7 2.1.4 Low birth weight (LBW) ......................................................................................................................................... 8 2.2 Nutritional status of adolescents ................................................................................................................................. 9 2.3 Nutritional status of adult population ...................................................................................................................... 9 2.4 Nutrition in older persons.............................................................................................................................................10 2.5 Micronutrient Deficiencies in the South-East Asia Region...........................................................................11 2.5.2 Status of other micronutrient deficiencies ..................................................................................................13 2.6 Diets in the WHO South-East Asia Region.............................................................................................................13 2.6.1Consumption of minimum acceptable diets by young children ........................................................13 2.6.2 Dietary risk factors for noncommunicable disease risk .......................................................................14 2.6.3 Fruit and vegetable consumption.....................................................................................................................14 3. The Strategic Framework and Action Plan ...................................................................................................................15 3.1 Goal............................................................................................................................................................................................15 3.2 Objectives...............................................................................................................................................................................15 3.3 Scope and purpose ............................................................................................................................................................15 3.4 Policy context .......................................................................................................................................................................15 3.5 Time frame ............................................................................................................................................................................16 3.6 Monitoring .............................................................................................................................................................................16 3.7 Guiding principles .............................................................................................................................................................16 3.8 Strategic directions and outcomes of the action plan are set out in the following theory of change...................................................................................................................................................................................17 3.9 Role of the WHO .................................................................................................................................................................17 3.10 Nutrition and diet-related noncommunicable diseases risk targets ....................................................18 4. The Action Plan ...........................................................................................................................................................................20 5. References .....................................................................................................................................................................................25

i

List of tables Table 1: Level of public health burden caused by anaemia among nonpregnant women, children and pregnant women. ............................................................................................................................................................................12

List of figures Figure 1: The double burden of malnutrition across the life course. .................................................... 2 Figure 3: Prevalence of stunted children and overweight children aged < 5 years (-2SD Height-forage Z scores) in SEAR. ............................................................................................................................ 6 Figure 4: Prevalence of wasting in children aged <5 years (-2SD Weight-for-height Z scores) in SEAR. ...................................................................................................................................................... 7 Figure 5: Prevalence of underweight (-2SD Weight-for-age Z scores) in children <5 years in SEAR. . 7 Figure 6: Prevalence of low birth weight children in SEAR. ................................................................. 8 Figure 7: Proportion of stunted, underweight and overweight/obese female adolescents aged 15–19 years in selected countries of SEAR.................................................................................................. 9 Figure 8: Trend in prevalence of overweight (mean BMI ≥25 kg/m2) in adults (both sexes) in 2010 and 2014 in SEAR................................................................................................................................. 10 Figure 9: Proportion of older persons (aged 60 years and over) in SEAR. ......................................... 10 Figure 10: Prevalence of anaemia among children aged < 5 years and non-pregnant women in SEAR. .............................................................................................................................................................. 12 Figure 11: Consumption of minimum acceptable diets by 6–23 month old children in SEAR. .......... 13 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 Region. ................................................... 14 Figure 13: Percentage of adults who ate < 5 servings of fruits and vegetables per day. .................... 14 Figure 14: Strategic directions and outcomes of the action plan. ....................................................... 17 Figure 15: Global nutrition and diet-related noncommunicable disease targets. .............................. 19 List of annexes Annex 1. Supporting global and regional resolutions/mandates and content analysis of technical areas covered. ...................................................................................................................................... 27 Annex 2. Regional monitoring framework for policy, capacity and legislative indicators. ............... 28 Annex 3. Selected evidence-based interventions (e-Library of Evidence Based Nutrition Actions) to reduce the double burden of malnutrition. ......................................................................................... 29 Annex 4. Indicator definitions for Global Nutrition and diet related Noncommunicable Diseases targets. ................................................................................................................................................. 32 Annex 5. 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). .................................................................................................................................. 33 Annex 6. Example of cross-sectoral Government engagement and potential multisectoral action. .. 48

ii

Abbreviations BMI BMS CIP DHS eLENA FAO GDP GHI GNP HDI ICN 2 IDD USI IYCF IMR LBW MICS MDG NCD REACH SAM SD SEAR SUN SDG U5MR UNICEF WASH WHA WHO WIFS IDA IEC IFA IYCF LMICs Body Mass Index breast milk substitutes Comprehensive Implementation Plan Demographic and Health Survey Electronic Library of Evidence for Nutrition Actions Food and Agriculture Organization Gross Domestic Product Global Hunger Index Gross National Product Human Development Index Second International Conference on Nutrition Iodine Deficiency Disorder Universal Salt Iodization Infant and Young Child Feeding Practices Infant Mortality Rate Low Birth Weight Multiple Indicator Cluster Survey Millennium Development Goal Noncommunicable Diseases Renewed Efforts Against Child Hunger and Undernutrition Severe Acute Malnutrition standard deviation South-East Asia Region Scaling Up Nutrition Sustainable Development Goal Under Five Mortality Rate United Nations Children’s Fund Water, Sanitation and Hygiene World Health Assembly World Health Organization Weekly Iron and Folate Supplementation Iron Deficiency Anaemia Information, Education and Communication Iron Folic Acid Infant and Young Children Feeding Low and Middle-Income Countries

iii

Executive summary Economic growth accompanied by investments in social development and health have resulted in improvements in the nutritional status of the populace in the WHO South-East Asia Region. However, despite progress on the Millennium Development Goals (MDGs), targets of halving poverty and hunger, reducing child mortality and underweight, malnutrition continues to persist. The ongoing nutrition transition in the Region is characterized by persistent undernutrition, which includes micronutrient deficiencies, and concomitant overweight and obesity (the double burden), and associated risk of noncommunicable diseases (NCDs). In South-East Asia Region, an estimated 60 million children in the 0–5 year age group are stunted, 45 million are underweight and 8.8 million are overweight. Anaemia and other micronutrient deficiencies are a significant public health problem in many Member States. Undernutrition contributes to about 45 % of preventable deaths of children under 5 years annually. Increased overweight and obesity underpin the high rates of NCDs in Member States, with 55 % of all deaths attributed to NCDs. Maternal undernutrition, as well as overweight and obesity have a transgenerational impact. Poor maternal nutrition is a determinant of low birth weight, associated with stunting. Both low birth weight and stunting in turn increase risk of overweight, obesity and noncommunicable diseases in later life. Maternal overweight and obesity are also related to child overweight. Poverty and inequity, inadequate nutrition, want of access to health and nutrition services, infections and lack of clean water and sanitation are some determinants of undernutrition. Changing dietary habits fuelled by globalization of markets with increased availability of energy dense, nutrient-poor foods, and inadequate physical activity lead to overweight and obesity. The double burden of malnutrition affects Member States to varying degrees, and urgent and sustained efforts are needed to address the problem. 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 between Member States, experts and the WHO secretariat. It advances efforts established under the previous regional strategy, and brings together guidance from global and regional policy platforms on promoting integrated approaches to address all forms of malnutrition concurrently. Policy actions from the Global Strategy on infant and young child feeding; the Comprehensive Implementation Plan for Maternal, Infant and Young Child Nutrition; the framework for action of the 2nd International Conference on Nutrition (ICN2); the Ending Childhood Obesity Commission report; and the post 2015 development agenda have informed the action plan. The emphasis of the action plan is on improving nutrition governance, adopting global guidance and institution of legislation, improving capacity, multisectoral engagement and community empowerment to ensure sustainable solutions to nutrition problems. These aspects are articulated through four strategic directions. This plan will serve Member States as an advocacy and reference tool, to ensure that interventions covering the double burden of malnutrition are addressed comprehensively and simultaneously in Member State policies, strategies and actions. The plan also provides direction to the Regional Office and country offices on the pertinent areas of support for Member States.

iv

1. Introduction Malnutrition,1 in all its forms, threatens human health and development. Today, most low and middle-income countries face an increasing 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)2 such as cardiovascular disease, diabetes mellitus and cancer is threatening already stretched and under-resourced health systems and economies.(2) By 2030, NCDs are expected to contribute to two thirds of the disease burden in low and middle-income countries.(2) The South-East Asia Region has historically carried a high burden of child undernutrition, caused by socioeconomic disadvantages, and other biological and social determinants. The picture is now changing with a concomitant rise in both child and adult overweight and obesity. Evidence indicates that 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. (3) As indicated in Figure 1, the behavioural and biological responses of a child to the obesogenic environment is shaped partly in utero, placing many on the pathway to obesity when faced with an unhealthy diet and low physical activity, as seen in today’s transitioning societies.(4) Low birth weight and stunted children who experience rapid weight gain during childhood and adolescence are at greater risk to develop NCDs. (5) For South-East Asia, and especially for its stunted populations, the risks of a mismatch between their genetic programming (in preparation for a resource-poor environment after birth) and the unhealthy diet environment after birth are greatly increasing NCD risk. (6) 1.1 Suboptimal diets The predominant dietary patterns in the South-East Asia Region are plant based, often inadequate in energy, protein, and micronutrients, and low in diversity giving rise to stunting, wasting and anaemia in young children. (7) Significant protein-energy deficits are common (8). At the same time, particularly in urban areas, diets higher in refined grains and sugars, and fats are getting more common. Healthy diets where adequate energy should be obtained mostly from unrefined carbohydrates, protein from plant and animal sources, are shifting away from saturated fats to unsaturated fats, and elimination of trans fatty acids; limiting intake of free sugars, sodium and increasing fruits, legumes, whole grains and nut consumption needs to be advocated. Intrauterine life, infancy and the preschool period have all been considered as critical periods where long-term regulation of energy balance is programmed. Therefore, a life-course perspective (Figure 1) along with measures to reduce the obesogenic environment3 has the greatest potential to address both undernutrition and overweight and obesity (4, 9), with an emphasis on prevention in children under five years of age, school aged children,4 adolescents5 and pregnant women. 1 2

Malnutrition is defined as nutritional excesses of macronutrients and micronutrients as well as deficiencies (WHO 1995). World Health Organization. Noncommunicable diseases. http://www.who.int/mediacentre/factsheets/fs355/en/ -accessed 1 August 2017. 3 An environment that promotes high energy intake and sedentary behaviour. 4 Children between ages 6 and 11 years.

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 Consequences of malnutrition Worldwide, more than one third of child deaths and one fifth of the total disease burden are due to maternal and child undernutrition. (10) Final adult height, which is largely determined in childhood, reflects the nutrition quality during early life. (11) Stunting during the prenatal period and infancy impairs cognitive development, with reduced school performance. In adult life, work performance is reduced, and stunting is associated with an increased risk of noncommunicable diseases. (10, 12) Loss of attainment of height causes an annual loss of two to three percent of GDP, undermining efforts to eradicate poverty. (13) Micronutrient deficiencies add to the social and economic burden, compromising the immune system, diminishing cognitive functions and intellect, causing anaemia and other illnesses. (1) Of a total 13.7 million deaths in the South-East Asia Region during 2012, 6.8 million were due to NCDs, principally cardiovascular diseases, diabetes, cancer and chronic respiratory diseases (14). By 2030, an estimated 32 percent of the total proportion of diabetes cases will be from the South-East Asia Region. (15) Together, both undernutrition and NCDs represent a significant economic and social cost to countries with an estimated cost of more than US$ 30 trillion globally over the next 20 years. (15) 1.3 Addressing the 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) Poor diets, physical inactivity and infections contribute to immediate causes of malnutrition. Inadequate care, suboptimal and unhealthy diets, poor water and sanitation, lack of food safety, inadequate health care and sedentary behaviours underlie the double burden of malnutrition. Finally, basic causes of malnutrition at the societal level include inadequate access to food supply, maternal education, 5

Boys and girls between ages 11 and 19 years.

2

inadequate investments in health services, social protection schemes and poverty. Such determinants should be examined and addressed through a nutrition lens that considers both aspects of the double burden of malnutrition that also considers country specific contexts. Figure 2: Conceptual framework of malnutrition.

Basic, underlying and immediate causes are included in this figure, as well as outcomes of malnutrition. ASEAN/UNICEF/WHO (2016) Regional Report on Nutrition Security in ASEAN, Volume 2, Bangkok, UNICEF.

1.4 Emerging challenges in nutrition 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.6 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 could play a part in the prevention of degenerative conditions of the elderly and an improvement in quality of life.

6

National Institute on Aging, National Institutes of Health. Global Health and Ageing. United States: NIH Publication, 2011.

3

Climate change Climate change increases the incidence and severity of extreme weather events and magnifies the risk of disasters globally.7 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, stability and utilization, thereby exacerbating current states of malnutrition. It is the poorest and vulnerable groups such as young children and women with inadequate resilience to cope that would be most affected. Obesogenic environment Mechanization and urban lifestyles that promote increased screen time and other sedentary behaviours are becoming more common in the South-East Asian Region, along with an abundance of low-cost, high-energy foods due to globalization and aggressive marketing by industry.

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. 7

4

2. Profile of nutritional status in the WHO South-East Asia Region The WHO South-East Asia (SEA) Region represents a diverse range of 11 low- and middle-income countries, with wide variations in geography, culture, social development and nutrition transition. Over the past two to three decades, the Region has seen significant social, economic and demographic changes that have greatly influenced the nature of nutrition issues currently faced by countries. Of the world’s population, 26% lives in the South-East Asia Region, with more than 90 percent of the Regional population being in Bangladesh, India and Indonesia. (17). The rate of urbanization in Asia (1.5% per annum) is the highest in 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 the population is rural. (19) The Region has the Bangladesh largest working age population in the world, representing enormous human Bhutan resource potential. Literacy rates, especially among women, are rising consistently, contributing to human and social capital. In Thailand, Sri Lanka, Indonesia 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) Democratic People’s Republic of Korea India Robust economic growth accompanied by intensive efforts for social development Indonesia have resulted in declining poverty and improvements in the Human Development Maldives 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 Myanmar declined significantly from 34 deaths per 1000 live births in 2000 to an estimated Nepal 26 deaths in 2015.8 Significant progress has been made in reducing undernutrition. Sri Lanka Bangladesh (21) reported a 35–40% decline in child stunting and underweight between 2004 and 2014. Similarly, a 60% reduction in stunting prevalence and 70% Thailand reduction in underweight among under-five children was reported from Bhutan Timor- Leste 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 years9 and a significant increase in exclusive breastfeeding rates. (23) However, while undernutrition is declining, micronutrient deficiencies, particularly anaemia, remains a significant problem, and child, adolescent and adult overweight and obesity is increasing in prevalence.



Data not available for Democratic People’s Republic of Korea and for Bhutan. 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. 9 International institute for population sciences. National family health survey, India. http://rchiips.org/NFHS/factsheet_NFHS-4.shtml – accessed 1 August 2016. 8

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2.1 Nutritional status of children aged 0–5 years10,11 2.1.1 Stunting and overweight in children < 5 years: Stunting12 is the cumulative result of chronic malnutrition and deprivations from the prenatal period and childhood. Overweight may or may not be superimposed on stunting and results from diets excessive in energy, together with reduced physical activity. Figure 3 indicates the prevalence of both stunting as well as overweight in young children.13 The double burden varies between countries with over 10% of children in under-five age group estimated to be overweight in India, Indonesia and Thailand and less than 3% in Bangladesh, Myanmar, Nepal and Sri Lanka. The regional prevalence of overweight in children under five years was 3.3% in 2005 and 4.9% in 2014.14 Prevalence of stunting is declining across all countries in the Region. The overall Annual Average Rate of Reduction of 1 percentage point per year is much slower than the estimated 3.9% needed to meet Global nutrition targets. Although the overall prevalence of stunting in SEAR countries has been reduced from 59% in 1990 to 32.9% in 2013, it translates to 60.8 million stunted children at present. (24) Figure 2: Prevalence of stunted children and overweight children aged < 5 years (-2SD Height-forage Z scores) in SEAR15. 100 90 80 70 60 50 40 30 20 10 0

Percentage of under five children (%)

50.2 36.1 33.6 38.7 27.9 20.3 36.4 35.1 37.4 14.7 16.3 32.9

Stunting Overweight

Source: WHO/UNICEF/World Bank joint monitoring estimates 2015. 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 noted that the prevalence of stunting is low. The most recent data

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. 11 For the purpose of uniformity, the data for nutrition profile 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. 12 Defined as height that is more than two standard deviations below the World Health Organization Child Growth Standards median. 13 Defined as weight for age more than 2 standard deviations above the WHO growth standards median (birth to less than 5 years of age). 14 WHO/UNICEF/World Bank joint monitoring estimates 2015. http://www.wssinfo.org/ - accessed 1 August 2016. 15 National Nutrition Survey 2015 of Bhutan showed that 21.2% of children are stunted. 10

6

from MICS indicate that the prevalence of stunting is 10.5% for children under 5 years of age and the prevalence of overweight is 8.2% in children under 5 years of age.16

2.1.2 Wasting in children < 5 years of age17: Wasting is the result of recurrent acute deprivations of nutrition. In 2014, in the SEA Region, 14.5% of the children were wasted (25.9 million children wasted and 8.1 million severely wasted) as indicated in Figure 4. (24) Figure 3: Prevalence of wasting in children aged <5 years (-2SD Weight-for-height Z scores) in SEAR18. Precentage of under five children (%) 100 90 80 70 60 50 40 30 20 10 0

14.3

5.9

15.1 4

13.5

21.4 10.2 7.9 11.3 6.7 11

Data updated by October 2015. The specific year when the data was obtained in each country is given in parenthesis. National data is mainly originated from various household surveys included in the WHO/UNICEF/World Bank joint monitoring estimates 2015.Threshold of public health significance >5 percent (green), high severity (>10 percent , yellow). Thailand noted that the prevalence of stunting is low. The most recent data from MICS indicates that prevalence of wasting is 5.4 percent in children under 5 years of age.

2.1.3 Underweight in children < 5 years: Most of the countries of the Region show a significant decline in prevalence of underweight (figure 5). Despite this decline, in 2014, 46 million children in the Region were estimated to have low weight for age (24). Figure 4: Prevalence of underweight (-2SD Weight-for-age Z scores) in children <5 years in SEAR19.

UNICEF, MICS. Multiple Indicator Cluster Survey (MICS) 2015/16: Thailand. http://mics.unicef.org/surveys - accessed 1 August 2016. Defined as more than two standard deviations below the median weight-for-height of the WHO Child Growth Standards median and below minus three standard deviations (-3 SD) are considered to be severely wasted. 18 National Nutrition Survey 2015 of Bhutan reported prevalence of 4.4% wasting and 9% underweight among children age 0-59 months 19 Defined as weight for age less than 2 standard deviations below the WHO growth standards median (birth to less than 5 years of age). 16 17

7

Precentage of children under five (%)

100 90 80 70 60 50 40 30 20 10 0

32.6 12.8 15.2

29.4 19.9 17.8

22.6

30.1

37.7 26.3 9.2

Data updated by October 2015. The specific year when data were obtained in each country is given in parenthesis. National data are mainly originated from various household surveys included in the WHO/UNICEF/World Bank joint monitoring estimates 2015. Threshold of public health significance >30% (very high severity), high severity (>20%); <1 % (low severity).

2.1.4 Low birth weight (LBW): LBW (birth weight < 2500 g) is associated with higher morbidity and mortality especially in the neonatal period. The prevalence of LBW is the highest in India, followed by Bangladesh, Nepal and Sri Lanka (Figure 6). However, birth weight figures are likely to be underreported due to home deliveries. Figure 5: Prevalence of low birth weight children in SEAR. Percentage of children born with weight <2500g (%) 100 90 80 70 60 50 40 30 20 10 0

22 10 6

28 9 11 18 9 17 11 12

Source: State of World’s Children 2015: Reimagine the Future (UNICEF 2015).

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2.2 Nutritional status of adolescents Stunting 20. 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 for stunting (145 cm of height). (Fig. 10) Thinness 21.The DHS data from six countries of the Region show that thinness among adolescent girls is in the range of 24–47%, indicating significant energy deficits in diet. Overweight and obesity 22 23. Often seen side by side with thinness and stunting in the same community, overweight /obesity24, caused by unhealthy diet and low physical activity is a growing concern among adolescents in the Region. (Figure 7)

Figure 6: Proportion of stunted, underweight and overweight/obese female adolescents aged 15–19 years in selected countries of SEAR.

100 90 80 70 60 50 40 30 20 10 0 Bangladesh India Maldives Nepal Sri Lanka Timor-Leste BMI ≥ 25kg/m2 BMI <18.5kg/m2 Height <145 cm

Source: Bangladesh DHS 2011; India NFHS3 2005-06; Maldives DHS 2009; Nepal DHS 2011; Sri Lanka DHS 2006; TimorLeste DHS 2009-10. BMI of > 25 kg/m2 has been taken as overweight, and BMI of 30 kg/m2 as obese.

2.3 Nutritional status of adult population More than one-fifth of adults are overweight in the Region, 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 Short stature/stunting among reproductive age women is frequently defined as height less than 145 cm, a cut-off chosen because of its association with increased obstetric risk. 21Thinness or underweight is defined as Body Mass Index (BMI) less 18.5 kg/m2. 22 BMI-for-age more than 2 SD above the WHO growth reference median for ages less than 5 years. 23 From age 5 to less than 19 years: BMI-for-age more than 1 SD above WHO growth reference median. 20

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1.3 kg/m2/decade in Maldives between 1980 and 2008. The Global status report 2014 also shows high BMI levels in Maldives and Thailand. (25) Figure 7: Trend in prevalence of overweight (mean BMI ≥25 kg/m2) in adults (both sexes) in 2010 and 2014 in SEAR. 100 90 80 70 60 50 40 30 20 10 0

Percentage of adults (%)

18 16

24 27

19

20

2022

25 21

2730 1518

18 16

2225

2730 1315

2010 2022

2014

Source: Global Health Observatory Data Repository, WHO 2013. http://www.who.int/gho/en

2.4 Nutrition in older persons Figure 9 provides the population projection estimates of older persons 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 8: Proportion of older persons (aged 60 years and over) in SEAR.

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100 Percentage of older persons (%) 90 80 70 60 50 40 30 20 10 0 26.9 19.4 12.0 12.4 11.5 7.0 7.0 21.0 13.0 12.4 8.0 6.0 12.0 7.0 13.0 9.0 11.0 10.6 8.0 15.7 4.4 6.7

2015

2030

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.

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). 2.5.1Anaemia Anaemia prevalence across all countries is mainly nutritional in nature and primarily attributed to iron deficiency and partly to folic acid and vitamin B12 deficiencies. Iron deficiency is the most prevalent micronutrient deficiency across all age groups and affects physical, cognitive and social health.(28) Adolescents 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%) show that adolescent anaemia is a moderate to severe public health problem. 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 among children as indicated in Table 1.

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Figure 9: Prevalence of anaemia among children aged < 5 years and non-pregnant women in SEAR25. 100 90 80 70 60 50 40 30 20 10 0

Percentage (%)

56 43

55 44 34 25

59 48 32 22 30 37 40 30

51 36 36 26 29 24

Children <5 years 45 22

Nonpregnant women Severe public health problem Moderate public health problem

Data are based on WHO’s modelled estimates (from 1995 to 2011) in national estimates of anaemia for the year 2011, WHO. The global prevalence of anaemia in 2011. Geneva: World Health Organization; 2015. 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).26

Table 1: Level of public health burden caused by anaemia among children, non-pregnant women, and pregnant women.

Children aged 6–59 months Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Anaemic Public Health children27 Significance 56% 55% 34% 59% 32% 30% 40% 51% 36% 29% Severe Severe Moderate Severe Moderate Moderate Severe Severe Moderate Moderate

Women 15–49 years (nonpregnant) Anaemic Public nonHealth pregnant28 Significance 43% Severe 44% Severe 25% Moderate 48% Severe 22% 37% 30% 36% 26% 24% Moderate Moderate Moderate Moderate Moderate Moderate

Women 15–49 years – (pregnant) Anaemic Public Health pregnant2 Significance 48% 46% 27% 54% 30% 39% 33% 44% 25% 30% Severe Severe Moderate Severe Moderate Moderate Moderate Severe Moderate Moderate

25

Bhutan and Timor-Leste recent nutrition survey reported that 44% of children in Bhutan and 62.5% in Timor- Leste suffer from anaemia. (22, 31) 26 27

National Health Exam Survey. Thailand. Percentage with blood haemoglobin concentration <110 g/L (for children 6-59 months and pregnant women). 28 Percentage of non-pregnant women with blood haemoglobin concentration <120 g/L.

12

Timor-Leste

45%

Severe

22%

Moderate

24%

Moderate

Adapted from Annex 3. 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). WHO Worldwide prevalence of anaemia 1993–2005: WHO global database on anaemia. WHO, Geneva, 2008 (De Benoist B, McLean E, Egli I, Cogswell M, editors).

2.5.2 Status of other micronutrient deficiencies Vitamin A: Among young children< 5 years the estimated prevalence of night blindness in SouthEast 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 South-East Asia 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 the WHO South-East Asia Region 2.6.1Consumption of minimum acceptable diets by young children Breastfeeding and complementary feeding practices determine the nutritional status of young children. Figure 11 indicates that 6–23 month old breastfed children are consuming minimum acceptable diets, a composite indicator of dietary diversity (consuming foods from 3 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) Figure 10: Consumption of minimum acceptable diets by 6–23 month old children in SEAR.

100 90 80 70 60 50 40 30 20 10 0

Percentage of 6-23 month old children (%)

83 63

41 34 21 22 25

Bangladesh India 2005- Indonesia 2011* 2006 2012

Maldives 2009

Nepal 2011

Sri Lanka Timor- Leste 2006-2007 2009-2010

* Children consuming foods from 4+ food groups. Source: Country Demographic and Health surveys.

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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 11: 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 Region. Estimated sodium intake (g/d) 10 9 8 7 6 5 4 3 2 1 0

3.54

3.64

3.79

4.49 3.72 3.36 3.31

5.31 3.89 3.87

4.47

All data have been obtained from the publication from Powles et al. (35) For comparability reasons, data from the most recent surveys for each country have not been included.

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 12: Percentage of adults who ate < 5 servings of fruits and vegetables per day.

14

100 90 80 70 60 50 40 30 20 10 0

96 98 94 83 83 84 67 65 70

94 93 95

99 99 99 87 85 88

97 97 97 90 78 71

Percentage of adults (%)

Total Men Women

Bangladesh 2010

Bhutan 2014

Indonesia 2006

Maldives 2011

Myanmar 2014

Nepal 2012-13

Sri Lanka Timor2003 Leste 2014

Source: STEPs country fact sheets, http://www.who.int/chp/steps/reports/en/

3. The Strategic Framework and Action Plan 3.1 Goal Reduce the double burden of malnutrition in the South-East Asia Region. 3.2 Objectives   To promote and sustain an enabling environment for the implementation of nutrition interventions. To promote effective implementation and scaling up of evidence-based, cost-effective direct and indirect nutrition interventions through the life course 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 and decision-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. It provides overarching guidance/directions on policy actions to countries to ensure that interventions covering the double burden of malnutrition are addressed comprehensively through programmes, while taking into account the country context. This plan does not focus on physical activity, which is an integral component of healthy lifestyles, since it is addressed comprehensively in other regional plans. 3.4 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 1) and the objectives of policy

15

platforms including the Scaling Up Nutrition (SUN) Movement and UN Secretary-General’s Zero Hunger Challenge. 3.5 Time frame The action plan spans the period of 10 years (2016–2025), in line with the Global Nutrition and NCD targets,29,30 and the Decade of Action for Nutrition 2016–2025. 3.6 Monitoring The Regional office will track progress of implementation of the action plan in the medium (2021) and long term (2025) through monitoring of key selected indicators that reflect the double burden of malnutrition (Annex 2). The plan will be reviewed in 2021 and revised as needed and an endterm assessment will be conducted in 2025. 3.7 Guiding principles The following guiding principles underpin the action plan: Life-course approach: A continuum of interventions across the life course is essential for improvement in nutrition. A special focus will be on the “window of opportunity,” from conception to two years (first 1000 days), which is the best opportunity to pause the intergenerational cycle of malnutrition. The action plan will also focus on nutrition of the school-aged child and adolescent. Schools offer the opportunity to promote healthy diets and provide life skills on nutrition and health that are the foundation for good nutrition. Ensuring human rights and the right to food: A human rights approach to policies, strategies and programmes designed to address equity, availability, accessibility, acceptability, quality and universality. The right to food is a human right, protecting the right for people to feed themselves in dignity, and have sufficient, accessible food that can adequately meet their dietary needs. Commitment and accountability: Political will and commitment to good governance is needed to address double burden of malnutrition. Robust mechanisms are needed to monitor policy development and implementation, thus facilitating the accountability of governments, civil society and the private sector on commitments. Sustainable solutions that build self-reliance and empowerment: Strengthening and reorienting strategies for food systems so that they become health promoting and are economically and environmentally sustainable. This would be done through a focus on policy coherence between nutrition and agriculture. Multisectoral approach: Collaboration and coordination with various sectors, e.g. health, education, environment, social protection, labour, water and sanitation, agriculture, transport, etc., through joint strategies with common goals are essential to address the multiple underlying causes of malnutrition.

29

World Health Organisation. Nutrition: Global targets 2025. Geneva. http://www.who.int/nutrition/global-target-2025/en/ -accessed 1 August 2016. 30World Health Organziation. Noncommunicable diseases and mental health. Geneva http://www.who.int/nmh/ncd-tools/definition-targets/en/ accessed 1 August 2016.

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Equity: Equitable coverage of interventions, particularly for disadvantaged or otherwise vulnerable population groups, who are at high risk for all forms of malnutrition are promoted.

3.8 Strategic directions and outcomes of the action plan are set out in the following theory of change. Figure 13: Strategic directions and outcomes of the action plan.

INPUTS/PROCESSES Strategic directions to create an enabling environment for effective implementation of interventions 1. Improve nutrition governance through enhanced political commitment and evidence informed, context-specific sectoral policies. 2. Develop, adopt/adapt relevant guidelines, legislation and regulatory frameworks needed to implement evidence-based interventions. 3. Strengthen health systems to address the double burden of malnutrition with adequate resources, capacity strengthening and comprehensive monitoring. 4. Empower communities, support and strengthen academia and civil society to promote healthy diets and form strategic alliances with other stakeholders. OUTPUTS Evidence based interventions contextual to country context implemented and scaled up* OUTCOMES Global nutrition and diet related NCD targets IMPACT Reduced double burden of malnutrition in the SouthEast Asia Region

*Evidence-informed guidance for nutrition interventions is available through the eLibrary of evidence for nutrition actions (eLENA) and other guidance documents. Selected direct and indirect interventions are provided in Annex 3.

3.9 Role of the WHO The Regional and country offices will be engaged in a variety of roles to support, facilitate and strengthen Member States to implement policy actions to reduce the double burden of malnutrition.

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Policy advocacy and planning   Support in setting targets and developing national policies, strategies and action plans to reduce the double burden of malnutrition. Advocate for resources to nutrition, support the establishment of partnerships and coordination mechanisms within health and other sectors to promote healthy diets and 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.



Technical guidance and policy support to  Access normative products and tools.  Translate and establish global and regional guidance into effective interventions.  Monitor nutrition outcomes and implement national action plans.  Build additional capacity needed in special areas, such as legislation, standards and specifications for the promotion of healthy diets, food labelling and fortification of food with micronutrients.  Strengthen human resource capacity in countries for effective and sustainable implementation of relevant interventions. 3.10 Nutrition and diet-related noncommunicable diseases risk targets31 The policy actions and interventions stated in the plan will contribute to achieving the voluntary Global nutrition targets (Figure 15) in the Comprehensive Implementation Plan on Maternal, Infant and Young Child nutrition (WHA 2012), and the diet-related NCD targets of the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases (WHA 66.10). Annex 4 provides indicator definitions.

31

Definitions provided in annex.

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Figure 14: Global nutrition and diet-related noncommunicable disease targets. Global nutrition targets 2025 40% reduction in the number of children under five who are stunted 50% reduction of anaemia in women of reproductive age 30% reduction in low birth weight No increase in childhood over weight Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50% Reduce and maintain childhood wasting to less than 5% The WHO Global Action Plan for the Prevention and Control of NCDs includes two further nutritionrelated targets. A 30 % relative reduction in mean population intake of salt/sodium

Halt the rise in diabetes and obesity

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4. The Action Plan The framework for implementing the strategic directions to create an enabling environment for implementation of nutrition interventions is given below. Annex 5 provides a mapping of associations between policy actions, 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 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. Policy development needs 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 policy actions should be promoted. Policy actions Establish a high-level coordination mechanism to guide multisectoral nutrition actions Ensure policies that provide adequate financing for nutrition Develop/update national policies and plans in nutrition and related sectors to reflect the double burden of malnutrition Policy indicators Higher-level coordination mechanism established with specific terms of reference Adequate resources (as identified by costing analysis) are earmarked and available for implementation of nutrition action plans National nutrition and/or related health policies and plans have addressed the double burden of malnutrition32 Multisectoral nutrition action plans with operational mechanisms are updated with identified budget lines Multisectoral nutrition action plans are implemented and monitored At least three key nonhealth policies address the double burden of malnutrition 33 Policy coherence ensured between nutrition and agriculture National nutrition targets and diet-related NCD targets identified and indicators based on the global monitoring framework are included in monitoring mechanism Country frameworks are developed and implemented to protect food policies and dietary guidance from conflict of interest Nutrition is addressed in policies, strategies and plans on healthy ageing

Identify national targets and indicators for nutrition and dietrelated NCD risk factors that address country priorities Ensure policy actions to insulate nutrition policy-making from conflict of interest to safeguard public good Build on existing WHO policy frameworks relevant to healthy and 32

Annex 6 provides an example of multi sectoral actions.

33

Education, social protection, sports (or relevant policies) identified as important in the country context.

20

active ageing to include nutrition Ensure that emerging challenges such as climate change and natural disasters address nutrition in related policies and plans

Country health emergency /disaster preparedness plans explicitly address the double burden of malnutrition

Strategic direction 2 Develop, adopt /adapt relevant guidelines, legislation and regulatory frameworks needed to implement evidence-based interventions. Development and adaptation of guidelines and legislation and regulatory frameworks are vital in reducing the double burden of malnutrition. Evidence-based guidance is available at the global level and should be adopted by countries to enable successful implementation of nutrition actions. Policy actions Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet-related risk of NCDs Policy indicators Country food-based dietary guidelines that promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized Strategies and roadmap developed for population reduction of salt, sugar and fat intake Country develops a national nutrition plan that includes WASH (Water, Sanitation, and Hygiene) Fiscal policies are developed and enacted for food products that are high in sugar , fat and salt Policies for subsidizing local fruits and vegetables are enacted Micronutrient (supplementation) guidelines within the country are updated regularly Food fortification legislation for iodization of salt and other relevant-identified micronutrients are developed and implemented Legislation enacted and implemented to ensure mandatory labelling of food products for both front of pack and back of pack labelling of nutrients A watchdog mechanism established in a country to ensure that health and nutrition claims are based on codex guidelines and adequate scientific evidence Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated

Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruits and vegetables Ensure that regulations and guidelines are in place for supplementation and fortification of products as suitable for the country context Enact legislation and its implementation on appropriate nutritional information for processed , pre-packaged food products

Promote healthy and safe foods for informal sector to enable the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and

21

Policy actions management of nutrition emergencies Promote, protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms

Policy indicators International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions are legislated and implemented Maternity protection measures 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 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 to implement WHO’s Recommendations on Marketing of unhealthy foods and beverages to children School guidelines and standards ensuring a healthy food environment are developed and implemented Guidance provided on food supplementation for pregnant and lactating women and young children

Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet-related risks of NCDs Develop guidelines for supplementary food assistance to vulnerable groups for improving 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. Availability, access and affordability of nutrition services is critical to achieving the Global Nutrition and diet related NCD targets. A comprehensive, evidence-based capacity development process that will integrate latest research, learning tools and technology to enhance leadership and workforce capacity are essential. Policy actions Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary health-care packages Ensure adequate financing for nutrition through separate budget line for nutritionrelated activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population-based nutrition services Policy indicators Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions. Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population Proportion of health-care facilities that offer prevention/treatment counselling and other

Promote nutrition services in clinical conditions and settings for prevention and

22

Policy actions treatment of severe acute malnutrition, obesity and other nutrition-related conditions

Health infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition

Policy indicators nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition-related conditions Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation Established management of safe water and the accessibility of sanitation facilities at community settings is supported Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized

Strategic direction 4 Empower communities, support and strengthen academia and civil society to promote healthy diets and form strategic alliances with other stakeholders. Policy action to promote empowerment through strengthening civil society organizations is key to promoting community empowerment. Support for academia to promote country-based research would ensure selection and implementation of actions based on country context. Forming strategic partnerships with the food sector is also important in promoting healthy diets to reduce the double burden of malnutrition. Policy actions Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require childcare settings, pre-schools, schools, children’s and youth sports facilities and events to create healthy food environment Engage with private sector to reduce the Policy indicators Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available Policy measures that appropriately engage

23

obesogenic environment Promote healthy diets and lifestyle at the workplace

relevant private sector, to implement actions, aimed at reducing overweight, obesity and dietary risk of NCDs are instituted Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces

24

5. References 1. 2. 3. 4. 5. 6. 7. Shrimpton R, Rokx C. The double burden of malnutrition: a review of global evidence. Health, Nutrition and Population (HNP) Discussion Paper. 2012. World Health Organization. Global status report on non communicable diseases 2014. Geneva: WHO, 2014. Barker DJP. Mothers, babies and health in later life. 2nd edn. Edinburgh: Churchill Livingstone, 1998. World Health Organization. Report of the commission on ending childhood obesity. Geneva: WHO, 2016. Darnton-Hill I, Nishida C, James WPT. A life course approach to diet, nutrition and the prevention of chronic diseases. Public Health Nutrition. 2004 Feb;7(1A):101-21. Deurenberg P, Yap M, van Staveren WA. Body mass index and percent body fat: a meta analysis among different ethnic groups. Int J Obes Relat Metab Disord. 1998 Dec;22(12):1164-71. Food and Agriculture Organization, Regional office for Asia and the Pacific. The state of food and agriculture in Asia and the Pacific region. Bangkok. http://www.fao.org/docrep/010/ai411e/AI411E02.htm - accessed 2 August 2016. 8. Lee Da Eun Rachel. Children's protein consumption in Southeast Asia: consideration of quality as well as quantity of children's protein consumption in Southeast Asia. Wharton Research Scholars Journal. Paper 115. 2014. http://repository.upenn.edu/wharton_research_scholars/115 - accessed 2 August 2016. World Health Organization. Diet, nutrition and the prevention of chronic diseases. Report of a joint WHO/FAO expert consultation. WHO Technical Report Series 916. Geneva: WHO, 2003. http://whqlibdoc.who.int/trs/who_trs_916.pdf - accessed 2 August 2016.

9.

10. Scaling up nutrition. http://scalingupnutrition.org/about/why-nutrition - accessed 2 August 2016. 11. Victora C. G., M. de Onis, P. C. Hallal, M. Blössner, R. Shrimpton. 2010. Worldwide timing of growth faltering: revisiting implications for interventions. Pediatrics. 2010 Mar;125(3):e473-80. 12. Prendergast AJ, Humphrey JH. The stunting syndrome in developing countries. Paediatr Int Child Health. 2014 Nov;34(4):250-65. 13. Horton S, Steckel RH. Malnutrition: global economic losses attributable to malnutrition 1990-2000 and projections to 2050. 2011. http://www.copenhagenconsensus.com/sites/default/files/malnutrition.pdf - accessed 2 August 2016. 14. Global status report on noncommunicable diseases. World Health Organization 2014. 15. World Health Organization. Global health estimates. 2014. http://www.who.int/healthinfo/global_burden_disease/en/ - accessed 2 August 2016. 16. ASEAN, UNICEF, WHO . Regional report on nutrition security in ASEAN. Volume 2. Bangkok; UNICEF, 2016. 17. The World Bank: http://data.worldbank.org/indicator/SP.POP.TOTL - accessed 2 August 2016. 18. United Nations. World urbanization prospects: 201 revision. New York: United Nations, 2014. http://esa.un.org/unpd/wup/Highlights/WUP2014-Highlights.pdf - accessed 2 August 2016.

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19. The World Bank. http://data.worldbank.org/indicator/SE.ADT.LITR.ZS/countries - accessed 2 August 2016. 20. United Nations Development Programme. Human development reports. New York. http://hdr.undp.org/en/content/table-2-human-development-index-trends-1980-2013 - accessed 2 August 2016. 21. Ministry of Health and Family Welfare, Bangladesh. Bangladesh demographic and health survey 2014. Dhaka, 2016. https://dhsprogram.com/pubs/pdf/FR311/FR311.pdf - accessed 2 August 2016. 22. Ministry of Health, Bhutan. 2015 National Nutrition Survey (NNS). Thimphu. 23. Ministry of Health, India. India National Family Health Survey 2015. New Delhi. 24. WHO, UNICEF, World Bank, Joint child malnutrition estimates (UNICEF-WHO-WB). 25. Compare regional trends in numbers of children affected by malnutrition (1990-2014). Geneva: WHO. http://apps.who.int/gho/data/view.wrapper.nutrition-1-3?lang=en&showonly=nutrition – accessed 3 August 2016. 26. Finucane MM, Stevens GA, Cowan MJ, Danaei G, Lin JK, Paciorek CJ, et al. National, regional, and global trends in body mass index since 1980: Systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet. 2011 Feb 12; 377(9765): 557–567. 27. United Nations, Department of Economic and Social Affairs, Population Division. World Population Ageing 2015. Highlights (ST/ESA/SER.A/368). New York, 2015. 28. World Health Organization, UNICEF. Joint statement by the World Health Organization, the World Food Programme and the United Nations Children’s Fund. Preventing and controlling micronutrient deficiencies in populations affected by an emergency. Geneva. http://www.who.int/nutrition/publications/WHO_WFP_UNICEFstatement.pdf - accessed 3 August 2016. 29. World Health Organization. Iron deficiency anaemia: assessment, prevention and control- a guide for programme managers. Geneva: WHO, 2001. 30. World Health Organization. Global prevalence of vitamin A deficiency in populations at risk 1995– 2005: WHO global database on Vitamin A Deficiency. Geneva: WHO, 2009. 31. Bleichrodt N, Born MP. A meta-analysis of research on iodine and its relationship to cognitive development. In: Stanbury JB, ed. The damaged brain of iodine deficiency. New York, Cognizant Communication, 1994. Pp. 195–200. 32. Global Iodine Nutrition Scorecard 2015. http://www.ign.org/cm_data/Scorecard_2015_August_26_new.pdf - accessed 3 August 2016. 33. World Health Organization. Nutrition Landscape Information System. Geneva: WHO. http://www.who.int/nutrition/nlis/en/ - accessed 3 August 2016. 34. World Health Organization. From burden to “Best Buys”: reducing the economic impact of non communicable diseases in low-and Middle-Income Countries. Geneva: WHO, 2011. http://www.who.int/nmh/publications/best_buys_summary.pdf - accessed 3 August 2016. 35. Powles J, Fahimi S, Micha R, Khatibzadeh S, Shi P, Ezzati M, et al. Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open. 2013 Dec 23; 3(12):e003733.

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Annexes Annex 1. Supporting global and regional resolutions/mandates and content analysis of technical areas covered. Targets Technical areas NCDs (salt/sweet/fat) Infant + Young child Children + adolescent General population (adult) Undernutrition (stunting, wasting underweight) and nutrient Micro + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Global Global Strategy on infant and young child feeding 2003 Global Strategy on Diet, Physical Activity and Health 2004 Comprehensive Implementation Plan on Maternal Infant and Young Child Nutrition (WHO, 2014) and 2025 Global Nutrition targets (WHA65.6) Rome Declaration and 2nd International Conference on Nutrition and the framework for actions 2014, adopted by the WHA in 2015 Report of the Commission on ending Childhood Obesity 2016 Global Action Plan for prevention and control of NCD’s 2013–2020 Sustainable Development Goal 2 targets at 2025, 2030 UN Decade of Action on Nutrition. 2016– 2025 Regional Regional Nutrition Strategy; Addressing malnutrition and micronutrient deficiencies 2011–2015 Action plan for the prevention and control of noncommunicable diseases in South-East Asia 2013–2020 South-East Asia Regional Strategic Framework for Improving Neonatal and Child Health and Development 2012 Strategic Action Plan to reduce the double burden of malnutrition in South- East Asia Region 2016–2025

+ + + + + + +

+

+

+

+

+

+

+

+

(+ ) +

+

+ +

+ +

+

+ + (+)

+ +

+ + + + +

+

+

+

Healthy systems + + + +

Overweight and Obesity

Breastfeeding

Maternal

27

Annex 2. Regional monitoring framework for policy, capacity and legislative indicators. These indicators will be assessed in 2016 (baseline), 2021 (mid- term) and 2025 (end term). Policy and progress Indicator definitions indicators for monitoring by WHO SEARO

1

2 3

4 5.

National nutrition policies, strategies or action plans with explicit reference to both undernutrition and overweight and obesity are available Government has a functioning a multistakeholder coordination process for nutrition Countries have identified time-bound nutrition targets based on global nutrition targets and diet related noncommunicable diseases (NCD) targets. Appropriately skilled personnel with competencies to deliver nutrition services are available Countries have conducted regular national level nutrition surveys

National nutrition policies, strategies or action plans with explicit reference to implementing actions to reduce undernutrition and overweight and obesity are available34. Yes=2, In process= 1, No=0 A multi-stakeholder coordination mechanism for nutrition is established and functional35 Yes=2 In process=1, No=0 Country has identified time-bound nutrition targets and diet-related NCD targets in public policy documents. Yes=2, In process= 1, No=0 No. of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population32 Country has conducted a Demographic and Health Survey / 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) new surveys undertaken33 Country has food-based dietary guidelines that promote healthy diets are developed and used for nutrition promotion. Yes=2, In process= 1, No=0 Country has a comprehensive legislation for effective implementation of the International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions 32 Yes=2, In process= 1, No=0 Country has legislation enacted to implement WHO’s Recommendations on Marketing of unhealthy foods and nonalcoholic beverages to children32 Yes=2, In process= 1, No=0 Country has developed and implemented a mechanism for promoting healthy diets for the informal food sector. Yes=2, In process= 1, No=0 Country has developed/implemented the following36  Meals provided in schools adhere to minimum nutrition

6

7

8

9

10 34

Country food-based dietary guidelines that promote healthy diets are developed and used for nutrition promotion Government has adopted legislation for effective national implementation and monitoring of the International Code of Marketing of Breast milk Substitutes (ICBMS) and subsequent relevant WHA resolutions Legislation or regulations enacted to implement WHO’s Recommendations on Marketing of unhealthy foods and non-alcoholic beverages to children. Country has developed and implemented a mechanism for promoting health diets in the informal food sector Countries have developed and implemented processes to promote

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. 35 HANCI: Hunger and Nutrition Commitment Index. http://www.hancindex.org/explore-the-data/understanding-theindicators/ - accessed 1 August 2016. 36 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.

28

healthy dietary environments in schools to reduce the double burden of malnutrition



standards based on national or regional dietary guidelines (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,)

Annex 3. Selected evidence-based interventions (e-Library of Evidence Based Nutrition Actions) to reduce the double burden of malnutrition. Direct Nutrition Interventions Breastfeeding Breastfeeding: continued breastfeeding Breastfeeding education for increased breastfeeding duration Breastfeeding: early initiation Breastfeeding: exclusive breastfeeding Breastfeeding: implementation of the Baby-friendly Hospital Initiative Breastfeeding: regulation of marketing breast-milk substitutes Complementary feeding Supplementary feeding in community settings for promoting child growth Deworming to combat the health and nutritional impact of helminth infections Anaemia/iron deficiency Optimal timing of cord clamping for the prevention of iron deficiency anaemia in infants 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 children in malaria-endemic areas Iron: intermittent supplementation in preschool and school-age children Deworming to combat the health and nutritional impact of helminth infections*37 Intermittent iron and folic acid supplementation in menstruating women Intermittent iron and folic acid supplementation in menstruating women in malaria-endemic areas Low birth weight Low birth weight: breastfeeding of low-birth-weight infants Low birth weight: cup-feeding for low-birth-weight infants unable to fully breastfeed Low birth weight: demand feeding for low-birth-weight infants Low birth weight: donor human milk for low-birth-weight infants Low birth weight: feeding of very-low-birth-weight infants Low birth weight: kangaroo mother care to reduce morbidity and mortality in low-birth-weight infants Low birth weight: micronutrient supplementation in low-birth-weight and very-low-birth-weight infants Low birth weight: mother’s milk for low-birth-weight infants Low birth weight: standard formula for low-birth-weight infants following hospital discharge Moderate acute malnutrition Moderate acute malnutrition: supplementary foods for the management of moderate acute malnutrition in children Severe Acute Malnutrition Severe acute malnutrition: identification of severe acute malnutrition in children 6–59 months of age Severe acute malnutrition: identification of severe acute malnutrition requiring inpatient care in children 6–59 months of age Severe acute malnutrition: management of infants under 6 months of age with severe acute malnutrition 37

Also relevant to growth

29

Severe acute malnutrition: management of severe acute malnutrition in children 6–59 months of age with oedema Severe acute malnutrition: micronutrient intake in children with severe acute malnutrition Childhood Obesity Exclusive breastfeeding to reduce the risk of childhood overweight and obesity 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 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 Vitamin D supplementation in children with respiratory infections Water, sanitation and hygiene interventions to prevent diarrhoea Zinc supplementation in the management of diarrhoea 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 Noncommunicable diseases Noncommunicable diseases: increasing fruit and vegetable consumption to reduce the risk of noncommunicable diseases Potassium: increasing intake to control blood pressure in children Sodium: reducing sodium intake to control blood pressure in children 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 Pregnancy and post-partum women Maternal nutrition; balanced energy and protein supplementation during pregnancy 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: periconceptional 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

30

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 Other guidance and recommendations selected from the Ending Childhood Obesity Commission Report Appropriate and context-specific nutrition information and guidelines for both adults and children are developed and disseminated in a simple, understandable and accessible manner to all groups in society. Implement an effective tax on sugar-sweetened beverages. Develop nutrient-profiles to identify unhealthy foods and beverages. Establish cooperation between Member States to reduce the impact of cross-border marketing of unhealthy foods and beverages. Implement interpretive front-of-pack labelling, supported by public education of both adults and children for nutrition literacy. Require settings such as schools, child-care settings, children’s sports facilities and events to create healthy food environments. Monitor and manage appropriate gestational weight gain. Provide clear guidance and support to caregivers to encourage the consumption of a wide variety of healthy foods for children. Establish standards for meals provided in schools, or foods and beverages sold in schools and other child-care settings meet healthy nutrition guidelines. Require inclusion of nutrition and health education within the core curriculum of schools . Improve the nutrition literacy and skills of parents and caregivers Develop and support appropriate multicomponent weight management services for children and adolescents who are overweight or obese as part of universal health coverage. Indirect Nutrition Interventions Supporting women's empowerment and changes to intra household food allocation. Promoting agriculture and nutrition friendly healthy food systems. In-kind household food distributions Early Child development interventions Classroom education for girls Social protection and safety nets including cash transfers: Water and sanitation initiatives: the critical importance of water, sanitation and hygiene (WASH) for nutrition status children have been demonstrated. Along with several other factors, poor hygiene and sanitation cause high levels of maternal and child undernutrition38

38

Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Ruel MT & Alderman H.the Maternal and Child Nutrition Study Group. Lancet, Volume 382, Issue 9891, 10 –16 August 2013, Pages 536–551.

31

Annex 4. Indicator definitions for Global Nutrition and diet related Noncommunicable Diseases targets. Indicator Indicator definition (assessment method) Stunting Prevalence of low height-for-age in children under five years of age Wasting Prevalence of weight-for-height <2 SD in children under five years of age Low birth weight Prevalence of infants born <2500 g Overweight Prevalence of weight-for-height >2 SD in children under five years of age Anaemia among pregnant women Prevalence of haemoglobin<11 g/dL in pregnant women Anaemia among nonpregnant women Prevalence of haemoglobin<12 g/dL in nonpregnant women Exclusively breastfed children Prevalence of exclusive breastfeeding in infants aged six months or less Salt intake Age standard mean population intake of salt (sodium Chloride) per day in grams in persons aged 18+ years Diabetes Age standard prevalence of raised blood glucose/diabetes among persons aged 18+ years or on medication for raised blood glucose Underweight women The prevalence of underweight in women of reproductive age Numerator: Number of children under five with height-for age below -2SD Denominators: Total number of children under five measured Numerator: Number of children under five with weight for height below -2SD Denominators: Total number of children under five measured Numerator: Number of LBW singleton live births to women <2500g Denominator: Total number of singleton live births to women Numerator: Number of children under five with weight for height above+2SD Denominators: Total number of children under five measured Numerator: Number of pregnant women aged 15-49 years who had haemoglobin concentration <11g/dl Denominator: Total number of pregnant women 15-49 years old Numerator: Number of non-pregnant women aged 15-49 years who had haemoglobin concentration <12g/dl Denominator: Total number of nonpregnant women 15-49 years old Numerator: Infants 0–5 months of age who received only breast milk during the previous day Denominator: Infants 0-5 months of age Numerator: Sum of sodium excretion in urine samples from all respondents aged 18+years Denominator: Number of survey respondents aged 18+ years Numerator: Number of respondents aged 18+ years with fasting plasma glucose value ≥126 mg/dl or on medication for raised blood glucose Denominator: Number of survey respondents aged 18+ years

Numerator: Number of women aged 15–49 years in the sample with BMI<18.5 kg/m² Denominator: Total number of women aged 15–49 years in the sample Numerator: Number of women aged 15–49 years in the Overweight women The prevalence of overweight in women of sample with BMI≥25 kg/m² reproductive age Denominator: Total number of women aged 15–49 years in the sample 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. World Health Organization. Noncommunicable diseases global monitoring framework: indicator definitions and specifications. Geneva: WHO, 2014. http://www.who.int/nmh/ncdtools/indicators/GMF_Indicator_Definitions_Version_NOV2014.pdf - accessed 1 August 2016.

32

Annex 5. 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 direction 1 Strategic direction 2 Strategic direction 3 Strategic 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 measure(s) Intermediate outcomes Proportion of women aged 15-49 years with low body mass index (<18.5 kg/m2) a Number of births during a given reference period to women aged 15-19 years /1000 females aged 15-19 years *a Prevalence of diarrhea in children under 5 years of age a

40% reduction in the number of children under five who are stunted The change in the number of heightfor-age < (-)2 SD in children under five years of age between 2010 and 2025

Process indicators Proportion of children aged 6-23 months receiving a minimum acceptable diet a Percentage of births in baby friendly facilities a Proportion of mothers of children 0-23 months receiving counselling, support or messages on optimal breastfeeding at least once in the last year a

Policy indicators --Strategic direction 1—

Policy actions --Strategic direction 1--

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized Country develops a national nutrition plan that includes WASH (Water, Sanitation, and Hygiene (WASH)

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs

Reduce and maintain childhood wasting to less than 5% The prevalence of weight-for-height <(-)2 SD in children under five years of age between 2010 and 2025

Policies for subsidizing local fruit and vegetable are enacted

Proportion of stunted women of reproductive age (15-49 years) a

Proportion women aged 15-49 years receiving counselling /treatment on appropriate weight gain Proportion of population using a safely managed drinking service a Proportion of

Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables Ensure that regulations and guidelines are in place for supplementation and fortification of products as suitable for the country context Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases

Micronutrient (supplementation) guidelines within the country are updated regularly Food fortification legislation for iodization of salt and other relevant identified micronutrients are developed and implemented Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity

33

Targets and its measure(s)

Intermediate outcomes

Process indicators population using a safely managed sanitation service a Proportion of children with severe acute malnutrition having access to appropriate treatment including therapeutic foods and nutrition counselling a Proportion of children aged 12-59 months receiving at least one dose of deworming medication a Percentage of pregnant women aged 15-49 years receiving 1+ ANC visit (including nutrition counselling) b Percentage of pregnant women aged 15-49 years receiving 4+ ANC visit (including nutrition counselling) b Proportion of children under five years old with diarrhea (in last two weeks) receiving oral dehydration salts (ORS packets or pre-packaged ORS fluids) a

Policy indicators Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions are legislated and implemented Maternity protection measures 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 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 School guidelines and standards ensuring a healthy food environment are developed and implemented

Policy actions Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Promote protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms

Guidance provided on food supplementation for pregnant and lactating women and young children Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available

Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary health-care packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions

Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track

34

Targets and its measure(s)

Intermediate outcomes

Process indicators and utilized

Policy indicators

Policy actions data on double burden of malnutrition Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require child-care settings, preschools, schools, children’s and youth sports facilities and events to create healthy food environments Policy actions --Strategic direction 1--

Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available

Targets and its measure(s)

50% reduction of anaemia in women of reproductive age The change of number of haemoglobin<11 g/dL in pregnant women aged 1549 years between (period of 1993-2005) and 2025 The change of number of haemoglobin<12 g/dL in nonpregnant women aged 15-49 years between (period of 1993-2005) and 2025

Intermediate outcomes Proportion of women aged 15-49 years with low body mass index (<18.5 kg/m2) a Number of births during a given reference period to women aged 15-19 years /1000 females aged 15-19 years a

Process indicators Proportion of pregnant women aged 15-49 years receiving weekly iron-folic acid supplementation a Proportion of nonpregnant women aged 15-49 years receiving weekly ironfolic acid supplementation a Proportion women aged 15-49 years receiving counselling/treatment on appropriate weight gain Proportion of population using a safely managed drinking service a Proportion of population using a safely managed sanitation service a Percentage of pregnant women aged 15-49 years receiving 1+ ANC visit (including nutrition

Policy indicators --Strategic direction 1--

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs

Country develops a national nutrition plan that includes WASH (Water, Sanitation, and Hygiene (WASH)

Policies for subsidizing local fruit and vegetable are enacted

Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables

35

counselling) b Percentage of pregnant women aged 15-49 years receiving 4+ ANC visit (including nutrition counselling) b

Micronutrient (supplementation) guidelines within the country are updated regularly Food fortification legislation for iodization of salt and other relevant identified micronutrients are developed and implemented Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated School guidelines and standards ensuring a healthy food environment are developed and implemented Guidance provided on food supplementation for pregnant and lactating women and young children Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation Efficient and effective nutrition surveillance actions suitable for tracking the double burden of

Ensure that regulations and guidelines are in place for supplementation and fortification of products as suitable for the country context

Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary healthcare packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions

Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and

36

malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skillsbased nutrition education in schools is available Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces Targets and its measure(s) Intermediate outcomes Proportion of women aged 15-49 years with low body mass index (<18.5 kg/m2) a Process indicators Proportion of pregnant women aged 15-49 years receiving weekly iron and folic acid supplements a Percentage of births in baby friendly facilities a Proportion women aged 15-49 years receiving counselling/treatment on appropriate weight gain Percentage of pregnant women aged 15-49 years receiving 1+ ANC visit (including nutrition counselling) b Percentage of pregnant women aged 15-49 years receiving 4+ ANC visit (including nutrition Policy indicators --Strategic direction 1--

identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition Recognize the importance of professional and civil society organizations to promote and support healthy diets

Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition

Require child-care settings, preschools, schools, children’s and youth sports facilities and events to create healthy food environments Promote healthy diets and lifestyle at the workplaces

Policy actions --Strategic direction 1--

30% reduction in low birth weight The change of number of infants born <2500 g between (period of 2006-2010) and 2025

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs

Policies for subsidizing local fruit and vegetable are enacted

Micronutrient (supplementation) guidelines within the country are updated regularly Food fortification legislation for iodization of salt and other relevant identified micronutrients are developed and implemented Healthy and safe food guidelines

Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables Ensure that regulations and guidelines are in place for supplementation and fortification of products as suitable for the country context

Promote healthy and safe foods for

37

counselling) b

are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated Maternity protection measures enacted and aligned with ILO Convention 183 School guidelines and standards ensuring a healthy food environment are developed and implemented Guidance provided on food supplementation for pregnant and lactating women and young children Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Established management of safe water and the accessibility of sanitation facilities at community settings is supported Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil

informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Promote protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary health-care packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions

Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition Recognize the importance of

38

society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available Targets and its measure(s) Intermediate outcomes Proportion of overweight and obese women 1849 years of age (body mass index ≥25 kg/m2) a Proportion of overweight in schoolage children and adolescents 5-18 years (BMI-for-age >+1 SD) a Process indicators Proportion of children 6-23 months of age receiving a minimum acceptable diet a Percentage of births in baby friendly facilities a Proportion of mothers of children 0-23 months receiving counselling, support or messages on optimal breastfeeding at least once in the last year a Proportion women who received counselling/treatment of appropriate body weight Proportion of schoolage children and adolescents 5-18 years receiving counselling/treatment on appropriate weight gain Proportion of children and adolescent diagnosed as overweight or obese who received appropriate weight management service d Policy indicators --Strategic direction 1--

professional and civil society organizations to promote and support healthy diets

Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require child-care settings, pre-schools, schools, children’s and youth sports facilities and events to create healthy food environments Policy actions --Strategic direction 1--

No increase in childhood overweight The change of prevalence of weight-forheight >2 SD in children under five years of age between 2010 and 2025

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs

Strategies and roadmap developed for population reduction of salt, sugar, and fat intake Fiscal-policies are developed and enacted for food products that high in sugar , fat, and salt Policies for subsidizing local fruit and vegetable are enacted Legislation enacted and implemented to ensure mandatory labelling of food products for both front of pack and back of pack nutrient labelling A watchdog mechanism established in country to ensure that health and nutrition claims are based on codex guidelines and adequate scientific evidence Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables Enact legislation and its implementation on appropriate nutritional information for processed, pre-packaged food products

Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the

39

Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions are legislated and implemented Maternity protection measures 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 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 to implement WHO’s Recommendations on Marketing of unhealthy foods and beverages to children School guidelines and standards ensuring a healthy food environment are developed and implemented Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation

management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Promote protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms

Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary health-care packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions

Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established

Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of

40

malnutrition Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition

Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require child-care settings, pre-schools, schools, children’s and youth sports facilities and events to create healthy food environments Engage with private sector to reduce the obesogenic environment Promote healthy diets and lifestyle at the workplaces

Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available Policy measures that appropriately engage relevant private sector, to implement actions, aimed at reducing overweight, obesity and dietary risk of NCDs are instituted Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces Targets and its measure(s) Intermediate outcomes Proportion of children born in the last 24 months who were put to the breast within one hour of birth a

Process indicators Percentage of births in baby friendly facilities a Proportion of mothers of children 0-23 months receiving counselling, support or messages on optimal breastfeeding at least once in the last year a

Policy indicators --Strategic direction 1--

Policy actions --Strategic direction 1--

Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50% The prevalence of infants aged 0-5 months received only breast milk during the previous day between (period of 2006-2010) and 2025

Number of births during a given reference period to women aged 15-19 years/1000 females aged 15-19 years a

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCD’s

Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated

Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies

41

International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions are legislated and implemented Maternity protection measures 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 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 food supplementation for pregnant and lactating women and young children Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100 000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutritionpromoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces

Promote protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms

Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary healthcare packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Promote healthy diets and lifestyle at the workplaces

42

Targets and its measure(s)

Intermediate outcomes

A 30% relative reduction in mean population intake of salt/sodium The change of agestandardized mean population intake of salt (sodium Chloride) per day in grams in persons aged 18+ years between 2010 and 2025

Process indicators Agestandardized mean population intake of salt (sodium Chloride) per day in grams in persons aged 18+ years c Percentage of households that have adequately iodized salt (>15 ppm) a

Policy indicators --Strategic direction 1--

Policy actions --Strategic direction 1--

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs

Strategies and roadmap developed for population reduction of salt, sugar, and fat intake Fiscal-policies are developed and enacted for food products that high in sugar , fat, and salt Policies for subsidizing local fruit and vegetable are enacted Micronutrient (supplementation) guidelines within the country are updated regularly Food fortification legislation for iodization of salt and other relevant identified micronutrients are developed and implemented Legislation enacted and implemented to ensure mandatory labelling of food products for both front of pack and back of pack nutrient labelling A watchdog mechanism established in country to ensure that health and nutrition claims are based on codex guidelines and adequate scientific evidence Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated Legislation enacted to implement WHO’s Recommendations on Marketing of unhealthy foods and beverages to children School guidelines and standards ensuring a healthy food environment are developed and Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables Ensure that regulations and guidelines are in place for supplementation and fortification of products as suitable for the country context Enact legislation and its implementation on appropriate nutritional information for processed, pre-packaged food products

Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and overweight and obesity and diet related risks of NCDs

43

implemented Guidance provided on food supplementation for pregnant and lactating women and young children Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutritionpromoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available Policy measures that appropriately engage relevant private sector, to implement actions, aimed at reducing overweight, obesity and dietary risk of NCDs are instituted Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces

Develop guidelines for supplementary food assistance to vulnerable groups for improving health and nutritional status Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require child-care settings, preschools, schools, children’s and youth sports facilities and events to create healthy food environments Engage with private sector to reduce the obesogenic environment Promote healthy diets and lifestyle at the workplaces

44

Targets and its measure(s)

Halt the rise in diabetes and obesity The change of agestandardized prevalence of raised blood glucose/diabetes among persons aged 18+ years(defined as fasting plasma glucose concentration ≥ 7.0 mmol/l (126 mg/dl) or on medication for raised blood glucose) between 2010 and 2025 The change of prevalence of overweight and obesity in adolescents (defined according to the WHO growth reference for school-aged children and adolescents, overweight – BMI for age and sex >1 SD, and obese – BMI for age and sex >2 SD) between 2010 and 2025 The change of agestandardized prevalence of overweight and obesity in persons aged 18+ years (defined as body mass index ≥ 25 kg/m2 for overweight and body mass index ≥ 30 kg/m² for obesity) between 2010 and 2025

Intermediate outcomes Agestandardized prevalence of raised total cholesterol among persons aged 18+ years (defined as total cholesterol ≥5.0 mmol/l or 190 mg/dl); and mean total cholesterol concentration c

Process indicators Age-standardized prevalence of persons (aged 18+ years) consuming less than five total servings (400 grams) of fruit and vegetables per day c Age-standardized mean proportion of total energy intake from saturated fatty acids in persons aged 18+ years c Age-standardized mean proportion of persons aged 18+ years receiving counselling/treatment on appropriate weight gain Proportion of adolescents receiving counselling/treatment on appropriate weight gain Proportion of children and adolescent diagnosed as overweight or obese who received appropriate weight management service d

Policy indicators --Strategic direction 1--

Policy actions --Strategic direction 1--

Country food based dietary guidelines which promote nutritious diets with emphasis on diversified diet, high in fiber, and low in fat, sugar and salt are developed and utilized Strategies and roadmap developed for population reduction of salt, sugar, and fat intake Fiscal-policies are developed and enacted for food products that high in sugar , fat, and salt Policies for subsidizing local fruit and vegetable are enacted Legislation enacted and implemented to ensure mandatory labelling of food products for both front of pack and back of pack nutrient labelling A watchdog mechanism established in country to ensure that health and nutrition claims are based on codex guidelines and adequate scientific evidence Healthy and safe food guidelines are developed for informal food sector , disseminated and their utilization monitored National guidelines developed and in use for relevant diseases/conditions including obesity

Ensure availability and operationalization of legislature and guidelines to promote healthy diets to reduce the double burden of malnutrition and minimize diet related risk of NCDs Promote fiscal policies to reduce unhealthy diets and enhance accessibility of healthy foods such as targeted subsidies for fruit and vegetables Enact legislation and its implementation on appropriate nutritional information for processed, pre-packaged food products

Nutrition Guidelines for disaster preparedness or emergencies are developed and disseminated International Code of Marketing of Breast milk Substitutes (the Code) and subsequent relevant WHA resolutions are legislated and implemented Maternity protection measures 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 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 to implement WHO’s Recommendations on Marketing of unhealthy foods and beverages to children School guidelines and standards ensuring

Promote healthy and safe foods for informal sector to enabling the healthy diets environment Review, develop and disseminate national guidelines on prevention and treatment of nutritional care in the management of common diseases Review, develop and disseminate guidelines for disaster preparedness, response and management of nutrition emergencies Promote protect and support breastfeeding and complementary feeding practices through comprehensive legislation and monitoring mechanisms

Enact legislation/regulation and mechanisms to promote healthy foods for children to reduce undernutrition and

45

a healthy food environment are developed and implemented Country Health systems have defined an essential package of nutrition interventions reflecting the double burden of malnutrition Adequate resources earmarked and available for implementation of nutrition interventions Existing curricula/programmes for health and nutrition workers are evaluated and revised to include the double burden of malnutrition Number of appropriately skilled personnel with competencies to deliver nutrition services /public health nutritionists/100,000 population Proportion of health-care facilities that offer prevention/treatment counselling and other nutrition services for undernutrition and overweight and obesity Defined, systematic bidirectional pathway developed and implemented for referral between primary care and referral of nutrition related conditions Food laboratories are upgraded to ensure food safety and support implementation of healthy diet legislation

overweight and obesity and diet related risks of NCDs Ensure health systems incorporate Maternal and Child Health and Nutrition in essential primary health-care packages Ensure adequate financing for nutrition through separate budget line for nutrition related activities Ensure qualified personnel with skills and competencies to develop, deliver and evaluate population based nutrition services

Promote nutrition services in clinical conditions and settings for prevention and treatment of severe acute malnutrition, obesity, and other nutrition related conditions Health Infrastructure established or upgraded to facilitate the implementation of policy and legal directions to ensure food safety and promote healthy diets Initiate actions to develop and operationalize comprehensive nutrition surveillance systems and identify relevant indicators to inform, monitor and evaluate policies and programmes to track data on double burden of malnutrition Recognize the importance of professional and civil society organizations to promote and support healthy diets Engage academia institutions to address knowledge and evidence gaps in promoting and creating healthy eating and physical active environments to reduce double burden of malnutrition Create a demand for healthy lifestyles (diversified diets and physical activity) in communities to reduce all forms of malnutrition Require child-care settings, pre-schools, schools, children’s and youth sports

Efficient and effective nutrition surveillance actions suitable for tracking the double burden of malnutrition established Disaggregated data on nutritional status (reflecting the double burden) available and utilized

Relevant professional and civil society organizations have formed networks and action groups to promote healthy diets and physical activity as well as support nutrition-promoting programmes and education campaigns Academia engaged in locally relevant nutrition research, monitoring, evaluation and surveillance to reduce the double burden of malnutrition

Community advocacy plan developed and implemented to promote healthy, diversified diets Strategies and actions of mass social marketing campaigns are available and executed Teacher training and guidance to support participative, skills-based nutrition education in schools is available

46

Policy measures that appropriately engage relevant private sector, to implement actions, aimed at reducing overweight, obesity and dietary risk of NCDs are instituted Healthy diets and lifestyle legislation and guidance are developed and implemented in workplaces

facilities and events to create healthy food environments Engage with private sector to reduce the obesogenic environment Promote healthy diets and lifestyle at the workplaces

47

Annex 6. Example of cross-sectoral Government engagement and potential multisectoral action. Sector Health Nutrition Areas Food security Food safety Food safety and hygiene regulations Food inspections Food standards

Healthy lifestyle Promoting healthy diets Promotion of exercise Infection control Family Planning

Nutrition Micronutrient supplementation Management of SAM Dietary guidelines Baby friendly hospitals Breast and complementary feeding promotion

Public works/Urban development

Rural roads Irrigation

Water and sanitation improvement

Urban bike lanes Pedestrian walk ways Road safety Smoke free environment Bio-fortification to improve nutrition density Nutrition oriented agriculture research Nutrient promoting farming systems, agronomic practices and crops Nutrition education Anaemia control

Agriculture

Food and agriculture policies to promote availability, affordability and quality Sustainable intensification of production Promotion of home gardens

Regulation to improve food safety in processing, transport and storage

Education

Promotion of gardens School meals

school

Food safety and hygiene education

Physical exercise Life skills and sex education Gender equality

Industry/trade/commerce

Food availability (manufacturing marketing)

Food standards and

Food regulations

safety

Product formulation to reduce saturated and trans fats, sodium and sugar content Food fortification Nutrition labelling Code of breast milk substitutes Nutrition information campaigns Nutrition labelling Food taxes

Public information

Marketing of foods to children

Finance and economy

Food subsidies

Source: Adapted from Shrimpton and Rokx, 2012 (1).

48