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Strategy on nutrition for the Eastern Mediterranean Region 2020–2030

7 décembre 2019 Organisation mondiale de la santé

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Strategy on nutrition for the Eastern Mediterranean Region

2020–2030

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WHO Library Cataloguing in Publication Data

Names: World Health Organization. Regional Office for the Eastern Mediterranean Title: Strategy on nutrition for the Eastern Mediterranean Region 2020–2030 / World Health Organization. Regional Office for the Eastern Mediterranean Description: Cairo: World Health Organization. Regional Office for the Eastern Mediterranean, 2019 Identifier: ISBN: 978-92-9274-467-0 (pbk.) | ISBN: 978-92-9274-468-7 (online) Subjects: Nutrition Policy | Strategic Planning | Nutritional Status | Healthy Diet | Regional Health Planning | Eastern Mediterranean Region Classification: NLM QU 145.7

This publication was originally published under ISBN: 978-92-9022-299-6, 978-92-9022-298-9

Contents

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

1. Introduction ................................................................................................................. 8

2. The nutrition situation in the Eastern Mediterranean Region .......................... 9 2.1 Regional context ................................................................................................. 9 2.2 Regional nutrition situation ............................................................................ 10 2.3 Developments in the nutrition landscape .................................................... 18

3. Vision and objectives of the nutrition strategy for the Eastern Mediterranean Region, 2020–2030..................................................................................................... 22

4. Underlying principles and strategic approaches ................................................ 24

5. Six key areas for action ............................................................................................ 27 5.1 Sustainable, resilient food systems for healthy diets .................................. 27 5.2 Aligned health systems providing universal coverage of key

nutrition actions ............................................................................................... 30 5.3 Social protection and nutrition education .................................................... 32 5.4 Trade and investment for improved nutrition ............................................ 33 5.5 Safe and supportive environment for nutrition at all ages ........................ 34 5.6 Strengthened governance and accountability for nutrition ....................... 36

6. Monitoring and evaluation framework ................................................................ 38

7. Conclusions ................................................................................................................ 41

References ......................................................................................................................... 43

Annexes 1. Levels of economic development and health challenges in countries of

the Region ................................................................................................................... 47 2. The six key areas for action: ICN2 Framework for Action

recommendations and relevant information resources ...................................... 49 3. List of suggested indicators for actions in the six key areas for action .......... 63

Executive summary

Malnutrition in all its forms takes a heavy toll on the health, well-being and sustainable development of populations in WHO’s Eastern Mediterranean Region. Some countries, especially those affected by conflict, continue to experience high levels of food insecurity, undernutrition and micronutrient deficiencies. The growth of an estimated 20.2 million children under-5 years of age has been stunted by poor nutrition. At the same time, 53% of women, 45% of men and 8% of school-age children or adolescents are obese. Noncommunicable diseases (NCDs) are now responsible for two thirds of deaths in the Region, and unhealthy diets – along with physical inactivity – are key contributors to this burden.

Throughout this decade the Regional strategy on nutrition 2010‒2019 and plan of action has been in place to support Member States strengthen or establish action on nutrition. Since the current strategy was adopted in October 2010,1 there have been significant changes in the nutrition landscape. Many countries in the Region have continued to move through the nutrition and epidemiological transition and the burden of diet-related NCDs has increased, while other countries have seen increases in undernutrition associated with conflict and political instability. Over the same period, there has also been a series of landmark global and regional commitments to tackle malnutrition in all its forms. New global targets on maternal, infant and young child nutrition, as well as global targets on NCDs, have been agreed and integrated into the 2030 Agenda for Sustainable Development. To accelerate progress towards these global targets the United Nations declared a Decade of Action on Nutrition between 2016 and 2025, centred around six key areas for action.

Despite these welcome commitments at the global, regional and national levels, countries are still struggling to implement strategies, policies and regulatory measures to address malnutrition. Much work remains to be done to meet the nutrition and NCD targets. There is now greater recognition that current food systems are failing to deliver nutrition for all and that radical transformation of food systems is needed to improve access to healthy, sustainable diets. Meanwhile, there is a growing body of evidence on the effectiveness, cost‒effectiveness and feasibility of policy interventions to improve nutrition, and there is an urgent need to translate this knowledge into action and to disseminate lessons from implementation on the ground. More than ever, there is a need for comprehensive, multisectoral action to address malnutrition in all its forms across the Region.

1 Resolution EM/RC57/R.4 (http://applications.emro.who.int/docs/EM_RC57_r4_en.pdf?ua=1, accessed 18 September 2019.

http://applications.emro.who.int/docs/EM_RC57_r4_en.pdf?ua=1

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

Given this challenging context, there continues to be strong demand from Member States for WHO technical support to develop strategies and support implementation of policies to improve nutrition. This comprehensive nutrition strategy has been developed to establish a framework for efforts to reach agreed targets on nutrition, diet-related NCDs and sustainable development, as well as to guide implementation of the remainder of the United Nations Decade of Action on Nutrition in the Region.

The vision, overall objective and specific objectives of the nutrition strategy are outlined below.

Vision: Countries in the Eastern Mediterranean Region have strengthened action on nutrition to achieve food security, end all forms of malnutrition and improve nutrition throughout the life course by 2030.

Overall objective: To support Member States strengthen efforts to ensure universal access to healthy and sustainable diets and implement effective nutrition actions, in order to:

• improve nutrition throughout life course, including for mothers, infants, children, adolescents and older people;

• prevent undernutrition, overweight, obesity and diet-related NCDs; and • support and protect nutrition in emergency situations.

Specific objectives:

1. To support countries to operationalize a current national nutrition strategy and plan of action in order to achieve global and regional targets2 and, by 2030, to:

• reduce the number of children under 5 who are stunted by 50%; • reduce and maintain childhood wasting to less than 3%; • reduce the prevalence of overweight in children under 5 to not more than 3%; • reduce low birth weight by 30%; • reduce anaemia in women of reproductive age by 50%; • improve rates of early initiation of breastfeeding and continued breastfeeding

and, specifically, increase the rate of exclusive breastfeeding in the first 6 months up to at least 70%;

• halt the rise in diabetes and obesity in adults; • halt the rise in overweight in school-age children and adolescents 5‒18 years

old; • reduce mean population intake of salt/sodium by 30%;3 • virtually eliminate industrially-produced trans fats from the food supply.

2 See Section 6 on monitoring and evaluation for information on indicators and interim targets. 3 Countries concerned about iodine deficiency should fully implement universal salt iodization and, if necessary, increase iodine levels as salt intakes are decreased.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

2. To provide a framework for countries to accelerate efforts to improve nutrition and food security through the six key action areas of the United Nations Decade of Action on Nutrition:

• Sustainable, resilient food systems for healthy diets • Aligned health systems providing universal coverage of essential nutrition

actions4 • Social protection and nutrition education • Trade and investment for improved nutrition • Safe and supportive environments for nutrition at all ages • Strengthened governance and accountability for nutrition.

Section 1 of this document sets out the background to the development of this strategy. Section 2 summarizes the health and nutrition situation in the Eastern Mediterranean Region, provides a brief summary of dietary changes and implementation of nutrition action across the Region and outlines recent global and regional developments in the nutrition landscape. Section 3 outlines the vision, objectives, goals and targets of the new strategy. Some important principles and key approaches to underpin the strategy are set out in Section 4. Six key areas for action are set out in Section 5, and a framework for monitoring and evaluation is proposed in Section 6. Section 7 presents conclusions.

4 The overall targets on reduction of stunting and wasting are also relevant to this key area for action.

1. Introduction

Malnutrition in all its forms takes a heavy toll on the health, well-being and sustainable development of populations in WHO’s Eastern Mediterranean Region. Some countries, especially those affected by conflict, continue to experience high levels of food insecurity, undernutrition and micronutrient deficiencies. The growth of an estimated 20.2 million children under-5 years of age has been stunted by poor nutrition. At the same time, 53% of women, more than 45% of men and 8% of school- age children or adolescents are obese. Noncommunicable diseases (NCDs) are now responsible for two thirds of deaths in the Region, and unhealthy diets – along with physical inactivity – are key contributors to this burden.

The Regional strategy on nutrition 2010‒2019 and plan of action has supported Member States to strengthen or establish action on nutrition. Many countries in the Region have continued to move through the nutrition and epidemiological transition and the burden of diet-related NCDs has increased, while other countries have seen increases in undernutrition associated with conflict and political instability. Recent years have also seen a series of landmark global and regional commitments to achieve food security and eliminate malnutrition in all its forms, generating unprecedented momentum to improve nutrition, including declaration of a United Nations Decade of Action on Nutrition between 2016 and 2025.

Countries are still struggling, however, to implement strategies, policies and regulatory measures to address malnutrition in all its forms, and much more progress is needed to meet globally agreed targets. It is clear that current food systems are failing to deliver nutrition for all and that radical transformation of food systems is needed to improve access to healthy, sustainable diets.

Meanwhile, there is a growing body of evidence for effective interventions to improve nutrition. More than ever, there is a need to translate this knowledge into comprehensive, multisectoral action to address malnutrition in all its forms across the Region.

Given this challenging context, there continues to be strong demand from Member States of the Region for WHO technical support to develop strategies and support implementation of policies to improve nutrition. This new regional nutrition strategy for 2020–2030 proposes a framework for such efforts to reach the agreed targets on nutrition, diet-related NCDs and sustainable development in the Region.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

2. The nutrition situation in the Eastern Mediterranean Region

2.1 Regional context

WHO’s Eastern Mediterranean Region spans from Pakistan in the east to Morocco in the west, hosting a population of nearly 679 million people in 22 countries characterized by diverse socioeconomic status and health challenges (See Annex 1). Countries vary greatly in terms of income – from among the world’s highest to lowest – as well as in terms of access to technology, water, sanitation and electricity. There are also huge disparities within countries, which are reflected in health inequalities.

Crises affect nearly two thirds of countries in the Region, with more than 76 million people directly or indirectly affected by conflict, environmental threats and natural disasters. The Region is home to more than 30 million displaced persons and more than 62 million people need health care as a result of emergencies, mainly due to political conflict. These crises have severe consequences for the well-being of populations and economies, health systems and infrastructure. In some countries, emergencies have reversed health gains of recent decades. Food insecurity has greatly increased in countries affected by conflict, and in Yemen, the conflict has led to the world’s largest food crisis.

Diversity across the Region is, in fact, one the biggest challenges to improving the health and nutritional status of its populations.

Poverty, conflict, unhealthy lifestyles and environmental degradation have undermined efforts to reduce and prevent disease, disability and death in the Region. Despite some health gains, progress towards achievement of the Sustainable Development Goals (SDGs) and their related health targets has been uneven and is not on track in some countries. The Region has the highest neonatal mortality rate and the second highest maternal mortality ratio (166 maternal deaths per 100 000 live births) and under-5 mortality rate globally (52 per 1000 live births, of which half are neonatal). There are huge differences between and within countries – more than 90% of neonatal and under-5 deaths occur in only nine countries of the Region, and mostly in remote and rural areas.

The Region continues to experience outbreaks of emerging and re-emerging infectious diseases, which have a significant impact on health and economic development. In addition, NCDs are now responsible for 62% of deaths, causing more than 2.2 million deaths in the Region every year. That figure is projected to increase to more than 3.8 million by 2030 and countries are not on course to reach SDG target 3.4 to reduce by one third premature mortality from NCDs by 2030 (1).

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

2.2 Regional nutrition situation

The diversity within the Region is also reflected in the nutritional status of its people. The Region suffers from a double burden of malnutrition, with growing food insecurity and high prevalence of undernutrition at the same time as high, and increasing, rates of overweight, obesity and diet-related NCDs. The Region has been experiencing a nutrition transition ‒ a shift towards unhealthy diets and sedentary lifestyles. Table 1 provides information on the stage of transition in countries of the Eastern Mediterranean Region.

2.2.1 Maternal, infant, young child and adolescent nutrition

Despite some progress, poor maternal, infant, young child and adolescent nutrition continues to threaten the health and development of women, adolescents and children in the Region. There remains much scope to improve the nutritional status of these groups in order to reduce disease and prevent premature death, and maximize the development potential of children and the societies in which they live.

Undernutrition was an underlying cause in 45% of deaths of children under-5 years of age in 2015, and nearly one in five (19.3%) babies born in the Region are low birth weight. There is great variation between countries, with the rate increasing to over 30% in Pakistan and Sudan and 45% in Yemen.

In addition, there are still large numbers of children who are too short for their age (stunted) because they are chronically undernourished or who are too thin (wasted) because of acute undernutrition. The prevalence of stunting has declined since 2010 but continues to be high in the Region. In 2018, the growth of 20.2 million children, nearly one in four (24.7%), was stunted. The average rate of stunting in high-income countries was 10%, 23% in middle-income countries and 46% in low-income countries (2). This affects the development of these children and their capacity to contribute to society. Across the Region, 6.4 million children (7.8%) were too thin for their height (moderately or severely wasted) and, of these, 2.7 million were severely wasted (2).

Table 1. Stages of nutrition transition in countries of the Region

Stage of transition Countries Countries in advanced nutrition transition: High levels of overweight and obesity and moderate levels of undernutrition and micronutrient deficiencies in some population subgroups

Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates,

Countries in early nutrition transition: Characterized by moderate levels of overweight and obesity, moderate levels of undernutrition in specific population and age groups, and widespread micronutrient deficiencies

Egypt, Islamic Republic of Iran, Jordan, Lebanon, Morocco, Palestine, Tunisia

Countries with significant undernutrition, including countries in complex emergency situations: Particularly high levels of acute and chronic child malnutrition, widespread micronutrient deficiencies and emerging overweight, obesity and diet-related NCDs in certain socioeconomic subgroups

Afghanistan, Djibouti, Iraq, Libya, Pakistan, Palestine (Gaza Strip), Somalia, Sudan, Syrian Arab Republic, Yemen

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

Meanwhile, 4.7 million children (5.7%) were overweight in 2018, with serious implications for their health and well-being throughout the life course. The prevalence of child overweight in the lower-middle income countries of the Region is twice as high as in other lower-middle income countries in the world (3).

Furthermore, during 2011–2016, only 29% of babies in the Region were exclusively breastfed, with rates only reaching over 50% (the agreed global target) in Afghanistan and Palestine (Fig. 1).

Many children also continue to face the “hidden hunger” of vitamin or mineral deficiencies. Although high-quality, comparable data are scarce, available national data suggest that between 7.4% and 88% of children under 5 and between 7.4% and 40.9% of school-aged children have anaemia (4). Prevalence of vitamin A deficiency among children under 5 is estimated to affect 22% of children in the Region (5) and ranges from 0.5% to 72.9% according to national survey data (6).

Micronutrient malnutrition in adults also continues to be a challenge, particularly among women of reproductive age, where it contributes to poor health outcomes for women and to the inter-generational cycle of malnutrition. Maternal short stature and iron deficiency anaemia contributed to 20% of maternal deaths. Anaemia among women of reproductive age (15‒49 years) ranged from 20.0% to 50.4% (surveys between 2011 and 2015) in countries of the Region, but many countries have no data on anaemia prevalence (5).

Fig. 1. Exclusive breastfeeding in the Region

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

Adolescents make up about a fifth of the Region’s population, and adolescence is an important phase when young people adopt many lifelong behaviours which may affect their risk of disease in adulthood. Poor nutritional status of adolescent girls has particularly important consequences for those who become pregnant during their teenage years – posing severe risks to the health of the young woman and her child. Iron deficiency anaemia is one of the leading causes of adolescent disability-adjusted life years in low- and middle-income countries of the Region.

Previously, deficiencies of iodine, folic acid, vitamin D and zinc have also been identified as a problem in the Region – particularly among vulnerable groups – but there is a lack of reliable, current data. There has been progress in addressing iodine deficiency across the Region – with more countries declared free of iodine deficiency disorders and many countries achieving universal salt iodization.

2.2.2 Overweight, obesity and diet-related NCDs

While the Region continues to suffer from high rates of undernutrition, the burden of overweight, obesity and diet-related chronic diseases continues to increase due to the nutrition transition towards unhealthy diets and sedentary lifestyles, especially in high-income and middle-income countries.

The age standardized prevalence rate of overweight (including obesity) among adults has been estimated at 49%, with a higher prevalence among women (52.6%) compared to men (45.4%). The average estimate for prevalence of obesity in the Region is 20.8%, with higher prevalence among women (26.0%) than men (15.7%). In some countries, more than 60% of the adult population of the Region is either overweight or obese5. The evolution of overweight and obesity is closely linked to physical inactivity and unhealthy diet, with the Region having a high prevalence of physical inactivity in adults (35%) in 2016, the second highest regional prevalence rate in the world (5).

NCDs cause 62% of deaths in the Region, with NCD-related deaths predicted to increase by 25% in the next decade compared to the projected global increase of 17%. Unhealthy diet – along with tobacco use and physical inactivity – is a leading risk factor in these NCD-related deaths. The Region has seen the greatest increase in the prevalence of diabetes and has the highest prevalence rate globally, with 14% of the population affected. More than two in five deaths (45%) are attributed to cardiovascular diseases, and these rates are also among the highest in the world.

2.2.3 Nutrition in emergencies

Food security and access to adequate nutrition in the Region is being seriously undermined in countries affected by emergencies and ongoing conflict.

5 Global Health Observatory Repository (http://apps.who.int/gho/data/view.main.GLOBAL2461A?lang=en, accessed 18 September 2019).

http://apps.who.int/gho/data/view.main.GLOBAL2461A?lang=en

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

In 2014‒2016, around 10% of the population in the Food and Agriculture Organization of the United Nations (FAO)’s Near East and North Africa Region6 were undernourished and 12% of the population were affected by severe food insecurity (3). The gap in food security and malnutrition between countries affected by conflict and other countries in the Region has been growing – the level of undernourishment in countries affected by conflict, at 27.2%, is now six times higher than the level in non-conflict countries (4.6%) (3). Prevalence of food insecurity is also almost double in countries affected by conflict (19.0% compared to 9.8%).

Conflict, unrest and population displacement is increasing the prevalence of malnutrition. While 7.5 million children (9.1%) across the Region are wasted, the prevalence was highest in Djibouti, Sudan, Yemen and Somalia and has been increasing in Iraq, Libya, Egypt and Sudan (4). The prevalence of underweight was highest in Afghanistan and Yemen and has been increasing in Djibouti, Sudan, Iraq, Libya and the Syrian Arab Republic (4). The highest rates of stunting were recorded in Yemen, Pakistan, Afghanistan, Sudan and Djibouti, ranging from between 29.7% and 46.5% (4). The lack of access to diverse healthy diets in crisis situations also gives serious cause for concern, as does the impact of emergencies on breastfeeding and infant and young child feeding.

2.2.4 Dietary trends and the food environment

Across the Region, a nutrition transition from traditional diets towards diets that are higher in saturated or trans fats, salt and added sugars – coupled with increased physical inactivity – has been driving the double burden of malnutrition.

In most countries of the Region, there has been a gradual increase in the calories available in the last few decades, according to FAO food availability data, along with an increase in the supply of fat and in the proportion of calories derived from fat (4). In several countries of the Region – such as the Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, the Syrian Arab Republic and Saudi Arabia – the fat supply almost doubled in the four decades to 2011 (4). Intakes of saturated fat (as a percentage of total calories) is above 10% in many countries and above the regional recommendation of 7% in nearly all countries for which there are data (Fig. 2).

Intakes of trans fats are also above 1% of energy in nearly all countries for which data exist, and contribute to more than 5% of energy in Egypt and Pakistan (Fig. 3). The availability of sugar, in grams per capita per day, is higher that the WHO recommended average intake of 25 g for women and 35 g for men) in all countries for which data are available, except Afghanistan (7) (Fig. 4). Children in many countries of the Region tend to consume food and drink products that are high in sugar and nutrient-poor. Half of adolescents drink, on average, at least one soft drink per day, and this is considerably higher in some countries.7

6 These figures relate to the Near East and North Africa Region of FAO, which does not correspond exactly to WHO’s Eastern

Mediterranean Region. 7 Global school-based Student Health Survey data, 2011.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

Estimates of sodium intake, based on 24-hour urinary sodium excretions studies carried out in six countries8 of the Region between 2009 and 2014, suggest that sodium intakes are above the WHO recommended intake of 2 g per day (equivalent to 5 g of salt) in both men and women in all cases.9

Source: Micha, R., et al., Global, regional, and national consumption levels of dietary fats and oils in 1990 and 2010: a systematic analysis including 266 country-specific nutrition surveys. BMJ: British Medical Journal, 2014. 348.

Fig. 2. Saturated fat intakes in countries of the Region (saturated fat as a percentage of energy intake)

Source: Al Jawaldeh and Al-Jawaldeh (2018) (8)

Fig. 3. Trans fats intakes in countries of the Region (trans fatty acids as a percentage of energy intake)

8 Islamic Republic of Iran, Jordan, Lebanon, Morocco, Saudi Arabia and United Arab Emirates. 9 Study among women only in the United Arab Emirates.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

Source: Based on FAO statistics, 2017.

Fig. 4. Per capita sugar supply in countries of the Region (g per capita per day)

WHO dietary guidelines for the Eastern Mediterranean Region

WHO recommends for adults a reduction in salt intake to less than 5 g per person per day (2 g per day of sodium). For children, the recommended maximum level of intake of 2 g per day of sodium for adults should be adjusted downwards on the basis of the energy requirements of children relative to those of adults.

The intake of free sugars should be reduced throughout the life-course. WHO recommends less than 10% of total energy intake from free sugars, which is for a person of healthy body weight consuming approximately 2000 calories per day, but ideally less than 5% of total energy intake for additional health benefits. Considering the high prevalence of obesity and diabetes in the Region, WHO recommends that children and women should consume less than 5% (roughly 25 grams per person a day) of free sugars in their diet.

As part of a healthy diet, WHO recommends that less than 30% of total energy intake should be from fats. Unsaturated fats are preferable to saturated fats. Industrial trans fats are not part of a healthy diet. The total calories coming from saturated fats should be less than 10% of the total calorie intake, while trans fats should be less than 1%.

In practical terms, meeting the WHO recommendations for healthy diet and lifestyle, means eating a diet containing a variety of fruits, vegetables, and grain products, especially fibre-rich whole grains; fat-free and low-fat dairy products; legumes, poultry, and lean meats; and fish, preferably oily fish, at least twice a week.

Food and drink companies have increased spending to market their products and food marketing is now ubiquitous across the Region, largely relating to foods high in fat, sugars and/or salt (9). Furthermore, investment in food and drink marketing has grown faster on pan-regional television channels than on national channels (9).

2.2.5 Nutrition policy implementation

Most countries in the Region (89%) now have a comprehensive or topic-specific nutrition policy, according to data from WHO’s latest Global Nutrition Policy Review 2016‒2017 (10). Nearly four out of five countries (79%) report having a comprehensive nutrition policy that aims to address all forms of malnutrition, while 53% have a policy relating to a specific aspect of nutrition, such as infant and young child

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

nutrition. Fifty-three per cent of these policies were developed between 2011 and 2014 and 18% developed in 2015 or later; 17% had costed operational plans and 86% had a nutrition coordination mechanism.

The main action areas included in nutrition policies across the Region are infant and young child nutrition (84%), school health and nutrition programmes (84%), healthy diet (84%), vitamin and mineral nutrition (79%), acute malnutrition (53%) and nutrition and infectious diseases (37%) (10).

In relation to infant and young child nutrition, most countries (90%) have implemented interventions on growth monitoring and promotion and breastfeeding counselling (95%), while around half report implementation of the Baby Friendly Hospital Initiative (50%) and actions to address infant feeding in difficult situations (47%), and three quarters (75%) provide complementary feeding counselling. Most countries in the Region have taken some steps to regulate the marketing of breast-milk substitutes, with 17 countries having put some of the provisions of the International Code of Marketing of Breast-milk Substitutes into law (11). Of these, however, only six had fully implemented the provisions of the Code with a further four implementing many of the Code’s provisions. There is great scope to improve enforcement of the law and increase sanctions and penalties for violation. In addition, implementation of maternity protection is particularly low in the Region – with 92% of countries providing less than 12 weeks of statutory maternity leave by 2014, and none meeting the latest international standard on the duration of paid maternity leave (ILO Convention No. 183), which mandates a minimum leave period of 14 weeks (12).

Another key area of action is school health and nutrition – more than three quarters (79%) of countries in the Region reported having a school health and nutrition programme and these programmes generally aimed to tackle both child undernutrition and overweight or obesity. The most common elements were training for school staff, introduction of standards or rules for foods and beverages available in schools, inclusion of nutrition education in the school curriculum (58% of countries for all) and child growth monitoring in schools (53%). These were followed by provision of school meals/school feeding (47%), physical education in the school curriculum (47%), action on hygienic cooking facilities and clean eating environments (42%), provision of safe drinking-water free of charge (42%) and of adequate sanitation and hygiene (42%), a ban on vending machines in schools (26%), school milk schemes (26%), extra-curricular nutrition education (26%), standards for marketing of foods and non-alcoholic beverages (26%) deworming (21%), school gardens (21%) school fruit and vegetable schemes (16%), distribution of take-home rations (11%) and micronutrient supplementation (11%).

Specifically in relation to action to promote healthy diets and prevent overweight and obesity, the most common actions implemented in the Region were introduction of nutrition labelling (67%) – although only 56% concern nutrient declarations and 17% have introduced front-of-pack nutrition labelling – dissemination of dietary guidelines (65%) and nutrition and diet counselling (56%), followed by programmes to promote

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

reformulation of foods (47%), rules on nutrition and health claims (41%), media campaigns (39%), a ban on industrial trans fatty acids in food and drink products (24%), fiscal policies ‒ taxes or subsidies (24%), regulation of marketing of food and non-alcoholic beverages to children (22%) and portion size control (12%). More recent data suggest that, in 2017, the adoption of national policies to limit saturated fatty acids and virtually eliminate industrially produced trans fatty acids in the food supply was fully achieved in 12 countries (54.5%) (13). In addition, implementation of fiscal measures (taxes on unhealthy foods, subsidies on healthy foods or removal of subsidies on less healthy foods) had been expanded, most notably with an increase in the introduction of taxes on sugar-sweetened beverages (member countries of the Gulf Cooperation Council, for example, imposed a 50% tax on soft drinks and a 100% tax on energy drinks) (13). Progress in implementation of WHO’s Set of recommendations on marketing of food and non-alcoholic beverages to children remains slow and no country in the Region has adopted comprehensive policies restricting marketing of unhealthy food to children (9). In addition, 12 countries implemented at least one national public awareness and motivational communication campaign for physical activity, including mass media campaigns for physical activity behavioural change (13).

Improving access to, and consumption of, healthy, diversified diets is the best way to ensure adequate micronutrient intakes, but where this is not being achieved there is a role for supplementation and food fortification. Specifically in relation to action on vitamin and mineral nutrition, supplementation and food fortification was implemented widely across the Region. Twenty-one countries are implementing vitamin and mineral supplementation for pregnant women (most commonly iron or iron and folic acid), while eight countries report provision of supplements to women of reproductive age (folic acid, iron) and 16 report supplementation in children (vitamin A, iron, micronutrient powder, zinc, iodine) (10). Sixteen countries report fortification of salt, while 12 report fortification of wheat flour and six report fortification of oil, and one country reports fortification of sugar (10). Iron and folic acid were the fortificants most commonly added to wheat flour. A specific regional assessment of wheat flour fortification in 2018 found that 17 countries had some coverage of wheat flour fortified with iron and folic acid, and that this was mandatory in 11 countries (6). Despite this progress, a regional report on wheat flour fortification identified that further action was needed to expand coverage of wheat flour fortification and to ensure that it was effective (6).

Unfortunately, action to prevent and treat acute malnutrition continues to be needed in the Region. Twelve countries were implementing treatment of severe acute malnutrition with nutritional care and treatment of moderate acute malnutrition, while 10 were implementing food distribution programmes – such as emergency food aid programmes, direct food-based transfers, foods for infants and young children – to prevent acute malnutrition. In relation to action on nutrition and infectious diseases, seven countries in the Region report programmes on nutritional care and support for people living with HIV and those with tuberculosis ‒ groups which are particularly vulnerable to undernutrition. In addition, four countries report implementation of deworming programmes to tackle soil-transmitted helminths and other parasites that

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

can contribute to malnutrition.

Effective policy-making and accountability require effective nutrition surveillance and monitoring and evaluation systems. Eight countries have developed nutrition surveillance systems (14), however, nutrition data collection and analysis remain a challenge for the Region.

2.2.6 Regional challenges

Efforts to achieve food security and improve nutrition in the Region face particular challenges. To date, there has been underinvestment in health and nutrition, and resources are unevenly and inequitably distributed. Many countries are still dependent on donor funding, while health systems often rely on out-of-pocket expenditure and health coverage remains limited. There is also a shortage of human capacity, specifically in relation to nutrition, but also for health systems more generally.

Success in improving nutrition by ensuring access to healthy, sustainable diets and to essential nutrition actions requires multisectoral action and adoption of a health-in-all policies approach. To date, little emphasis has been placed on the role of other sectors across the Region, or on social, economic or environmental determinants of nutrition.

Many countries are heavily dependent on imported foods and marketing for food and drink products is often disseminated via pan-regional media outlets across country borders, creating particular challenges for national authorities. As elsewhere, action on nutrition can face strong opposition from vested interests which can weaken political will. Efforts are further undermined by poor awareness of the human and economic cost of malnutrition in all its forms.

In many countries, regulatory action can be undermined by weak or under-resourced mechanisms to adopt, implement and enforce legislation and standards. Throughout the Region health surveillance and information systems need to be strengthened and integrated in order to generate data to inform policy and monitor progress.

Furthermore, several countries in the Region continue to face additional challenges associated with conflict, displaced populations and political unrest. In addition, gender discrimination has significant consequences for the nutritional status, health, well-being and development of women and girls.

2.3 Developments in the nutrition landscape

There have been many significant developments in the nutrition landscape – at both global and regional levels – since 2010. Countries in the Region have made commitments to improve nutrition and are working towards achievement of various global and regional goals to improve the health and well-being of the Region’s population.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

Fig. 5. The triple billion target of WHO’s Thirteenth General Programme of Work

2.3.1 Key global developments

In September 2015, the world agreed to eliminate all forms of malnutrition by 2030 when Member States adopted the 2030 Agenda for Sustainable Development and its related goals. Addressing malnutrition in all its forms is firmly embedded in SDG 2 –

which aims to end hunger, achieve food security and improve nutrition, and promote sustainable agriculture – and SDG 3 to ensure healthy lives and promote well-being for all at all ages. Improving nutrition will also enable further progress towards achievement of the other SDGs.

The SDGs incorporate previous globally agreed goals on maternal, infant and young child nutrition and on addressing NCDs and their diet-related risk factors. Progress towards these goals has been guided by globally agreed action plans – namely, the Comprehensive implementation plan on maternal, infant and young child nutrition (15) and the Global action plan for the prevention and control of noncommunicable diseases 2013‒2020 (16).

The 2030 Agenda commitments to end malnutrition follow on from a common vision for global action to eradicate hunger and prevent all forms of malnutrition agreed at the Second International Conference on Nutrition (ICN2) in 2014 and set out in the Rome Declaration on Nutrition (17) and the accompanying Framework for Action10 (18). To accelerate efforts towards this common vision, the United Nations General Assembly declared a United Nations Decade of Action on Nutrition from 2016 to 2025.

10 The set of 60 voluntary ICN2 Framework for Action recommended policies and actions are presented for governments to

incorporate, as appropriate, into their national nutrition, health, education, agriculture, environment, development, trade and investment plans.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

In 2018, WHO also launched the first ever Global action plan on physical activity 2018‒ 2030: more active people for a healthier world, which aims to ensure that all people have access to safe and enabling environments and to diverse opportunities to be physically active in their daily lives. It recognizes the role of physical inactivity in development of overweight and obesity and thus the potential contribution of action on physical activity to address malnutrition (19).

WHO’s Thirteenth General Programme of Work 2019‒2023 sets out a triple billion target for ensuring healthy lives and promoting well-being for all at all ages (Fig. 5). This is to be achieved by ensuring that 1 billion more people benefit from universal health coverage, 1 billion more people are better protected from health emergencies and 1 billion more people enjoy better health and well-being. With a specific commitment to addressing the social, economic and environmental determinants of health, WHO’s Thirteenth General Programme of Work encompasses the key principle of “leaving no one behind” and its targets are complementary to the targets of the SDGs.

2.3.2 Regional developments

As part of its efforts to achieve the globally agreed goals and targets, the WHO Regional Office for the Eastern Mediterranean has set out its vision for 2023: Health for all, by all, so that everyone in the Region can enjoy a better quality of life (20). Vision 2023 sets out four strategic priorities for the Region: expanding universal health coverage; addressing health emergencies; promoting healthier populations; and making transformative changes in WHO. Member States are invited to adopt a three- pronged approach that combines a life-course approach with a health-in-all-policies approach and integrated multisectoral action, and WHO is committed to supporting Member States in these efforts.

Throughout the decade, countries of the Region have adopted several specifically- targeted regional frameworks and action plans of matters relating to nutrition and diet-related NCDs. In October 2018 a Regional framework for action on obesity prevention 2019‒2023 (21) was adopted, translating a series of policy priorities proposed in 2017 (22) into regional commitments. Strategic interventions and progress indicators are recommended in relation to fiscal measures, public procurement, food supply and trade, labelling, marketing, physical activity, mass media campaigns, breastfeeding, reformulation, health sector interventions, assessment and monitoring.

An earlier regional framework on noncommunicable diseases, updated in October 2015 (23), set out strategic interventions in the areas of governance, prevention and reduction of risk factors, surveillance, monitoring and evaluation and health care. Commitments in the area of prevention and reduction of risk factors include: ensuring healthy nutrition in early life and childhood, including breastfeeding promotion and regulating marketing of foods and non-alcoholic beverages to children; reducing average population salt intake in line with WHO recommendations; virtually eliminating trans fat intakes and reducing intake of saturated fatty acids; and promoting physical activity through a life-course approach.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

Action on nutrition is key to health, economic well-being and sustainable development

Improving nutrition is essential to improving for the health of populations of the Eastern Mediterranean Region and for the economic well-being and sustainable development of its Member States. While malnutrition in all its forms lowers economic productivity and increases health care costs, good nutrition results in higher labour productivity, greater mental capacity and longer, healthier lives. Well-nourished workforces support productive economies, including agriculture and food production. It is estimated that every dollar invested in nutrition brings an economic benefit of US$ 16 (24). Tackling the chronic malnutrition which stunts the growth of the Region’s children, for example, will bring benefits for economic productivity – each added centimetre of adult health is associated with an almost 5% increase in wage rates. Investing in good maternal nutrition and good nutrition in the first 1000 days of life will not only support the healthy growth and development of children, it will also enable them to achieve their full physical, intellectual and human development in adulthood – and, therefore, their economic productivity – as well as preventing the development of costly NCDs later in life.

In addition to being important for economic development, nutrition is central to many other aspects of the 2030 Agenda for Sustainable Development and to achievement of many of the SDGs. Ensuring good nutrition, for example, requires access to safe water and sanitation. Improving the nutrition of girls, women and children will improve schooling and contribute to reducing gender inequalities, while reducing nutrition inequalities will also lessen income inequalities. Transformation of food systems to ensure access to healthy, sustainable diets will reduce greenhouse gas emissions, soil degradation, loss of biodiversity and pressure on the world’s oceans, while responsible food consumption will reduce food waste and loss.

Source: Adapted from United Nations Standing Committee on Nutrition (25).

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

3. Vision and objectives of the nutrition strategy for the Eastern Mediterranean Region, 2020–2030

The Strategy on nutrition for the Eastern Mediterranean Region 2020‒2030 seeks to leverage the current momentum to improve access to healthy diets and address malnutrition in all its forms. It seeks to turn the commitments of the Rome Declaration on Nutrition and the regional Vision 2023 into concrete action and to achieve the previously agreed goals on health, nutrition and NCDs using the six key areas of the United Nations Decade of Action on Nutrition. In addition, it seeks to contribute to realization of health for all by all in the Eastern Mediterranean Region and achievement of the SDGs and the triple billion target of WHO’s Thirteenth General Programme of Work.

The vision, overall objective and specific objectives of the nutrition strategy are outlined below.

Overall objective: To support Member States strengthen efforts to ensure universal access to healthy and sustainable diets and implement effective nutrition actions, in order to:

• improve nutrition throughout life course for mothers, infants, children, adolescents and older people;

• prevent undernutrition, overweight, obesity and diet-related NCDs; and • support and protect nutrition in emergency situations.

Specific objectives:

1. To support countries to operationalize a current national nutrition strategy and plan of action in order to achieve global and regional targets11 and, by 2030, to:

11 See Section 6 on monitoring and evaluation for information on indicators and interim targets.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

• improve rates of early initiation of breastfeeding and continued breastfeeding and, specifically, increase the rate of exclusive breastfeeding in the first 6 months up to at least 70%;

• halt the rise in diabetes and obesity in adults; • halt the rise in overweight in school-age children and adolescents 5‒18 years

old; • reduce mean population intake of salt/sodium by 30%;12 • virtually eliminate industrially-produced trans fats from the food supply.

2. To provide a framework for countries to accelerate efforts to improve nutrition and food security through the six key action areas of the United Nations Decade of Action on Nutrition:

• Sustainable, resilient food systems for healthy diets • Aligned health systems providing universal coverage of essential nutrition

actions13 • Social protection and nutrition education • Trade and investment for improved nutrition • Safe and supportive environments for nutrition at all ages • Strengthened governance and accountability for nutrition.

Section 5 provides more information on how policies and programmes in these areas for action can be used to improve nutrition.

12 Countries concerned about iodine deficiency should fully implement universal salt iodization and, if necessary, increase

iodine levels as salt intakes are decreased. 13 The overall targets on reduction of stunting and wasting are also relevant to this key area for action.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

4. Underlying principles and strategic approaches

Action to improve nutrition throughout the Region in the coming decade should be underpinned by some important principles, enshrined in the five key approaches outlined below.

Life-course approach

WHO is committed to promoting health and well-being through a life-course approach, which results in a triple dividend – health, social and economic benefits – for people now, for their future and for the next generation. There are many critical points to improve nutrition across the life course, including the nutritional health of women before, during and after pregnancy, nutrition in infancy and early childhood and the adoption of lifelong healthy eating habits during childhood and adolescence. In addition, good nutrition throughout the life course is essential for healthy ageing.

Health-in-all-policies approach and integrated multisectoral action

Progress on ending malnutrition in all its forms depends on action beyond the health sector. Policies in many sectors impact on food security and nutrition, including agriculture, environment, social protection, education, transport, infrastructure, public procurement, trade and finance. Action is needed, for example, to transform food systems, implement taxes and improve social protection to improve nutrition through adoption of an integrated, multisectoral approach. WHO is committed to promoting a health-in-all-policies approach to underpin health and nutrition improvements in the Region.

The life course approach embedded in WHO strategy

The Global strategy for women’s, children’s and adolescents’ health 2016–2030 enshrines the life-course approach. In the Region, the life-course approach is also embedded in resolution EM/RC64/R.4 to operationalize the adolescent component of the global strategy urging countries to develop and/or update national adolescent health action plans and the Regional framework for action on preconception care 2019–2023 endorsed by the WHO Regional Committee for the Eastern Mediterranean in October 2018.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

Involving whole of society

Multisectoral action requires the involvement of multiple sectors beyond central and local government with progress depending on the actions of many, varied stakeholders and the adoption of a whole-of-society approach. Relevant stakeholders include individuals, families and communities, intergovernmental organizations and religious institutions, civil society, academia, the media, the voluntary sector and, as appropriate, the private sector and industry. There is a fundamental role for civil society to advocate for nutrition action in order to build broad public support and political will, and to help monitor progress against commitments. Food industry actors have an important role to play in transforming food systems. Robust safeguards are needed to prevent and manage conflicts of interest in policy development and implementation.

Addressing determinants of health

It is well recognized that malnutrition is multifactorial and that there are many social, economic and environmental determinants of various forms of malnutrition. There are very stark health inequalities between and within countries in the Region and poor nutrition contributes to these income, gender and other social inequalities. At the regional and country level, it is vital, therefore, that nutrition action address these social, economic and environmental determinants. All efforts to improve nutrition need to pay careful attention to the impact on the most vulnerable – including people in emergency situations, those living in extreme poverty and marginalized and excluded groups – and ensure that as nutrition improves in the Region, no one is left behind.

Anchored in a human rights approach

Every man, woman and child has the right to adequate food and nutrition.14 Countries which are party to the International Covenant on Economic, Social and Cultural Rights, therefore, already have a legal obligation to work towards realizing this right. Efforts to achieve food security and improve nutrition should therefore be anchored in a human rights approach, which supports the integration of gender, equity and human rights in national policies and planning.

Knowledge sharing and exchange of experience

Country efforts to implement a nutrition strategy should be informed by lessons learned from the experience of others on the ground. Regional cooperation needs to be supported by a platform for learning lessons from other countries in the Region and beyond. There is a clear need to share experiences, including both successes and failures. There is a role for WHO to facilitate the exchange and sharing of experiences 14 The Right to Food is realized when every man, woman and child, alone or in community with others, has physical and

economic access at all times to adequate food or means for its procurement. The right to adequate food shall therefore not be interpreted in a narrow or restricted sense, which equates it with a minimum package of calories, proteins and other specific nutrients. Committee on Economic, Social and Cultural Rights (35).

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

and to collect and showcase evidence of policy successes, including examples from other WHO regions.

In addition, WHO is committed to pursuing this approach and collaborating with civil society and United Nations partner organizations, including FAO, UNICEF and the World Food Programme (WFP), to support Member States in their efforts to end malnutrition in all its forms.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

5. Six key areas for action

This nutrition strategy is focused around the six key areas of action of the United Nations Decade of Action on Nutrition:

• Sustainable, resilient food systems for healthy diets • Aligned health systems providing universal coverage of essential nutrition actions • Social protection and nutrition education • Trade and investment for improved nutrition • Safe and supportive environments for nutrition at all ages • Strengthened nutrition governance and accountability.

For each of the areas, WHO recommendations for priority actions have been developed, which need to be considered within national contexts. Additional actions may also be appropriate to specific situations. These recommendations reflect WHO’s area of expertise, and Member States – as part of a multisectoral approach – will need to work with other United Nations agencies on the other important issues highlighted below, but which are not picked up as recommended priority actions.

Annex 2 sets out the recommendations from the ICN2 Framework for Action for each of the six areas and provides a detailed list of resources to help guide implementation. In this section, relevant regional frameworks, recommendations and guidance are shown in the boxes.

5.1 Sustainable, resilient food systems for healthy diets

The burden of malnutrition facing the Region is closely linked to the state of today’s food systems. Dramatic changes in what food is produced, how it is processed, marketed, made available to people and consumed or disposed of have increased the availability of calories and inexpensive food, which has reduced hunger for many but has not always improved access to diverse, micronutrient-rich foods. Meanwhile, foods high in salt, sugars, trans and saturated fats have become cheaper and more widely available. At the same time, today’s food systems are important drivers of climate change and other environmental pressures which threaten the future health of the planet and populations. Transformation of food systems is needed, therefore, so that nutritious, safe, affordable and sustainable diets are available to all.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

The actions outlined below will contribute to building sustainable, resilient food systems for healthy diets.

• Reform food systems: There is an urgent need to reform food systems to improve production of, and access to, foods which comprise healthy diets and to ensure greater sustainably. Two key elements are to strengthen local food supply chains – especially in this Region which is heavily dependent on food imports – and to increase the diversity of food production, in a sustainable way.

• Reduce food loss and food waste: Around a third of all food is lost or wasted every year, reducing the availability of food and negatively impacting the planet and on economic actors in the food chain. Policies to improve transport and storage infrastructure and to promote better industry practice and consumer behaviour are required.

• Reduce intake of saturated fat, sugars, salt and trans fat: Shifting dietary patterns have seen intakes of processed foods high in calories, unhealthy fats, sugars and salt increase across the Region. Policies, including regulatory measures, to improve the food supply by removing trans fats and reducing saturated fats, sugars and salt from food and drink products are needed, along with use of well-designed taxes and subsidies to create incentives for production and consumption of healthier foods and drinks.

• Improve food safety and address antimicrobial resistance: Food safety is critical for food security and good nutrition and relies on strong regulatory frameworks and effective food control systems. The active participation of Member States in the work of the Codex Alimentarius Commission and international food safety information exchange networks is important. Multisectoral collaboration between the public health, veterinary, food and environment sectors is needed to address antimicrobial resistance, which is threatening our ability to treat common infectious diseases.

There are other important areas for action to create sustainable, resilient food systems for healthy diets, but which are not the primary focus of this WHO strategy and relate more closely to the work of other United Nations partners. These include enhancing resilient food supply in crisis-prone areas and the management of water for improved nutrition (36).

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

Sustainable food systems – Regional framework on health and the environment

Modern food systems take a heavy toll on the environment, threatening the future health of the planet and populations. At the global scale food production is responsible for up to a third of greenhouse gas emissions and is a major source of soil and water pollution. It also accounts for almost three quarters of freshwater use and 40% of land use and contributes to biodiversity loss (26) (27) (28).

At the same time, global environmental change is likely to impact on food systems. The Regional framework for action on health and the environment 2019–2023, adopted in October 2018, includes a number of priorities and strategic actions for climate change and health. Identification of the current and future health effects of climate change should take into account the impact of food systems, and development of response strategies, plans and projects need to consider the impact on nutrition.

Regional initiatives to support fat, sugar, salt reduction

A number of regional initiatives have been developed to support this type of action. The Regional framework for action on obesity prevention 2019–2023, adopted in October 2018, includes the following among the priority areas for action:

• implementation of fiscal measures (implementation of a tax on sugar-sweetened drinks and other taxes and/or subsidies to promote healthy diets, as well as progressive elimination of subsidies on fats/oils and sugar)

• implementation of policies to progressively reformulate foods and beverages to eliminate trans fats and reduce total and saturated fat, salt, sugars, energy and portion size.

The Framework builds on earlier regional policy statements on fat and salt reduction and prevention of obesity, diabetes and cardiovascular disease.15 To monitor the impact of salt reduction efforts, the WHO Regional Office has issued guidance on obtaining measures of population-level sodium intakes (29).

WHO has developed the REPLACE action package to provide a six-step action package to support governments to ensure the prompt, complete and sustained elimination of industrially-produced trans fats from the food supply.

Regional guidance on food safety

The Regional framework for action on health and the environment 2019–2023 sets out strategic actions to manage and minimize food safety risks and strengthen capacities to respond to food safety events. These include mapping food contamination risks, compiling or updating food safety legislation and policies, as well as establishing a coordinated system for monitoring, preparedness and management of food poisoning.

Recommended priority actions

• Eliminate trans fats through the development of legislation to ban the use of industrially-produced trans fats in the food chain.

• Progressively reduce intakes of salt, sugars and saturated fats by improving the nutritional quality of foods through government-led reformulation programmes.

• Implement a tax on sugar-sweetened beverages and use other taxes and subsidies to promote healthy diets.

• Review food subsidy programmes and progressively eliminate subsidies for all types of fats/oils and sugar.

15 Policy statement and recommended actions for reducing fat intake and lowering heart attack rates in the Eastern Mediterranean Region, 2013; Policy statement and recommended actions to lower national salt intakes and lower death rates from high blood pressure and strokes in the Eastern Mediterranean Region, 2013; Policy statement and recommended actions for lowering sugar intake and reducing prevalence of type 2 diabetes and obesity in the Eastern Mediterranean Region, 2016; Proposed policy priorities for preventing obesity and diabetes in the Eastern Mediterranean Region, 2017.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

5.2 Aligned health systems providing universal coverage of key nutrition actions

Strong and resilient health systems, which provide universal coverage of key nutrition actions, will play a fundamental role in eliminating malnutrition in all its forms.

The actions outlined below will contribute to aligning health systems to provide universal coverage of key nutrition actions.

• Build strong and resilient health systems: Health systems need to be strong, resilient and accessible to all, without discrimination and with a special emphasis on the poor, vulnerable and marginalized segments of the population. Universal health coverage – which countries have already committed to expanding in the Salalah Declaration on Universal Health Coverage of 2018, and which is the first strategic priority of Vision 2023 for the Region – needs to include universal coverage of key nutrition actions.

• Reduce stunting and wasting among children under 5: Too many children in the Region are stunted or wasted, particularly in those countries affected by conflict and other crises. Policies, actions and investment are needed to improve coverage of treatment for wasting, improve the integrated management of childhood illnesses, improve disaster and emergency preparedness, improve maternal nutrition and health starting with adolescent girls and promote optimal infant and young child feeding.

• Integrate health service policies and programmes: Services that indirectly impact on nutrition include treatment and control of infectious diseases such as malaria, HIV/AIDS and tuberculosis (which can exacerbate, or be exacerbated by, undernutrition) and policies and programmes to ensure adequate support for safe pregnancy and delivery for all women, prevent adolescent pregnancy and to encourage birth spacing.

• Expand nutrition interventions related to health services: Other nutrition-related interventions can be delivered through the broader health system, away from health facilities. These can include, where appropriate, periodic deworming for all school-age children, provision of zinc supplementation and provision of iron and vitamin A supplements for pre-school children.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

WHO recommendations on health service actions to improve nutrition

Many actions to directly or indirectly improve nutrition are delivered through health systems. These include support for breastfeeding, nutrition counselling, management of acute malnutrition, micronutrient supplementation, growth monitoring and screening, diet therapy for obesity and other curative nutrition measures, treatment and control of infectious diseases and reproductive health services.

Key health sector policies and interventions relating to improving nutrition have been set out in the WHO Comprehensive implementation plan for maternal, infant and young child nutrition and the Global action plan for the prevention and control of noncommunicable diseases 2013–2020, which countries are already working to implement. WHO set out a consolidated set of all essential nutrition actions in Essential nutrition actions: mainstreaming nutrition through the life-course in 2019.

The Regional framework for action on obesity prevention 2019–2023 highlights a number of health sector interventions as priority areas for action, including interventions to promote and facilitate behaviour change, provision of dietary counselling for high-risk individuals and on healthy weight gain before and during pregnancy and integrating screening for overweight into primary health care.

The Regional framework for action on noncommunicable diseases also sets out a number of health service interventions, to improve early detection and management of NCDs and improve access to safe, affordable and quality essential medicines and technologies.

To support implementation, the Regional Office is developing a practice manual for management of obesity, hypertension and diabetes through diet therapy, as well as developing healthy lifestyle guidance and self- management skills for delivery through counselling.

Regional frameworks on preconception care and malaria

A Regional framework for action on preconception care 2019–2023, adopted in October 2018, sets out a number of strategic actions to improve nutrition.

The Regional malaria action plan 2016–2020: Towards a malaria-free Region sets out a goal of, by 2030, interrupting malaria transmission in areas where it is feasible and reducing the burden by more than 90% in areas where elimination is not immediately possible and sets out strategic approaches and relevant actions.

Recommended priority actions

• Strengthen health systems and implement policies and strategies to achieve universal health coverage of nutrition actions.

• Integrate direct and indirect nutrition actions – as set out in WHO action plans on maternal, infant and young child health and NCDs16 and in the regional frameworks on obesity prevention, NCDs, preconception care and malaria – into health systems, and ensure universal access to these actions.

• Adopt policies and mobilize resources to improve coverage of treatment for wasting, using the community-based management of acute malnutrition approach.

• Integrate disaster and emergency preparedness into relevant policies and programmes.

• Implement appropriate micronutrient supplementation programmes.17

16 A consolidated set of essential nutrition actions is detailed in Essential nutrition actions: Mainstreaming nutrition through the life-course (https://www.who.int/nutrition/publications/essential-nutrition-actions-2019/en/, accessed September 2019). 17 Depending on the context, WHO recommends micronutrient supplementation as follows: Daily iron supplementation for infants and children (6 months to 12 years) living in settings where the prevalence of anaemia in infants and young children is 40% or higher; Intermittent use of iron supplements for preschool or school age children in settings where prevalence in this group is 20% or higher; Daily calcium supplementation for pregnant women in populations with low dietary calcium intake; Iodine supplementation for pregnant and lactating women in countries where less than 20% of households have access to

https://www.who.int/nutrition/publications/essential-nutrition-actions-2019/en/

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

5.3 Social protection and nutrition education

Nutrition education and clear nutrition information remain important elements of any nutrition strategy, although information and education alone will not be enough to bring about the improvements needed. Measures to protect the nutritional status of the most marginalized, poorest and vulnerable populations, in times of crisis and in the long term, are also needed.

The actions outlined below will contribute to improving social protection and nutrition education.

• Improve nutrition education and information for behavioural change: Nutrition education encompasses a wide range of actions to influence consumer awareness, attitudes, social norms, skills, preferences and behaviour. Education is needed in schools and for teachers and those working in health, agriculture and social protection. There is also a role for social marketing campaigns, behaviour change communication and clear information about the nutritional quality of foods.

• Increase social protection: Social protection measures – such as, for example, cash and food transfers or school feeding programmes – are an effective way to reach the most nutritionally vulnerable, including children and pregnant women. It is important that nutrition objectives are built into social protection programmes and, in crisis situations, into humanitarian assistance programmes.

In addition, a regular and adequate income allows people to buy the diverse, safe and nutritious foods needed for a healthy diet and also to access health care and education. Measures to increase income for the most vulnerable and provide decent rural employment, therefore, should be part of multisectoral efforts for nutrition, but are outside the main focus of this strategy.

Media campaigns and nutrition labelling standards for better nutrition

The Regional framework for action on obesity prevention 2019–2023 highlights the role of social marketing and mass media campaigns on healthy diet and physical activity and recommends implementation or revision of standards for nutrition labelling to include mandatory front-of-pack nutrition labelling for all pre-packaged foods. The WHO Regional Office is providing support to Member States seeking to implement front-of-pack labelling.

Recommended priority actions

• Develop/update and disseminate national dietary guidelines for specific groups (children, adolescents, adults, pregnant and breastfeeding women, older adults).

• Integrate nutrition education into school curricula and into training and education for teachers, health workers and other relevant front-line workers.

iodized salt; Daily oral iron (30 mg to 60 mg of elemental iron) and 400 µg folic acid supplementation for pregnant women; Intermittent iron and folic acid supplementation in menstruating women in populations where the prevalence of anaemia among nonpregnant women of reproductive age is 20% or higher; Oral iron supplementation, either alone or in combination with folic acid, to postpartum women in settings where gestational anaemia is of public health concern; Vitamin A supplementation for pregnant women, infants and young children in areas where vitamin A deficiency is a severe public health problem; Zinc supplementation for infants and children with diarrhoea.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

• Implement mandatory standards for ingredient listing, back-of-pack nutrient declarations and simplified front-of-pack labelling for all pre-packaged foods.

• Where appropriate, implement school feeding programmes and other forms of nutrition-sensitive social protection (e.g., cash and food transfers) to safeguard vulnerable populations.

5.4 Trade and investment for improved nutrition

In today’s globalized world international trade has an important impact on nutrition, particularly in the Eastern Mediterranean Region where many countries rely heavily on imported food.

The actions outlined below will contribute to aligning health systems to enhancing trade and investment for improved nutrition.

• Enhance trade and investment in improved nutrition: It is clear that there is a strong economic case for governments and international institutions to invest in improving nutrition. Such investment needs to explicitly target nutrition improvements (and not, for example, focus on food security alone). All national policies and investments in food and agriculture – as well as in infrastructure, public services and human capacity – should take nutrition into account in order to ensure food security and enable healthy diets.

• Explore options in international trade for nutrition: Trade policies have the potential to improve nutrition, but they can also increase access to inexpensive, unhealthy foods and can sometimes restrict governments’ scope to take policy action to promote healthy diets. There is a need for countries to work together and across sectors, learning from others’ experiences within and beyond the Region, to identify the opportunities and risks for nutrition associated with trade policy and to implement complementary policies to offset any risks identified.

Recommended priority actions

• Establish and monitor national budget commitments to invest in nutrition. • Conduct a situation analysis of the national food supply (including imported

foods) to determine the sources of fats/oils, sugars and salt in the diet and explore the options for using standards, legal instruments and trade policy to improve the national and/or local food supply.

Standards, legislation and trade instruments to improve the food supply

The Regional framework for action on obesity prevention 2019–2023 highlights the opportunities to use food

standards, legal instruments and other approaches to improve the national and/or local food supply. There may be

scope to use compositional standards, tariffs, import restrictions, planning laws, sales bans, where appropriate, to

reduce the volume and improve the quality of fats/oils and reduce sugars in the food supply.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

5.5 Safe and supportive environment for nutrition at all ages

There has been increasing recognition in recent years of the critical role of supportive environments in improving nutrition.

The actions outlined below will contribute to securing safe and supportive environments for nutrition at all ages.

• Influence the food environment for healthy diets: The environments in which we buy, choose, prepare and eat food can influence what foods are available, affordable and appealing and can, therefore, have an important impact on diets. Measures that influence food environments provide important opportunities to promote healthy diets. There is also an important role for governments to develop or update national dietary guidelines to inform, evaluate and align measures to promote healthy diets.

• Protect, promote and support breastfeeding: Investment in breastfeeding support, promotion and protection is one of the most cost-effective and sustainable public health measures available. In 2017, only two countries in the Eastern Mediterranean Region were meeting the global target for exclusive breastfeeding and robust policy action is needed to improve rates across the Region.

Regional framework on obesity prevention

The Regional framework for action on obesity prevention 2019–2023 includes many actions to create healthy food environments. It includes, for example, recommendations for regulatory action to influence the relative affordability of foods (taxes/subsidies), the availability of food (nutrition standards for food in public institutions, food reformulation), the appeal of foods (regulating the marketing of foods to children and front-of-pack nutrition labelling, both based on robust nutrient criteria). Many countries across the Region pledged further efforts to prevent obesity in the Region in the Sharjah Declaration on Obesity Prevention in November 2018.

Support, promote and protect breastfeeding

Exclusive breastfeeding in the first six months and continued breastfeeding up to two years of age and beyond promotes optimal infant growth and development, protects against stunting, wasting and infection, while reducing the risk of overweight, obesity and diet-related NCDs in later life. Breastfeeding also provides some protection for mothers against obesity and some diet-related NCDs in later life, and is environmentally sustainable.

The recommended steps for governments in the Region are set out in the policy document “The urgent need to fully implement the International Code of Marketing of Breast-milk Substitutes”. The WHO Regional Office and UNICEF are providing support for the implementation of the Code, and monitoring its implementation using the NetCode protocol, and for the implementation of the Baby-Friendly Hospital Initiative and the newly updated Ten steps to successful breastfeeding (Revised 2018).18 Action is also needed to protect breastfeeding in humanitarian crises and to ratify the International ILO Maternity Protection Convention and implement maternity protection laws, as well as creating an enabling environment for men to share childcare responsibilities.

Implementation of WHO recommendations on food marketing to children

The WHO Regional Office continues to provide countries with technical support to implement the WHO Set of Recommendations on Marketing of Foods and Non-alcoholic Beverages to Children. A 2018 report on implementation of the recommendations in the Region emphasizes the importance of a comprehensive approach, building consensus and setting clear definitions for “marketing to children” and “unhealthy food”. It also acknowledges that if a comprehensive approach is not feasible, a stepwise approach (focusing initially on at least television and in-school marketing) is preferable to no intervention at all (9). The Regional Office has developed a nutrient profile model to help countries define which food marketing should be restricted (31).

18 Ten steps to successful breastfeeding. Geneva: World Health Organization, 2019 (https://www.who.int/nutrition/bfhi/ten- steps/en/, accessed 18 September 2019).

https://www.who.int/nutrition/bfhi/ten-steps/en/ https://www.who.int/nutrition/bfhi/ten-steps/en/

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

WHO recommendations on wheat flour fortification

The WHO Regional Office is providing support and guidance to countries on food fortification, particularly in relation to fortification of industrially-processed wheat flour (6). Countries are urged to follow the latest WHO recommendations on best practice (32) and to implement a mandatory approach, where possible.

• Reduce childhood overweight and obesity: A broad array of policies and interventions is needed, as set out in the wide-ranging final report of the Commission on Ending Childhood Obesity (30). Measures are required, for example, to provide dietary counselling to pregnant women, improve supplementary feeding programmes for infants and young children and create an environment conducive to physical activity from an early age. It is also important to promote breastfeeding and to end the inappropriate promotion of foods for infants and young children and reduce children’s exposure to marketing for unhealthy foods.

• Reduce anaemia in women of reproductive age: The Region is not on course to meet the target of reducing anaemia by 50% in this group by 2025. Control of anaemia in women of reproductive age is essential to prevent poor health outcomes for women and their children. In addition to actions relating to non- nutritional causes of anaemia, multisectoral action to improve intake of foods rich in micronutrients, particularly iron, through promotion of healthy and diversified diets, education on iron-rich foods and, where necessary, through fortification and supplementation. Policies should ensure provision of daily iron and folic acid to pregnant women as part of antenatal care, of intermittent iron and folic acid supplementation to menstruating women where the prevalence of anaemia is 20% or higher, and deworming, where appropriate.

• Improve water, sanitation and hygiene: Poor sanitation and hygiene, and a lack of access to safe drinking-water, can have severe consequences for childhood nutrition through their impact on diarrhoeal diseases, intestinal parasites and environmental enteropathy. Action is needed to implement culturally appropriate interventions, including improved household toilets or latrines, improved water supply, safe household water management and promotion of safe hygiene practices, including handwashing with soap.

Regional framework for action on health and the environment 2019–2023

The strategic actions set out in the Regional framework for action on health and the environment 2019–2023 include extending water supply and sanitation services to the underserved and improving service to the underserved and other regulations and management practices for priority water and sanitation as strategic actions, along with monitoring and surveillance.

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

Recommended priority actions

• Introduce and enforce mandatory guidelines for provision of healthy food in public institutions (e.g. schools, hospitals, military, prison and other government institutions).

• Reinforce the package of policies and interventions to promote, protect and support breastfeeding and appropriate complementary feeding (ensuring it includes full implementation of the International Code of Marketing of Breast-milk Substitutes and WHO guidance on ending inappropriate promotion of foods for infants and young children, mandatory implementation of baby-friendly health systems, introduction of maternity protection laws and implementation of a national policy on infant and young child feeding in emergencies).

• Implement the WHO Set of recommendations on marketing of foods and non-alcoholic beverages to children.

• Implement and monitor policies and practices for wheat flour fortification and for salt iodization, in line with the latest WHO recommendations on best practice

• Implement appropriate micronutrient supplementation policies (see 5.2).

5.6 Strengthened governance and accountability for nutrition

Success in implementing this strategy will depend on the extent of political commitment and the existence of an enabling policy environment and effective governance mechanisms.

The actions outlined below will contribute to strengthening governance and accountability for nutrition.

• Strengthen/develop governance and coordination mechanisms for food security and nutrition: Strong government leadership, robust nutrition governance, multisectoral participation and comprehensive multisectoral coordination mechanisms at various levels are needed, as well as adequate institutional capacity, the participation of civil society and inter-country collaboration and exchange.

• Advocate for a health-in-all-policies approach in policies and programmes related to nutrition: The actions of many sectors – including agriculture, environment, health, trade, education, employment, social welfare, media, urban planning and water, sanitation and hygiene – can impact on nutrition. A health-in- all-policies approach is needed to ensure the actions of all these sectors contribute to and reinforce the work of other sectors and incorporate nutrition objectives into their sectoral policies, legal frameworks and programmes.

• Integrate multisectoral information systems related to food and nutrition: Reliable data, statistics and information are essential to be able to inform and drive nutrition action and assess progress towards the agreed targets. It is also important for countries to have the capacity to analyse and interpret the information, in order to be able to communicate effectively with decision-makers. Robust integrated multisectoral and sustainable information systems on food, diets and nutrition are

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

needed to inform and improve policy development and provide accountability. Such systems need technical and financial support and could benefit from countries working together in sub-regional groupings to learn lessons from one another’s experience.

Recommended priority actions

• Establish or strengthen national cross-government, multisectoral coordination mechanisms for nutrition, with a clear mandate and allocated funds/resources.

• Develop/update and operationalize a current national action plan on nutrition (including national SMART targets) to give effect to this strategy.

• Establish or strengthen a food and nutrition surveillance system to provide information on nutrition status of populations and on factors that influence nutrition.

• Update and expand national food composition databases, with standardized methodology and reporting in line with WHO recommendations.

Regional guidance on food and nutrition surveillance systems

In 2013, the WHO Regional Office for the Eastern Mediterranean published technical guidance on the development of food and nutrition surveillance systems to help Member States develop systems that provide regular and updated information on the nutrition status of populations and on factors that influence nutrition (32).

Improving food composition data in the Region

Accurate, relevant and up-to-date data on the composition of foods commonly consumed is of vital importance to understand population diets, inform policy development and monitor the impact of policies. Since 2016, the WHO Regional Office has been supporting Member States to standardize and update food composition databases, in partnership with the European Food Information Resource (EUROFIR) and the Quadram Institute. The training and technical support provided through this project has enabled standardization of methodology and of reporting formats and the sharing of data between Member States to expand the available data on food composition in several countries of the Region (33).

Strategy on nutrition for the Eastern Mediterranean Region, 2020–2030

6. Monitoring and evaluation framework

In order to ensure that the policies and programmes set out in this strategy are translated into action on the ground, it is important to establish a monitoring and evaluation framework.

Globally, countries are working towards the existing nutrition and NCD goals which have been incorporated into the SDGs. In order to monitor progress, a Global Nutrition Monitoring Framework has been established which defines the indicators for the global nutrition targets (primary outcome indicators, intermediate outcome indicators, process indicators and policy environment and capacity indicators) (34). Similarly, countries are already tracking progress towards the NCD goals through the Global Monitoring Framework on Noncommunicable Diseases.

In the shorter term, WHO’s Thirteenth General Programme of Work also set out a series of indicators and targets for the period 2019‒2023 for stunting, wasting, salt/sodium, raised blood pressure, trans fats and childhood overweight. In addition, there are other targets which relate indirectly to nutrition: ensure access to safe drinking-water for 1 billion more people and ensure access to safe sanitation for 800 million more people.

In addition, throughout the decade countries of the Region have adopted some more specifically-targeted regional frameworks and action plans of matters relating to nutrition and diet-related NCDs. In October 2018 the Regional framework for action on obesity prevention 2019‒2023 (21) was adopted, translating a series of policy priorities proposed in 2017 (22) into regional commitments. An earlier regional framework on noncommunicable diseases, updated in October 2015 (23), set out progress indicators to assess Member States’ progress by 2018.

In order to be coherent with these initiatives – and recognizing that countries are already reporting a series of indicators – a preliminary monitoring framework for this strategy has been drawn up almost entirely on the basis of existing indicators (see Table 2). Further work to elaborate this monitoring framework, including completing the gaps in baseline data, defining indicators and targets for specific objective 2 and the key areas for action, identifying interim targets and process indicators will be required. A list of suggested indicators for actions in the six key areas for action is provided in Annex 3.

This monitoring framework should be adapted to the national context, national SMART commitments and interim targets defined, and whenever available, baseline data provided.

Strategy o nutrition for the WHO Eastern Mediterranean Region, 2020–2030

Table 2. Preliminary monitoring framework

Regional targets for specific objective 1:

Indicator definition and regional baseline

Interim targets

To support countries to operationalize a current national nutrition strategy and plan of action in order to achieve global and regional targets19 and, by 2030, to:

Baseline 2017: 17 countries have national nutrition policies, strategies or action plans of other policies and plans which focus on nutrition or healthy diet, 12 of which are recently developed

By 2025, 11 countries have updated their national nutrition action plans

• Reduce the number of children under-5 who are stunted by 50%

Baseline 2018: 24.7% children 0–59 months have height-for-age two standard deviations or more below the WHO child growth standards median20

Reduce by 30% by 2023 Reduce by 40% by 2025

• Reduce and maintain childhood wasting to less than 3%

Baseline 2018: 7.8% children 0–59 months have weight-for-height two standard deviations of more below the WHO Child growth standards median20

Reduce to less than 5% by 2023

• Reduce the prevalence of overweight in children under 5 years by 25%

Baseline 2018: 5.7% children 0–59 months with weight-for-height two standard deviations or more above the WHO child growth standards median20

Halt and begin to reverse the increase in childhood overweight and obesity by 2023

• Reduce low birth weight by 30%

Baseline 2014: 19.31% babies born weighing less than 2500 g at birth20

Phased interim targets to be determined

• Reduce anaemia in women of reproductive age by 50%

Baseline 2017: estimated regional prevalence is

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Publications

Date d'adoption 7 décembre 2019

Source Organisation mondiale de la santé