WORLD HEALTH ORGANIZATION EXECUTIVE BOARD 113th Session Provisional agenda item 3.7 EB113/44 Add.1 27 November 2003
Integrated prevention of noncommunicable diseases Draft global strategy on diet, physical activity and health
The Director-General submits herewith for the consideration of the Executive Board the draft global strategy on diet, physical activity and health.
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ANNEX DRAFT GLOBAL STRATEGY ON DIET, PHYSICAL ACTIVITY AND HEALTH
INTRODUCTION 1. Recognizing the heavy and growing burden of noncommunicable diseases, Member States requested the Director-General to develop a global strategy on diet, physical activity and health through a broad consultation process.1 To establish the content of the draft global strategy, WHO held six regional consultations with Member States, and consulted with United Nations agencies and other intergovernmental organizations, civil society, and the private sector; a reference group of independent international experts on diet and physical activity from all six WHO regions also advised WHO. Following the adoption of the strategy, an action plan for implementing the strategy will be developed at regional and national levels.
THE CHALLENGE 2. A profound shift in the balance of the major causes of death and disease is under way in most countries. Globally, the burden of noncommunicable diseases has rapidly increased. In 2001, noncommunicable diseases accounted for almost 60% of the 56.5 million deaths annually and 47% of the global burden of disease. In view of these figures and the predicted future growth in this disease burden, the prevention of noncommunicable diseases presents a major global public health challenge. 3. The world health report 20022 describes in detail how, in most countries, a few major risk factors account for much of the morbidity and mortality, and for noncommunicable diseases, the most important risks included high blood pressure, high concentrations of cholesterol in the blood, low intake of fruit and vegetables, being overweight, physical inactivity and tobacco use. Five of these global risk factors are closely related to diet and physical activity. 4. Unhealthy diets and physical inactivity are thus the leading causes of the major noncommunicable diseases, including cardiovascular disease, type 2 diabetes and certain types of cancer, and contribute substantially to the global burden of disease, death and disability. Other diseases related to diet and physical inactivity, such as dental caries and osteoporosis, are widespread causes of morbidity. 5. The burden of mortality, morbidity and disability attributable to noncommunicable diseases now weighs heaviest in the developing countries, where those affected are on average younger than in the developed world.2 Rapid changes in diets and in patterns of physical activity are further leading to escalating rates. Smoking also increases the risk for these diseases, although largely through independent mechanisms.
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Resolution WHA55.23. The world health report 2002: Reducing risks, promoting healthy life. Geneva, World Health Organization, 2002.
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6. In the poorest countries of the world, even though infectious diseases and undernutrition dominate their current disease burden, the major risk factors for chronic diseases are spreading. Malnutrition, both of deficiency and excess, is increasingly being found in developing countries, and even in the low-income segments of richer countries. An integrated approach to the causes of unbalanced nutrition and decreasing levels of physical activity would contribute to reducing the future burden of chronic noncommunicable diseases. 7. In some developed countries where noncommunicable diseases have dominated the national burden of disease, age-specific death and disease rates have been slowly declining. Progress is being made in reducing premature death rates from coronary artery disease, cerebrovascular disease and some tobacco-related cancers. However, the overall burden and number of patients remain high and many developed countries are experiencing increasing numbers of overweight and obese adults and children, and closely linked increases in type 2 diabetes. 8. The experience of developed countries and of low-income and middle-income countries in the early stages of economic development shows that patterns of unhealthy behaviours and the associated diseases are often set by the more affluent sectors of society. However, in time, all the major risk factors for chronic noncommunicable diseases tend to cluster among the poorest communities and contribute substantially to inequities associated with social class. 9. For all countries, current evidence suggests that the underlying determinants of noncommunicable diseases are largely the same. These include increased consumption of energydense, nutrient-poor foods that are high in fat, sugar and salt; reduced levels of physical activity at home, at work and for recreation and transport; and tobacco use. The variation in risk levels and related health outcomes at the population level is attributable mainly to the variability in timing and intensity of changes at the national and global levels. Of particular concern are the increasingly unhealthy diets and reduced physical activity of children and adolescents. 10. Maternal health and nutrition before and during pregnancy, and early infant nutrition are important in the prevention of noncommunicable diseases throughout the life course. Exclusive breastfeeding for six months and appropriate complementary feeding after that, contribute to optimal physical growth, mental development and the prevention of noncommunicable diseases. Infants who suffer growth restriction in utero, are of low birth weight, and/or are not breastfed, or are stunted as a result of micronutrient deficiencies, are at increased risk for noncommunicable diseases in later life. Taste, food preferences and physical activity habits are set early in life. 11. Most of the world’s elderly people live in developing countries, and the ageing of populations has a strong impact on morbidity and mortality patterns. Many developing countries will therefore be faced with an increased burden of noncommunicable diseases at the same time as the persisting burden of infectious diseases. In addition to the human dimension, maintaining the health and functional capacity of the increasing elderly population will be a crucial factor to reducing the demand for and cost of health services. 12. Diet and physical activity influence health both together and separately. Unbalanced diets and physical inactivity lead to noncommunicable diseases through multiple mechanisms besides those resulting from overweight and obesity. Thus, while the effects of diet and physical activity on health often interact, particularly in relation to obesity, there are additional health benefits from physical activity that are independent of nutrition and diet. Further, there are significant nutritional risks that are unrelated to obesity. Physical activity is a fundamental means of improving the physical and mental health of individuals.
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13. Noncommunicable diseases impose a heavy economic burden on already strained health systems, and inflict great costs on society. Health is a key determinant of development and a precursor of economic growth. The WHO Commission on Macroeconomics and Health has demonstrated the disruptive effect that disease has on development, and how investments in health are an important prerequisite for economic development. Programmes aimed at promoting healthy diets and physical activity for the prevention of diseases are key instruments in policies to achieve development goals. Such programmes must be effectively integrated into broader development and poverty-alleviation programmes.
THE OPPORTUNITY 14. A unique opportunity exists to formulate and implement an effective strategy for substantially reducing deaths and disease worldwide by improving diet and promoting physical activity. Evidence for the links between these health behaviours and later disease and ill-health is strong. There are effective interventions to enable people to live longer and healthier lives, reduce inequalities, and enhance development. By mobilizing the full potential of global players, this vision could become a reality for all populations in all countries of the world.
GOAL AND OBJECTIVES 15. The overall goal of the global strategy on diet, physical activity and health is to promote and protect health by guiding the development of sustainable actions at the community, national and global levels that, when taken together, will lead to reduced disease and death rates related to unhealthy diet and physical inactivity in populations. These actions support the United Nations Millennium Development Goals and have immense potential for major public health gains worldwide. The global strategy has four main objectives: (1) to reduce the risk factors for chronic noncommunicable diseases that stem from unhealthy diets and physical inactivity by means of essential public health action and health-promoting and disease-preventive measures; (2) to increase the overall awareness and understanding of the role of diet and physical activity in determining public health, and of the positive potential of preventive interventions; (3) to encourage the development, strengthening and implementation of global, regional, national and community policies and action plans to improve diets and increase physical activity that are sustainable, comprehensive, and actively engage all sectors, including civil society, the private sector and the media; (4) to monitor scientific data and key influences on diet and physical activity; to support research in a broad spectrum of relevant areas; and to strengthen the human resources needed to enhance and sustain health in this domain.
EVIDENCE FOR ACTION 16. Evidence shows that people can remain healthy into their seventh, eighth and ninth decades by following an optimal diet, maintaining regular physical activity, and not using tobacco. Extensive 5
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research in the past years has provided a good and growing understanding of optimal diets and the health benefits of physical activity, as well as the most successful individual and population-based public health interventions. While more research is needed, current knowledge warrants urgent public health action. 17. Noncommunicable disease risk factors frequently coexist and interact. As the general level of risk factors in the population increases, large proportions of populations are put at risk. Preventive strategies should therefore attempt to reduce risk throughout the population. Such risk reduction, even if modest, will cumulatively yield the greatest and most sustainable benefits for populations and which will far exceed the limited impact of interventions restricted to individuals at a high level of risk. Healthy diets and physical activity will provide widespread benefits for the population and, together with tobacco control, will constitute the best strategy to contain the mounting global threat of noncommunicable diseases. 18. The recent report of the Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Disease1 provides updated evidence and recommendations on population nutrient intake and physical activity goals for the prevention of major noncommunicable diseases. The findings confirm that healthy diets and physical activity are necessary for a long and healthy life. The Expert Consultation’s recommendations need to be translated into national recommendations, in the light of the local health situation, and into dietary guidelines. 19. For diet, the report recommends that populations should: • limit energy intake from fat and shift consumption away from saturated fats and trans-fatty acids towards unsaturated fats; • increase consumption of fruits and vegetables as well as legumes, whole grains and nuts; • limit the intake of “free” sugars; • limit salt (sodium) consumption from all sources and ensure that salt is iodized; • achieve energy balance for weight control. 20. For physical activity, the report recommends that individuals should engage in adequate levels throughout the life course. Physical activity is a key determinant of energy expenditure, and thus fundamental to energy balance and weight control. The beneficial effects of physical activity on the metabolic syndrome are mediated by mechanisms beyond controlling excess body weight. Different forms of physical activity are required for different health outcomes: at least 30 minutes of regular, moderate-intensity physical activity on most days of the week are required to prevent cardiovascular disease and diabetes, and muscle strengthening and balance training are needed to reduce falls and increase functional status among older adults. 21. The translation of these recommendations, together with effective tobacco control, into a global framework that leads to regional and national action plans will require sustained political commitment and the collaboration of many stakeholders. This framework will provide the basis for the effective prevention of chronic diseases.
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WHO Technical Report Series, No. 916, 2003.
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PRINCIPLES FOR ACTION 22. Drawing upon a broad consultation process, and experience with successful policies and strategies in countries and communities, the following principles have guided the development of the draft WHO global strategy on diet, physical activity and health: • Strategies need to be comprehensive, incorporating both policies and action and addressing all major causes of chronic diseases together; multisectoral, taking a long-term perspective and involving all aspects of society; multidisciplinary and participatory, consistent with the principles contained in the Ottawa Charter for Health Promotion (1986); based on the best available scientific research and evidence; and transparent. • As emphasized in The world health report 2002, there is great potential for improving public health by implementing preventive and health promotion measures that reduce the distribution of chronic disease risk factors (most notably in diet and physical activity, taken together) in the population. • A life-course perspective on noncommunicable disease prevention and control is critical. This starts with maternal health, pregnancy outcomes, infant feeding and child and adolescent health; reaches children at schools, adults at worksites and other settings, as well as the elderly, and encourages a balanced diet and regular physical activity throughout the life span. • Public health strategies to reduce noncommunicable diseases should be considered as part of a larger, comprehensive and coordinated effort on diet, physical activity and public health. All partners, especially governments, need to address simultaneously a number of issues. Diet extends to all aspects of unbalanced nutrition (e.g., overnutrition as well as undernutrition, micronutrient deficiency and excess consumption of certain nutrients); food security (accessibility, availability and affordability of healthy food choices); food safety; and support for and promotion of six months of exclusive breastfeeding. Physical activity issues include requirements for physical education and activity in school, working and home life (including both increased sedentariness and heavy physical labour, particularly in developing countries); increasing urbanization, and various aspects of city planning, transportation, safety and access to physical activity during leisure. • Priority should be given to activities that have a positive impact in the poorest populations and communities in countries. Many programmes exist that benefit mainly the more affluent populations. Strategies that benefit the lives of the poorest in a country will generally require community-based action with strong government intervention and oversight. • All partners need to be accountable in reducing these preventable risks to health and in putting in place policies and programmes that will make a difference. In this regard, evaluation, monitoring and surveillance are essential components of national strategies and actions. • Decisions about food, nutrition and physical activity are often made by women and are based on culture and traditional diets. Patterns of physical activity vary according to gender, culture and age. In many countries, the prevalence of chronic conditions related to diet and physical activity can vary greatly between men and women. Therefore, the strategy and action plans should be sensitive to gender differences.
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• Dietary habits, as well as patterns of physical activity, are often rooted in local and regional traditions. National strategies should therefore be culturally appropriate and capable of challenging cultural influences and of responding to changes over time.
RESPONSIBILITIES FOR ACTION 23. Bringing about changes in diet and increased physical activity will require the combined efforts of many stakeholders, public and private, over several decades. A combination of sound and effective strategies is needed, with close monitoring and evaluation of their impact. The following paragraphs describe responsibilities and provide recommendations, deriving from the consultation process, for WHO, Member States, international partners, civil society and nongovernmental organizations and the private sector.
WHO 24. WHO, in cooperation with other United Nations agencies, has the role, responsibility and the mandate to lead the development and implementation of the global strategy on diet, physical activity and health. As outlined below, to facilitate implementation of the strategy, action at the local, national, regional and global levels is warranted. 25. WHO, in cooperation with other United Nations agencies, will provide the leadership, evidencebased recommendations and advocacy for international action to improve dietary practices and increase physical activity, in keeping with the guiding principles and specific recommendations contained in this strategy. 26. WHO will hold discussions with the transnational food industry and other parts of the private sector in support of the aims of this global strategy, and of implementing the recommendations in countries. 27. WHO will support the implementation of programmes as requested by Member States, at any other appropriate level, and will focus on the broad, interrelated areas described below: • facilitating the development, strengthening and updating of regional and national policies on diet and physical activity for integrated noncommunicable disease prevention; • facilitating the development, updating and implementation of national food-based dietary and physical activity guidelines, in collaboration with national agencies and drawing upon global knowledge and experience; • providing guidance to Member States on the formulation of guidelines, norms, standards and other policy-related measures that are consistent with the objectives of the global strategy; • identifying and disseminating information on evidence-based interventions, policies and structures that are effective in optimizing the level of physical activity and promoting healthy diets in countries and communities;
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• providing appropriate technical support to build national capacity in planning and implementing the national strategy and in tailoring the strategy to local circumstances; • providing models and methods so that interventions on diet and physical activity are a systematic component of health care; • promoting healthy diet, nutrition and physical activity as an essential part of training for health professionals, by promoting and supporting training for health professionals in healthy diets and an active life, either as part of existing programmes or in special workshops, as key components of the strategy; • advising, coordinating and supporting Member States, using standardized surveillance methods and rapid assessment tools (such as WHO’s STEPwise approach to surveillance of noncommunicable disease risk factors), to measure changes in population distribution of risk – including patterns in diet, nutrition and physical activity – in order to assess the current situation, trends, and the impact of interventions. WHO will support Member States in establishing national nutrition surveillance systems, linked with data on the content of food items; • advising Member States on ways of engaging constructively with industry. 28. WHO, in close collaboration with United Nations agencies and other intergovernmental organizations (FAO, United Nations University and others), research institutes and other partners, will promote and support research in priority areas to facilitate programme implementation and evaluation. WHO will commission scientific papers, conduct analyses, and hold technical meetings on priority, practical research topics that are essential for effective country action. The use of evidence, including health impact assessment, cost-benefit analysis, national burden-of-disease studies, evidence-based intervention models, scientific advice and dissemination of good practice, should be improved to inform the decision-making process. 29. WHO will work with WHO collaborating centres to establish networks for research and training, mobilize resources, and facilitate coordinated, collaborative research as it pertains to the needs of developing countries in the implementation of this strategy. The networks will support WHO’s mandate for capacity building and will also serve to mobilize the contributions from nongovernmental organizations and civil society to the implementation of the strategy.
Member States 30. In order to improve diet and physical activity, this global strategy will foster the formulation of, and promote and support national policies and plans. Because of the great variations in and between different countries, regions should collaborate in implementing the strategy; regional strategies can provide considerable assistance to countries in implementing their national policies. 31. The role of government is crucial to achieving lasting change in public health. Governments have a primary steering and stewardship role in initiating and developing the strategy, ensuring that it is implemented and monitoring its impact in the long term. 32. Health ministries have an essential responsibility for coordinating and facilitating the contributions of many other ministries and government agencies. These include especially: ministries
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and governmental institutions with responsibility for policies on food, agriculture, youth, recreation, sports, education, commerce and industry, finance, transportation, media and communication, social affairs and environmental/sustainability planning, as well as local authorities and those responsible for urban development. 33. Governments are encouraged to build on existing structures and processes that already address aspects of diet, nutrition and physical activity. In many countries, existing national strategies and action plans on food, diet, nutrition and physical activity can be developed in accordance with this strategy, while in others they can be developed as the basis for advancing noncommunicable disease control. There should be a national coordinating mechanism that addresses diet and physical activity within the context of a comprehensive noncommunicable disease prevention and health promotion plan. Local government authorities should be closely involved. Expert advisory boards should be multisectoral and multidisciplinary; they should include technical experts and representatives of government agencies, with an independent chair to ensure that scientific evidence is interpreted without any conflicts of interest. 34. National strategies, policies and action plans that are developed to promote healthy diets and physical activity for the prevention of noncommunicable diseases should be supported by effective legislation, an appropriate administrative infrastructure and adequate funding. The various aspects of national strategies, policies and plans include: (1) national strategies on diet and physical activity: National strategies describe the measures to promote healthy diets and physical activity that are crucial to disease prevention and the promotion of health of the population, including integrated strategies for comprehensively addressing all aspects of unbalanced diets, including undernutrition and overnutrition. National strategies and action plans should include specific goals, objectives, and actions, similar to those outlined in this strategy. Of particular importance is the need to focus on elements that are necessary to implement the plan of action. These elements include identification of necessary resources and national focal points (key national institutes); intersectoral collaboration between the health sector and other key sectors such as agriculture, urban planning, and transportation; and monitoring and follow-up. (2) national dietary guidelines: The report of the Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases and recommendations of national expert bodies may form the basis for national guidelines. Such guidelines guide national nutrition policy, nutrition education efforts, other public interventions and intersectoral collaboration. These guidelines may be updated periodically in the light of changes in dietary and disease patterns. (3) national physical activity guidelines: National guidelines for health-enhancing physical activity should be prepared in accordance with the aims of this strategy and available expert recommendations. 35. Provision of accurate and balanced information should be ensured. Governments need to consider actions that will result in balanced information for consumers to allow healthy choices to be easy decisions, and to ensure the existence of appropriate health promotion and education programmes. In particular, information for consumers should be sensitive to literacy levels and the local culture, and understood by all segments of the population. In some countries, health-promoting programmes have been designed to address communication barriers and needs such as literacy levels. These programmes should be utilized for disseminating information about diet and physical activity. Some governments already have a legal obligation to ensure that factual information enables 10
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consumers to make fully informed choices on matters that may affect their health. On the other hand, actions may be specific to the policies adopted by the governments of particular countries. Governments should select the optimal mix of policies and programmes that are in accord with their national capabilities and epidemiological profile. The selection of what is best for an individual country will vary. Areas for action could include: (1) education, communication and public awareness: Appropriate public knowledge on the relationship between physical activity, diet and health, on energy intake and output, on diets and patterns of physical activity that lower the risk of noncommunicable diseases, and on healthy choices of food items provides a basis of good policy. There should be a platform for developing consistent, coherent, simple and clear messages, to be conveyed by government experts, nongovernmental and grass-roots organizations, and industry. Such messages should be communicated to people through several channels and in forms appropriate to local culture, age and gender. Schools, workplaces, educational and religious institutions, nongovernmental organizations, community leaders, as well as mass media, are in key positions to influence behaviour. Member States should form alliances to convey appropriate and effective messages about healthy lifestyles, including diet and physical activity. Health, nutrition and physical activity education and media literacy skills, starting in primary school, are important to counter food fads and misleading dietary advice. It is also important to provide support for action in developing countries that improves the level of health literacy, while taking into account local cultural and socioeconomic circumstances. (2) marketing, advertising, sponsorship and promotion: Food advertising affects food choices and influences dietary habits. Food and beverage advertisements should not exploit children’s inexperience or credulity. Messages that encourage unhealthy dietary practices or physical inactivity should be discouraged, and positive, healthy messages encouraged. Governments should work with consumer groups and with the industry (including the advertising sector) to develop appropriate approaches to deal with the marketing of food to children. (3) labelling: Consumers have the right to accurate, standardized and comprehensible information on the content of food items so that it is conducive to making healthy choices. Governments may require information on key nutritional aspects, as proposed in the Codex Guidelines on Nutrition Labelling.1 (4) health claims: As consumers’ interest in health grows, and increasing attention is paid to the health aspects of food products, producers increasingly use health-related messages. Such messages must not mislead the public about nutritional benefits or risks. 36. National food and agricultural policy should ensure consistency with the protection and promotion of public health. Governments should examine all food and agricultural policies for intended and unintended effects on the healthiness of the food supply. Food and nutrition policy should cover nutrition, food safety and sustainable food supply. Where needed, governments should consider policies that provide incentives and support for the production and marketing of healthier food. Efforts could involve support for: production and marketing (including storage, transport, preservation, and promotion) of fruit, vegetables and legumes and other healthy produce; innovations to produce healthier foods; distribution chains and policies for the export of healthy products. Member
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Codex Alimentarius Commission, document CAC/GL 2-1985, Rev. 1-1993.
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States are also encouraged to use tax policy and other fiscal measures in a manner that promotes health and is fiscally sustainable. Areas for action could include: (1) promotion of healthier food items: As a result of consumers’ increasing interest in health and the growing interest of governments in healthy nutrition, some governments have undertaken various measures, including market incentives, to promote the development, production and marketing of healthier food items. Many companies have responded by developing new products and are committed to reducing incrementally the levels of saturated fats, sugar and salt in their products as well as portion sizes. Governments could consider additional measures to encourage the reduction of the salt content of processed foods, measures to restrict hydrogenation of oils, and methods of reducing the excess sugar content of beverages and snacks. (2) price policies: Price reflects production costs and influences consumption choices. Public policies can influence prices through taxation, subsidies or direct pricing in a way that encourages healthy eating and lifelong physical activity. Several countries use fiscal measures to promote availability of and access to various foods; others use taxes to increase or decrease consumption of food; and some use public funds and subsidies to promote access among poor communities to recreational and sporting facilities. (3) food programmes: In many countries, there are programmes to provide food to population groups with special needs or cash transfers to enable families to improve their food purchases. Such programmes often concern children, families with children, poor people, and people with HIV/AIDS and other diseases. Special attention should be given to the quality of the food items and to nutrition education as a main component of these programmes, so that food distributed to or purchased by the families not only provides energy, but also contributes to a balanced and healthy diet. Food and cash distribution programmes should emphasize empowerment and development, local production and sustainability. (4) agricultural policies: Agricultural production often has a great effect on national diets. Governments can influence agricultural production through many policy measures. As emphasis on health increases and consumption patterns change, Member States need to take healthy nutrition into account in their agricultural policies. 37. Multisectoral policies to promote physical activity are needed. National physical activity policies should target change in a number of sectors. Governments should review national physical activity policies to ensure that they are consistent with best practice in population-wide approaches to increasing physical activity. Areas for action include: (1) ministries of health should take the lead in forming partnerships with key agencies, in order to develop with them a common agenda and work plan aimed at promoting physical activity; (2) promoting environments that facilitate physical activity, and developing the supportive infrastructure to increase access to and usage of these environments and facilities; (3) developing and implementing strategies to change social norms and to increase community understanding and acceptance of the need for integrating physical activity into everyday life (active living);
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(4) reviewing relevant public policies and legislation that have an impact on opportunities for physical activity – examples include policies on transport, urban planning, education, labour, social inclusion, and on health care funding related to physical activity; (5) promoting community policies related to physical activity – national and local governments can develop policies and provide incentives to ensure that (i) walking, cycling and other forms of physical activity are easy and safe; (ii) transport policies include non-motorized modes of transportation; (iii) labour and workplace policies encourage physical activity; and (iv) sport and recreation facilities embody sport-for-all concepts and principles. 38. School policies should support the adoption of healthy diets and physical activity. Schools influence the lives of most children in all countries. They should protect the good health of children by providing health information, teaching health literacy, and promoting healthy diets and physical activity, as well as other healthy behaviours. Schools should require daily physical education and should be equipped with appropriate facilities. Policies should support healthy diets at school and limit the availability of products high in salt, sugar and fats. Schools should consider, together with other responsible authorities, developing contracts with local food growers for school lunches to ensure a local market for healthy foods. 39. Policy consultations should be arranged. For public policies to be accepted and effective, there needs to be broad public discussion and involvement. To achieve this, Member States should establish mechanisms to ensure participation of nongovernmental organizations, civil society, communities, the private sector and the media in activities related to diet, physical activity and health. Ministries of health should be given responsibility for establishing these mechanisms, which should aim at strengthening intersectoral cooperation at the national, provincial and local levels and at encouraging community participation, and should be part of the community planning process. 40. Prevention should be built into health services. Routine contacts with health service staff should include practical advice to patients and families on the benefits of optimal diets and increased levels of physical activity. Governments should consider incentives to encourage preventive services and identify opportunities for prevention within existing clinical services. Governments should also consider an improved financing structure to encourage and enable health professionals to dedicate more time to preventing and managing chronic diseases. Areas for action could include: (1) health and other services: Health services, especially for primary health care, but also other services (such as social services) can counsel individuals on healthy diets and necessary physical activity. They should take a life course approach that stresses the importance of prenatal nutrition, exclusive breastfeeding for six months, and healthy diet and continuing regular physical activity from youth into old age. Special attention should be given to the new WHO growth standards for infants and preschool children (in preparation). These standards help to expand the definition of health beyond the absence of overt disease, to include the adoption of healthy practices and behaviours recommended by WHO and other national and international agencies (e.g., breastfeeding, nutritionally adequate and safe complementary feeding, nonsmoking and other lifestyle circumstances that promote physiological growth). Routine inquiries as to key dietary habits and physical activity, combined with simple counselling, can reach a great part of the population and be a cost-effective intervention. The measurement of key biological risk factors, such as blood pressure, serum cholesterol and body weight, combined with education of the population and counselling of patients, helps to promote the necessary changes. The identification of specific high-risk groups and measures to respond to their needs, including possible pharmacological interventions, are important components. Training of health
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personnel, availability of appropriate guidelines and possible incentives are key underlying factors in implementing these measures; (2) involvement with health professional bodies, health and consumer groups: Public awareness of government policies will be increased, and their effectiveness amplified, by enlisting strong professional, consumer and community support in a cost-effective way. 41. Investment should be made in surveillance, research and evaluation. Monitoring major risk factors and their responsiveness to changes in polices and strategies is critical. Many governments can build on systems already in place, at either the national or the regional level. Emphasis should initially be given to standard measures of physical activity, selected dietary components, and to body weight, as well as to levels of blood pressure, serum cholesterol and blood glucose and to tobacco use. National data, comparable among countries, are essential. Data that provide insight into withincountry patterns and variations are useful in guiding community action. Where possible, other sources of data should be used; for example, the transport and agriculture sectors and other sectors. Areas for action could include: (1) monitoring and surveillance: Monitoring and surveillance are essential tools for national diet and physical activity policies. Ongoing and standardized monitoring of diet, physical activity, nutrition-related biological risk factors and contents of food products, and communication to the public of the information obtained is an important part of national diet and physical activity policy. Of particular importance is the development of methods and procedures utilizing standardized data collection and a common minimum set of indicators, in collaboration with WHO. (2) research and evaluation: Applied research, especially in community-based demonstration projects, and in evaluating different interventions and policies, should be promoted. Such research (e.g., into the reasons for physical inactivity and poor diet, and on key determinants of effective intervention programmes), combined with the increased involvement of behavioural scientists, will lead to better informed policies and policy-makers and ensure that a cadre of expertise is created at national and local levels. Equally important is the need to put in place effective mechanisms for evaluating the efficacy and cost-effectiveness of national disease prevention programmes and policies, as well as the health impact of other policies. More information is needed, especially on the situation in developing countries. 42. Institutional capacity. Under the health ministry, national institutions for public health, nutrition and physical activity have an important role as focal points for experience, coordination and monitoring in relation to the implementation of national diet and physical activity programmes. They can provide the necessary expertise, monitor the developments, help to coordinate activities, participate in international collaboration and advise political decision-makers. 43. Financing national programmes. Various sources of funding, in addition to the national budget, to assist in the implementation of effective national diet and physical activity programmes, should be identified. The United Nations Millennium Declaration (September 2000) recognizes that economic growth is limited unless people are healthy. The most cost-effective interventions to contain the noncommunicable disease epidemic are prevention and a focus on the risk factors associated with these diseases: unhealthy diets, physical inactivity and tobacco use. Programmes aimed at promoting healthy diets and physical activity should therefore be viewed as a developmental need and should draw policy and financial support from national plans for development. At the same time, care must be exercised to avoid the distortions that often accompany accelerated development and adversely affect diet and patterns of physical activity. 14
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International partners 44. The role of international partners is of paramount importance in achieving the goals and objectives of the global strategy, particularly with regard to issues of a transnational nature, or where the actions of a single country are insufficient. Coordinated work is needed within the United Nations system and with major international agencies, nongovernmental organizations, professional associations, research institutions and the private sector. 45. WHO will enhance its long-standing collaboration with FAO in implementing the strategy. The latter organization has a special role in developing agricultural policies through its work with farmers and others involved in food production, and can play a crucial part in implementing the strategy. The composition of foods in production, and the supply and processing systems along the food chain, will need increasingly to respond to consumer demand and become more environmentally sound, economically viable and nutritionally balanced. Thus, more research into food supply, availability, processing and consumption will be necessary. 46. Collaboration with United Nations organizations. As a result of the strategy development process, closer interaction has also developed with other organizations of the United Nations system, such as UNESCO and UNICEF, and other partners, including the World Bank. Cooperation is also planned with organizations such as ILO, the United Nations Economic and Social Council, the regional development banks, WTO and the United Nations University. WHO will work with appropriate international agencies in developing and strengthening partnerships, including global and regional networks, consistent with the goal and objectives of this strategy, and in order to disseminate information, exchange experiences, and support regional and national initiatives. International collaboration will be promoted through the establishment and the coordination of networks. WHO will convene an ad hoc committee of the concerned United Nations partners to ensure continuing policy coherence and in order to draw upon each organization’s unique strengths. Partners can play an important role in a global network that targets such areas as advocacy, resource mobilization, capacity building and collaborative research. 47. Specific areas in which international partners could play a role in implementing the global strategy and policies for noncommunicable disease prevention and control include: • developing comprehensive intersectoral global strategies on diet, physical activity and prevention of noncommunicable diseases, including for instance the promotion of healthy diets in poverty-alleviation programmes; • drawing up guidelines for preventing nutritional deficiencies and infectious diseases in order to integrate and harmonize future dietary and policy recommendations designed to prevent and control noncommunicable diseases; • facilitating the development of national guidelines on diet and physical activity, in collaboration with national agencies; • cooperating in the development, testing and dissemination of models of community empowerment, involving local production, nutrition and physical activity education and enhanced consumer consciousness;
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• promoting the inclusion of noncommunicable disease prevention and health promotion policies relating to diet and physical activity as components of development policies and programmes; • promoting incentive-based approaches for global markets to encourage chronic disease prevention and control. 48. International standards. Public health efforts may be strengthened by the use of international norms and standards, particularly those developed by the Codex Alimentarius Commission (see resolution WHA56.23). Areas for further development include: labelling to allow consumers to be better informed about the benefits and content of foods; minimizing the impact of marketing on unhealthy dietary patterns among children; increasing information about healthy consumption patterns, including taking steps to increase the availability/consumption of fruit and vegetables; and production and processing standards. New multi-stakeholder approaches involving governments, private companies and consumer groups may be required to address issues such as sponsorship, promotion and advertising.
Civil society and nongovernmental organizations 49. Diet and physical activity are a fundamental part of the daily behaviours of individuals living within communities. Civil society and nongovernmental organizations have an important role to play in influencing both individual behaviour and the organizations and institutions that affect diet and physical activity. An important aim is to ensure that consumers ask that governments support healthy lifestyles, and that industry provides healthy products. Nongovernmental organizations can support the strategy effectively if they collaborate with national and international partners. Civil society and nongovernmental organizations can particularly: • lead grass-roots mobilization and advocate for healthy diets and physical activity to be placed on the public agenda; • support the wide dissemination of information on how to prevent noncommunicable diseases through balanced, healthy diets and physical activity; • form networks and action groups to promote the availability of healthy foods and possibilities for physical activity, and advocate for and support health-promoting programmes and health education campaigns; • organize campaigns and events that will stimulate action; • emphasize the role of governments in protecting and promoting public health, healthy diets and physical activity; monitor progress in achieving objectives; and monitor the work of other stakeholders such as the private sector; • play an active and leadership role in fostering the implementation of the global strategy; • put knowledge and evidence into practice.
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Private sector 50. The private sector can be a significant player in promoting healthy diets and physical activity. Food companies, retailers, sporting goods companies, the catering industry, advertising and recreation companies, insurance and banking groups, pharmaceutical companies and the media all have crucial parts to play as responsible employers and as advocates for healthy lifestyles. All could become partners with governments and nongovernmental organizations in implementing measures aimed at sending positive and consistent messages to facilitate and enable integrated efforts to encourage healthy eating and physical activity. Because many companies operate globally, international collaboration is crucial. Cooperative rather than adversarial relationships with industry have already led to many favourable outcomes related to diet and physical activity. Initiatives undertaken by the food industry to modify the fat, sugar and salt content of processed foods and to review many current marketing practices could accelerate health gains worldwide. Specific recommendations include the following: • promote healthy diets and physical activity in accordance with national guidelines and international standards and the overall aims of this global strategy; • limit the levels of saturated fats and trans-fatty acids, sugar and salt in existing products; • continue to develop and provide affordable, healthy and nutritious choices to consumers; • review the case for introducing new products with better health profiles; • provide consumers with adequate product and nutrition information; • follow responsible marketing practices that support the strategy, particularly with regard to the promotion and marketing of foods high in saturated fats, sugar or salt, especially to young children; • implement simple, clear and consistent food labelling practices and evidence-based health claims that will help consumers to exercise informed and healthy choices with respect to the nutritional content (salt, quality and quantity of fat and sugar) of foods; • provide information on food composition to national authorities; • manufacturers of sporting goods and related products can assist in developing and implementing physical activity programmes. 51. Workplaces are important settings for health promotion and disease prevention. In order to reduce exposure to risk through changes in patterns of diet and physical activity, people need to be given the opportunity to make healthy choices in the workplace. Further, the cost to employers of morbidity attributed to noncommunicable diseases is increasing rapidly. Workplaces should provide healthy food choices in cafeterias and support and encourage physical activity.
FOLLOW-UP AND FUTURE DEVELOPMENTS 52. Member States and WHO will monitor and report on the progress made in implementing the global strategy and in developing national strategies. Their reports will cover the following aspects:
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• patterns and trends of diet and physical activity and major noncommunicable disease risk factors related to diet and physical activity; • evaluation of the effectiveness of diet and physical activity programmes and policies; • information on the constraints or barriers encountered in the implementation of the strategy and the measures taken to overcome them; • information on legislative, executive, administrative, financial or other measures undertaken within the context of this strategy. 53. WHO will work through its regional offices and with Member States on plans for implementing and developing a monitoring system and relevant indicators on diet and physical activity. 54. Drawing on the experience gained, WHO will prepare a report on the progress of the implementation of the strategy, with possible proposals for amendments, for submission to the Fifty-ninth World Health Assembly in 2006.
CONCLUSIONS 55. Actions, based on scientific evidence and the cultural context, need to be implemented and monitored with assistance and leadership from WHO. But WHO and its Member States cannot succeed alone. A truly multisectoral approach that mobilizes the combined energy, resources and expertise of all global stakeholders is essential for sustained progress. 56. Progress in changing patterns of diet and physical activity will be gradual, and national strategies will need a clear plan for long-term and sustained disease-preventive measures. However, changes in risk factors and noncommunicable disease rates can occur quite quickly when effective interventions are made. National plans should therefore also have achievable short-term and intermediate goals. 57. The implementation of this strategy could lead to one of the largest and sustained improvements in population health ever seen. Success will result in improvements in global health that can rarely be matched by other possible measures.
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