WPRlRC53/SRl5
SUMMARY RECORD OF THE FIFTH MEETING Room A of the Kyoto International Conference Hall Wednesday, 18 September 2002 at 2 p.m. CHAIRPERSON: Dr Hideo SHINOZAKI (Japan) CONTENTS page 1.
Ministerial round table: diet, physical activity and health .............................. . ANNEX 1 ANNEX 2 A strategy for the prevention and control of noncommunicable diseases: a new challenge .................. . Physical activity and exercise - the enabling instruments ...
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MINISTERIAL ROUND TABLE: DIET, PHYSICAL ACTIVITY AND HEALTH: Item 18 of the Agenda (Document WPRJRC53/12) The CHAIRPERSON explained that this year's ministerial round table would be
preceded by presentations by two internationally renowned experts on diet, physical activity and health. The first speaker was Professor W. Philip T. James, Director of the Public Health Policy Group and Chairman of the International Obesity Taskforce. A summary of his presentation may be found in Annex 1. The second speaker was Dr M. Jegathesan, Chief Executive Officer, Sistem Hospital Awasan Taraf and Adjunct Professor, Faculty of Medicine and Health Sciences, University
Putra Malaysia. A summary of his presentation may be found in Annex 2. Dr Jegathesan also served as moderator of the round table. The presentations were followed by the ministerial round table on diet, physical activity and health.
The meeting rose at 5.45 p.m.
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ANNEXl A STRATEGY FOR THE PREVENTION AND CONTROL OF NONCOMMUNICABLE DISEASES: A NEW CHALLENGE
By Dr W. Philip T. James
The Asian challenge The escalating chronic diseases of adulthood are now the principal health burdens in the Asia-Pacific region. They already dominate health services and will increase markedly over the next 20 years. Governments should regard their populations as unusually prone to excessive weight gain and particularly abdominal obesity, type 2 diabetes, hypertension, ischaemic heart disease and strokes. There is reasonably clear evidence that these diseases are more severe and appear earlier in Asia than in other regions; probably because of the unusual combination of intergenerational mild to severe malnutrition of women and their children in combination with the sudden transition in eating habits and activity patterns. The health burdens caused by these diseases are probably increasing more rapidly in Asia than anywhere else in the world and governments can no longer ignore the problem. The question is: what should they be doing?
The dilemmas facing prevention There are three dilemmas: first, the assumption that prevention is slow and its effects small. This is wrong. Second, it is not often understood that the greatest health gains for a country usually come from changing the behaviour of the average family, rather than from focusing on high-risk groups. Third, the causes of the Asian epidemic of chronic diseases are environmental, so they need to be remedied by extensive measures, including some taken by ministries outside the health sector. Health services often have to cope with the consequences of other government policies.
The causes of noncommunicable diseases: the pressures Foods and drinks have an increasing energy density. This is because of reductions in the intake of vegetables, fruit and other high-fibre starchy foods and increases in animal fats, vegetable oils and sugars or syrups in poorer quality foods and drinks. Intensive marketing and changing cultural perceptions are contributing to the retreat from Asian foods. Physical
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activity is falling rapidly because of the systematic and highly successful measures by governments and commerce to reduce the need for physical work in the home, in transport and at the workplace. The challenge for ministries of health therefore is to work out the principal forces and processes involved and, where possible, to develop, with other ministries, measures which include effective public/private partnerships. These should include methods of handling any industrial group which does not adapt its products and approaches and uses techniques to confuse, question or obstruct change. The health costs of chronic diseases are now the concern of ministries of fmance, but many do not have access to health impact assessments of different options for change. Nor have many ministries of health managed to nurture the public, the media or the politically-active sector to gain the backing needed for change.
A new approach: define the principal drivers of both sedentary behaviour and the passive overconsumption of energy-dense diets To consider where changes are needed, first the principal contributors to fat, saturated fat, salt and syrup sugar intakes need to be assessed. This then allows targeting of (I) appropriate food and drink, and (2) the locations where these are consumed, e.g. home, school, work or "fast food" outlets. Table 1 provides a format for considering the major issues relating to physical facilities and the arrangements for food provision and physical activity. It includes economic issues requiring the ministry of health or associated ministries to contribute public funds or to specify charging schemes for public services. Policy development and socio-cultural issues are treated as separate categories. Socio-cultural issues are included because policy-makers are often concerned that particular sectors of society may have an inappropriate perception or a culturally-based conviction that a particular approach to a problem is appropriate or wrong. In such cases, health education, advocacy and promotional campaigns can be useful. Table 1 therefore simply illustrates the way that a ministry of health can think through the problems of how best to deal with critical issues requiring change; recognizing that some can be dealt with by altering funding priorities within the ministry, adopting new regulatory arrangements or by providing public information in an innovative way. Others are the responsibility of other ministers; the evidence from recent food safety problems shows the need for civil society backing for ministries of health when negotiating with other powerful ministries.
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Annex 1 Major issues to be considered in relation to food and drink Major issues to be considered in relation to food and drink include: Nutritional management of disease: criteria and drug use; health of medical personnel Facilities and standards of education and food provision for schoolchildren Breast-feeding promotion and controls on marketing to pre-school children Novel approaches to public and private sector catering; controls on restaurants Fast foods and drinks; safety, control options; pricing policies. The rural/urban transition and its effects on food availability; strategies for change Local food production and food manufacturing for health Urban planning as towns and cities grow rapidly: avoiding "food deserts" for the poor. Simple food labelling and standards; role of the Ministry of Health in the Codex Alimentarius Commission and the World Trade Organization Physical issues to be considered in avoiding sedentary states Physical issues to be considered in relation to avoiding sedentary states include: Prescribing exercise for staff and patients: promoting new evidence of benefits of exercise Hospital and health centre facilities in Asia: facilitating cycling and public transport Public and private sector workers' facilities: facilitating routine exercise School environments, facilities, priorities in education; considering sex differences Transport policies: making streets safe, controlling car use, promoting walking and cycling Work-based initiatives and transport to work
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Taking the initiative and ensuring progress Many health initiatives fail because governments develop them in response to new demands for action. However, new priorities soon divert the attention of ministers and senior officials. In practice progress is rarely made without involving the "four Ps": politicians, professionals, press and public. International experience, for example in Thailand in combating childhood malnutrition, shows that dramatic progress can be made if there is wide media, local government and community involvement. For example, ministries of health may chose to recruit an independent activist group or institution of professionals with civil society involvement to maintain momentum and provide ministries of health with political support. This is particularly important if health ministries are to gain effective cooperation from other ministries, for example education, agriculture, trade, transport, economic development or fmance, where health priorities are rarely considered and where the responses to health proposals on chronic diseases are often seen in terms of the need for "health education". There is a need to redefme health impact assessments, taking into account other government departments' policies, and to change the perception of the health sector as a cost to government to a societal investment. Thus health issues are often seen by governments as being less significant than an offer of investment or trade opportunities in agriculture, food manufacturing or retailing. Both affluent and less affluent countries in the Region are faced with alarming projections for disease and disability which could be combated by retaining many features of traditional Asian diets and not following the disastrous policies of Western countries.
Ministry of Health'. direct responsibilities Dietary quality; physical activity Physical Appropriately accessible health centres Promoting access to appropriate self· monttoring systems e.g. weigh~ blood pressure
Other ministries: specified on a national basis Environmental health Issues Fluoridation systems for water Facilities for iodizing salt Physical activity; Dietary quality; Ensuring playgrounds in schools, su~ble cycling and road systems; urban planning; sports facilities Designated urban areas for local food production
Food sarvty Jnutrition Catering in hospitals; mon~oring facilities
Food safetyJ nutrition Provision of appropriate local abattoirs Proper public toilet and sanitary facilities Proper catering facilities based on stringent hygiene requirements. Link to nutritional needs Establish appropriate penalties for inappropriate hygiene
Environmental health Issues Urban planning: green spaces, cycle paths, pm, playgrounds, lead-free air Establish facilities for fanners' markets
Economic
Primary health payments
for specific targets in management
Penalties for providing unsafe food; sales and tax policies in relation to nutritional quality of different food groups
Subsidize iodine for iodination purposes
RlHlvaluate taxation and subsidy policies
Consider agricultural subsidies/taxes in health terms Finance new public transport systems Promote urban agriculture, new outiets for high qual~, affordable foods in deprived areas Relonn agriculture policies Develop soil improvement, clean water, agricultural recycling, planting, fertilizer, pesticide, water use policies
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Policy
Baby·friendly Hos~ls Dietary guideijnes Establishing fortification policies Establish poijcies on health claims, e.g. functional foods
Health impact of multisectorai food safety policies
Establish specific guidelines for toxicants and contaminants in soil, water and primary food products Health impact assessment of agrochemical use
Health impact assessments of agricultural developments Food labeijng with appropriate, understandable health·related information
Establish criteria for ensuring pathogen and contaminant·free access to the food chain Establish systematic hazard analysis critical control point (HACCP) for food chain, systematic surveillance and mechanisms for emergency response Establish new criteria for excluding antibiotics as growth promoters and spec~ing veterinary use Educational initiatives for safety of fast food ouUets, modifying nutrient composition, and limiting and ensuring appropriate food waste disposal
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Sociacultural
Health education
Promote concept of limited clinical antibiotic use
Promote new concept of health impact of new traffic policy
Promote physical activity in the workplace Create breaslfeeding time and space in the workplace with NGO help
Change attitudes to cycle path use, pedestrian areas Educational initiatives lor caterers, communal use of school recreational facilities ,
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SUMMARY RECORD OF THE FIFTII MEETING
165 ANNEX 2
PHYSICAL ACTIVITY AND EXERCISE-THE ENABLING INSTRUMENTS Datuk Dr M Jegathesan Physical activity and exercise are recognized to be health-enhancing activities that promise not only to add 'years to one's life' but also 'life to one's years'. The principles governing their application have been evolving but are now fairly well understood. The global promotion of healthy lifestyles is making progress but has not yet reached all societies. There are barriers dividing knowledge and its application at both community and individual levels. At the individual level, clearly there are many who do not have access to knowledge about healthy behaviour and hence are not in a position to adopt it. However, even those who know about healthy behaviour often show 'inertia', and a lack of motivation to practice it. We can call this the 'knowledgelbehaviour paradox'. At the community level, barriers to implementation include lack of political will, absence of conviction, opposing interests (both political and economic), inadequate resources, and inappropriate criteria for prioritizing resource allocation.
Strategies for individuals and communities Health authorities have to find strategies that will be able to bridge these gaps. Healthenhancing activities, far from being difficult to implement, can be readily integrated into most people's lives by making relatively minor adjustments to daily routines. They need not necessarily be expensive in terms of time or money. On an individual level, all that is
required is the personal decision to make the change, the commitment to see it through and the motivation to sustain it. While such personal involvement will benefit the individual, wide public health impact can only be achieved if healthy behaviour is practised by large sectors of the population. For this, the government and public authorities have to provide awareness, expertise and an enabling or facilitating environment.
What it takes To enjoy the benefits of an exercise programme, all that needs to be done is for about 30 minutes, three to four times per week, to be allocated to appropriate exercise. This is the minimum requirement. Effective exercise does not have to be done in a single block of time
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Annex 2 and can be split into two or three ten-minute sessions per day. Nor does it always have to be formal, regulated activity. Much exercise can be done in an opportunistic way by, for example, walking instead of riding, taking the stairs instead of elevators, etc.
The role of health policy-makers
National policies Although many of the ingredients needed for holistic implementation of healthy lifestyle programmes are the responsibility of various agencies and ministries, health policymakers and managers can play an important catalytic role. They can have an effect across the entire spectrum, from national policies to influencing the behaviour of individuals.
Mechanisms for coordination A mechanism needs be created for this multisectoral collaboration and cooperation. One example would be a national fitness council, which could cut across several ministries or agencies. The tenets healthy lifestyle concept will need to be integrated into existing national policies covering health, development, education, town planning, sports, housing, human resources, transport, etc. It can become part of existing programmes such as 'healthy cities' and 'healthy workplaces'. Successful execution of this could be through a spectrum of interaction ranging from promotion (and advocacy), persuasion, pressure, to penalties (through legislation).
The enabling environment: facilities and programmes
The 'enabling environment' that needs be created will include the provision for facilities, equity of physical and economic access to them, and removal of obstacles for their use. Facilities would include recreational parks as well as mandatory facilities in housing Facility provision must go hand in hand with
areas, schools, universities and workplaces.
programmes that will facilitate and encourage their use. This will include introducing, reintroducting or re-emphasizing activities such as physical education in schools, competitive and recreational sports in institutions and exercise breaks in workplaces. Conditions should be in place to encourage the use of public transport, cycling and walking.
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Annex 2 Motivation Facilities and programmes will only have an impact if users are motivated. Hence awareness and promotional campaigns using the power of the media, the Internet and advertising are needed. So too are events encouraging mass participation especially involving entire families. Programmes and facilities will have to take into consideration cultural and social sensitivities. They can be augmented by incentives ranging from tax breaks for fitnessrelated expenses, discounts off insurance premiums for 'healthy behaviour', appropriate recognition and rewards such as inclusion in the criteria for university admissions and career promotions.
Strategic partnerships Apart from intersectoral collaboration and coordination there is a need for strategic partnerships with the private sector and with NGOs. Movements promoting 'family values' and combating substance abuse can make powerful allies.
Sport/fitness axis The relationship between national sporting prowess and fitness in the population at large needs to be examined. This should be synergistic, with each nourishing and feeding on each other. A generally fit nation should provide a broader base from which athletic excellence can emerge, while sports heroes should serve as examples and encourage the adoption of active lifestyles. That is, if love for sports is not confmed to the couch in front of the TV.
Fitness culture The end result should be the evolution of a 'fitness culture'. For this, a sustained and relentless effort will be needed. The use of role models such as sports personalities, senior athletes, elite disabled athletes and community and political leaders should be maximized.
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Annex 2
Leadersbip by example In this regard, health policy- and decision-makers will give their advocacy roles a great boost if they can be seen as 'living examples' of what they are advocating.
Conclusion Embracing the route to a healthy lifestyle is one of the most important personal decisions that one can make. It is a practice that is eminently applicable. The inputs in time and effort that an individual needs to make are small compared to the tremendous benefits that can be achieved. However, individuals need an environment that will empower, enable and facilitate and motivate them. This is the responsibility of the civil authorities. For the nation, modest investments in policies and programmes will bring great dividends in terms of increased health, well-being and productivity of the population at large.