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International Nutrition Policy – Theory and Implementation

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Table of content
List of figures ........................................................................................................................................... 5

List of tables ............................................................................................................................................ 7

List of acronyms and abbreviations......................................................................................................... 9

1. Introduction ................................................................................................................................... 13

2. Concept of nutrition policy ............................................................................................................ 14

2.1. Historical overview of nutrition policies and strategies ........................................................ 14

2.2. International nutrition policy ................................................................................................ 15

2.3. The make-up of a nutrition policy ......................................................................................... 16

2.4. Challenges and obstacles in nutrition policy ......................................................................... 18

3. Recent global nutrition initiatives ................................................................................................. 20

3.1. Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition ....... 20

3.2. WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020 ..................... 23

3.3. ICN2 and the Rome Declaration ............................................................................................ 25

3.4. The sustainable development goals ...................................................................................... 27

3.5. United Nations Decade of Action on Nutrition ..................................................................... 30

4. Diet-related causes of morbidity and mortality ............................................................................ 34

4.1. Obesity and non-communicable diseases ............................................................................. 34

4.2. Causes of under-nutrition ..................................................................................................... 35

4.3. Common micronutrient deficiencies: hidden hunger ........................................................... 39

5. Working together towards good nutrition and health.................................................................. 44

5.1. Health in all Policies............................................................................................................... 44

5.2. Key partners involved in international nutrition policies ...................................................... 47

5.2.1. UN System Standing Committee on Nutrition (UNSCN) ............................................... 48

5.2.2. UN Interagency Taskforce on NCDs (UN IATF) .............................................................. 50

5.2.3. Global Coordination Mechanism on NCDs .................................................................... 52

5.2.4. Committee on World Food Security (CFS) ..................................................................... 53

5.2.5. Scaling Up Nutrition (SUN) Movement ......................................................................... 54

6. From theory to practice: implementing nutrition policy .............................................................. 57

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6.1. Translation of nutritional epidemiology findings into dietary guidelines and health policy 57

6.2. Partnership, resource mobilization and key actors in nutrition............................................ 61

6.3. Guiding principles for developing WHO guidelines............................................................... 63

7. “Cost effective” nutrition interventions to combat the double burden of malnutrition .............. 71

7.1. The costs of malnutrition and NCDs ...................................................................................... 71

7.2. Interventions addressing child and maternal malnutrition .................................................. 72

7.2.1. Nutrition of women of child-bearing age and during pregnancy and lactation............ 73

7.2.2. Promotion of breastfeeding and limiting the marketing of breast-milk substitutes .... 81

7.2.3. Food marketing and advertising to children ................................................................. 88

7.3. The Food Systems Approach to ensuring sustainable food and nutrition security .............. 94

7.3.1. The concept of food system .......................................................................................... 95

7.3.2. Sustainable food systems to improve food security and support development .......... 97

7.3.3. A food systems approach to make diets healthier and fight NCDs ............................... 99

7.4. Diet-related NCD interventions ........................................................................................... 100

7.4.1. Limiting the intake of salt, saturated and trans fatty acids and sugars ...................... 100

7.4.2. Consumer education and information: Front-of-package labelling as an effective way

to healthier nutrition ................................................................................................................... 114

7.5. Coping with micronutrient deficiencies: Flour fortification, supplementation, safety

considerations ................................................................................................................................. 120

7.5.1. Background and principles of food fortification.......................................................... 120

7.5.2. Current situation of food fortification ......................................................................... 121

7.5.3. Effectiveness of food fortification ............................................................................... 127

7.5.4. Safety aspects .............................................................................................................. 129

7.5.5. Monitoring and evaluation .......................................................................................... 131

7.5.6. Challenges and obstacles to food fortification and how to address them ................. 132

8. Nutrition in emergencies ............................................................................................................. 135

8.1. Emergencies and their impact on food and nutrition security ........................................... 135

8.2. Global commitment to nutrition in emergencies................................................................ 139

8.3. The UN’s role in emergencies.............................................................................................. 139

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8.3.1. The Humanitarian Reform ........................................................................................... 140

8.3.2. The Transformative Agenda ........................................................................................ 144

8.3.3. The World Humanitarian Summit ............................................................................... 146

8.4. The role of the WHO in emergencies .................................................................................. 146

8.5. Interventions to address acute malnutrition ...................................................................... 152

8.6. Infant and young children feeding in emergencies ............................................................. 154

References ........................................................................................................................................... 158

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List of figures
Figure 1 The multisectoral approach to healthier diet and less malnutrition ...................................... 17
Figure 2 Voluntary global targets for the prevention of noncommunicable diseases to be met by 2025
(within the frame of targets related to nutrition and physical activity) (modified from [WHO, 2013a])
............................................................................................................................................................... 24
Figure 3 The Sustainable Development Goals....................................................................................... 28
Figure 4 Causes of malnutrition (modified from [UNICEF, 2013a]) ...................................................... 38
Figure 5 Causes and underlying determinants of health issues ............................................................ 44
Figure 6 Cooperative network of UN agencies and other stakeholders for the achievement of the
SDGs....................................................................................................................................................... 48
Figure 7 Determinants of the quality of evidence................................................................................. 57
Figure 8 Graphic representations of food-based dietary guidelines from various countries ............... 61
Figure 9 Forms of commitment for nutrition and their reinforcement (adapted from [WHO/FAO,
2018]) .................................................................................................................................................... 62
Figure 10 Process of developing a WHO Guideline [WHO, 2014d] ....................................................... 65
Figure 11 Format of a GRADE evidence profile ..................................................................................... 68
Figure 12 Actors in the development and dissemination of marketing and determinants of its impact
............................................................................................................................................................... 92
Figure 13 The UK Food Standards Agency (FSA) nutrient profiling model developed for OfCom to
classify foods in the context of television advertising to children ........................................................ 94
Figure 14 A model of the activities and outcomes of the food system and their drivers ..................... 95
Figure 15 Sustainability in food systems (modified from [FAO, 2018a])............................................... 98
Figure 16 Global deaths from all causes in 2017 by associated risk factor [GBD, 2018] .................... 102
Figure 17 Age-standardized death rates per 100,000 attributable to systolic blood pressure ≥140 mm
Hg in 2015 by region and socio-demographic index (SDI) .................................................................. 103
Figure 18 The SHAKE package of measures to develop, implement and monitor salt reduction
strategies (adapted from [WHO, 2016b]) ........................................................................................... 105
Figure 19 The REPLACE action package of the WHO [WHO, 2018f] ................................................... 109
Figure 20 Key actions to reduce sugar intake at population level (based on [PHE, 2015]) ................ 111
Figure 21 The NOURISHING Framework of the World Cancer Research Fund to promote healthy diets
and reduce obesity [WCRF, 2018] ....................................................................................................... 113
Figure 22 Examples of front-of-pack labels used in different countries ............................................. 117
Figure 23 Legislative status of salt iodization in 2019 [Global Fortification Data Exchange; Delshad &
Azizi, 2017] .......................................................................................................................................... 122
Figure 24 Countries with mandatory flour and/or grain fortification in 2019 .................................... 123
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Figure 25 Nutrients added mandatorily to wheat flour. ..................................................................... 124

Figure 26 Example of a system for the monitoring and evaluation of food fortification programmes
[Allen et al., 2006] ............................................................................................................................... 132
Figure 27 Chronology of the UN’s Humanitarian System (modified from [OCHA, 2019]) .................. 140
Figure 28. Global cluster lead agencies [IASC, 2015] ......................................................................... 142
Figure 29 Guiding principles of the WHO's response to emergencies [WHO, 2017d] ........................ 150
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List of tables
Table 1 Characteristics of nutrition policies .......................................................................................... 17
Table 2 Differences between disease prevention and health promotion as objectives of health and
nutrition policies .................................................................................................................................... 18
Table 3 Nutrition and its interaction with the Sustainable Development Goals .................................. 29
Table 4 SMART Commitments for action on nutrition .......................................................................... 31
Table 5 Examples of Action Networks ................................................................................................... 32
Table 6 Priorities within the WHO's Ambition and Action in Nutrition 2016-2025 [WHO, 2017a] ...... 32
Table 7 Anthropometric criteria for the diagnosis of malnutrition....................................................... 36
Table 8 Clinical symptoms of protein-energy malnutrition .................................................................. 37
Table 9 Components of food security ................................................................................................... 38
Table 10 Working Groups of the WHO GCM/NCD ................................................................................ 53
Table 11 Comparison of RCTs of drugs and RCTs of nutrients or foods (modified from Satija et al.,
2015)...................................................................................................................................................... 58
Table 12 Elements of the PICO format for the formulation of key questions ...................................... 67
Table 13 Significance of the four levels of quality of evidence in GRADE ............................................. 69
Table 14 Critical nutrients during pregnancy and lactation .................................................................. 74
Table 15 Nutrition-sensitive strategies increase the impact of nutrition-specific actions (modified
from [Arnold, 2016] ............................................................................................................................... 76
Table 16 Supplementation schemes for iron, folic acid and iodine in non-pregnant women of child-
bearing age (15-49 y.) [modif. from WHO, 2013c] ................................................................................ 78
Table 17 WHO recommendations on supplementation with micronutrients during pregnancy and/or
lactation [WHO, 2013c] ......................................................................................................................... 80
Table 18 Ten steps to successful breastfeeding [https://www.who.int/nutrition/bfhi/ten-steps/en/]
............................................................................................................................................................... 82
Table 19 Steps in setting up a national Code monitoring system (based on [WHO/UNICEF, 2017a] ... 86
Table 20 Legal status of the International Code of Marketing of Breast-Milk Substitutes by WHO
region in 2018 [WHO, 2018e] (given as number of countries) ............................................................. 88
Table 21 Recommendations on the marketing of foods and non-alcoholic beverages to children ..... 89
Table 22 Mandatory limits, bans and labelling of trans-fats in foods in 2019 [WHO, 2019a] ............ 108
Table 23 Types of taxes on sugar-sweetened beverages (modified from [WCRF, 2018]) .................. 112
Table 24 Classification criteria for front-of-pack nutrition labels ....................................................... 116
Table 25 Principles for front-of-pack labelling [WHO, 2019b] ............................................................ 119
Table 26 Countries with voluntary fortification of flour and grain products (data from Food
Fortification Initiative Network [FFI]) .................................................................................................. 124
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Table 27 Legal status of flour and grain fortification by WHO region (data from Food Fortification
Initiative Network [FFI]). ..................................................................................................................... 125
Table 28 Status of oil fortification by country in 2019 (source: [Global Fortification Data Exchange
(https://fortificationdata.org)] ............................................................................................................ 126
Table 29 Safety categories of micronutrients based on the recommended nutrient intake level (RNI)
and the tolerable upper intake kevel (UL) [Meltzer et al., 2003]........................................................ 130
Table 30 Integrated food security phase classification (IPC) (modified from [IPC, 2008]). ................ 136
Table 31 IPC acute food insecurity classification at area and household level (modified from [IPC,
2012].................................................................................................................................................... 137
Table 32 Responsibilities of cluster leads at country level [IASC, 2006] ............................................. 143
Table 33 The IASC Protocols [UNICEF, 2018c; IASC website] .............................................................. 145
Table 34 WHO levels for graded emergencies (modified from [WHO, 2017d]................................... 151
Table 35 Definition of WHO protracted grades (modified from [WHO, 2017d]) ................................ 152
Table 36 Composition of multiple micronutrient supplements for pregnant women, designed to
provide daily recommended intake of each nutrient (one RNI) [WHO, 2013c].................................. 157
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List of acronyms and abbreviations

ACC UN Administrative Committee on Coordination

AMDR Acceptable macronutrient distribution range

BFHI Baby-Friendly Hospital Initiative

BMI Body Mass Index (= body weight in kg / (body height in m)2)

BMS Breast-milk substitutes

CEB UN Chief Executives Board for Coordination

CERF Central Emergency Response Fund

CFE Contingency Fund for Emergencies

CFS Committee on World Food Security

CoP Communities of practice

CVD Cardiovascular disease

EAR Estimated average requirement of a nutrient

ECOSOC UN Economic and Social Council

EFSA European Food Safety Authority

EHA Emergency and Humanitarian Action Programme of the WHO

EMR Eastern Mediterranean Region (of the WHO or more general)

ERC Emergency Relief Coordinator

ERF Emergency Response Framework

FAO Food and Agriculture Organization of the United Nations

FBDG Food-based dietary guidelines

FDA U.S. Food and Drug Administration

FFI Food Fortification Initiative

FFQ Food frequency questionnaire

FOP Front-of-pack

FSAU Food Security Analysis Unit for Somalia

GAIN Global Alliance for Improved Nutrition

GBD Global Burden of Disease

GCM/NCD Global Coordination Mechanism on NCDs

GDG Guideline Development Group (WHO)

GRADE Grading of Recommendations, Assessment, Development and Evaluation

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HAC Department of Health Action in Crises (WHO)

HAZ Height-for-age z-score

HC Humanitarian Coordinator

HCT Humanitarian Country Team

HFSS foods Foods and beverages high in saturated fats, trans fats, sugars and salt

HiAP Health in All Policy

HIC High-income country

HLPE High Level Panel of Experts on Food Security and Nutrition

IASC Inter-Agency Standing Committee

ICN International Conference on Nutrition

IFAD International Fund for Agricultural Development

IFE Infant and Young Child Feeding in Emergencies

IGN Iodine Global Network

IMS Incident Management System

IPC Integrated Food Security Phase Classification

L3 emergency Level 3 emergency

LIC Low-income country

LMIC Lower middle-income country

LoU Letter of Understanding

MAM Moderate acute malnutrition

MDD Micronutrient deficiency disease

MoU Memorandum of Understanding

MUAC Mid-upper arm circumference

NCD non-communicable disease

NFA National Fortification Alliance

NHD WHO Department of Nutrition for Health and Development

NTD Neural tube defect

NUGAG WHO nutrition guidance expert advisory group

OCHA Office for the Coordination of Humanitarian Affairs

PEM Protein energy malnutrition

PICO Population, Intervention, Comparator, Outcomes (a format for formulating key

questions when developing WHO guidelines)
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PRI Population reference intake

RCT Randomized controlled trial

RDA Recommended dietary allowance

RNI Recommended nutrient intake

SAM Severe acute malnutrition

SDG Sustainable development goals

SFA Saturated fatty acid

SUN Scaling up Nutrition Movement

TA Transformative Agenda

TFA Trans fatty acid

UL Tolerable upper level of nutrient intake

UN United Nations

UNDAF United Nations Development Assistance Framework

UNDP United Nations Development Programme

UNEP United Nations Environmental Programme

UNGA United Nations General Assembly

UNHCR United Nations High Commissioner for Refugees

UNIATF United Nations Interagency Taskforce on NCDs

UNICEF United Nations Children’s Fund

UNSCN United Nations System Standing Committee on Nutrition

WASH Water, sanitation and hygiene

WCO WHO country office

WFP World Food Programme

WHA World Health Assembly

WHE WHO Health Emergencies Programme

WHO World Health Organization

WHZ Weight-for-height z-score

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Preface
This book is based on teaching material for the post-graduate course “International Nutrition Policy,
Theory and Implementation” offered for Master and PhD students at the Department of Nutritional
Sciences of the University of Vienna, Austria.
The objective of this course and hence, this book, is to acquaint students with the current world
nutrition and health concerns and to familiarize them with the basics, methods, as well as monitoring
and evaluation of employed strategies and intervention programs and how to develop an action plan.
It includes an introduction to the background of global nutrition policy (definition, historical
overview, justification, concept) and examples for its implementation at regional and national level.
In this context, a particular focus is laid on the prevention and control of all forms of malnutrition and
associated noncommunicable chronic diseases, also taking into account a food-systems approach.
Reference will be made to the strategies and problem-oriented interventions of agencies of the UN
system (WHO, FAO, UNICEF, WFP, and World Bank).

Vienna, November 2019 Ibrahim Elmadfa

Ayoub Al-Jawaldeh

Alexa L. Meyer
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1. Introduction
The current global situation of nutrition is characterized by the co-existence of hunger and
undernutrition on the one side and overnutrition leading to overweight and obesity on the other.
Both forms of malnutrition, undernutrition and micronutrient deficiencies as well as overnutrition
and excessive intake of energy substrates like fat and sugar and of sodium, for instance,
concomitantly occur in countries of all income levels alike. Indeed, poverty is often associated with a
high risk of unhealthy nutrition and obesity.
Malnutrition due to inadequate food and nutrient intake is further aggravated by disease making
access to health care and sanitation and the existence of a good social care environment essential
determinants of good nutritional status. Food insecurity that leads to malnutrition is caused and
influenced by many factors besides physical access to food, including the socioeconomic and political
environment. In addition, the effects of climate change and decreasing biodiversity pose an
increasing threat to global food security.
While undernourishment is still a great concern, especially in children and pregnant women, the
global rate of obesity is rising steadily and with it the prevalence of noncommunicable diseases.
Considering that all forms of malnutrition contribute to morbidity and premature mortality and also
exert a high social and economic burden, actions to counteract malnutrition and assure adequate
and healthy nutrition to everyone are urgently needed. In light of the multiple factors influencing
food availability and quality on one side and consumer behaviour on the other, multisectoral
approaches are needed. However, globalization makes it increasingly difficult for countries to act
independently. In turn, the exchange of experiences and support also offers an opportunity to
increase the efficiency of interventions aimed at improving nutrition and health. Recently, nutrition is
receiving more attention as its critical role for development is being recognized. International
nutrition policy borne by the World Health Organization, other UN organizations but also a growing
number of recognized civil society movements provides the framework for coordinated and effective
actions to contribute to the achievement of a sustainable development.
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2. Concept of nutrition policy

2.1. Historical overview of nutrition policies and strategies

A general definition of a policy is that of a principle or a plan to guide decisions, actions and
outcomes. However, the term policy can have a wide range of different meanings. It can be a way of
working or an unwritten cultural or ethical code. Policies include laws, procedures, guiding principles,
statements of intent or working frameworks, in the form of written documents or unwritten
practices. Policies differ in their respective social, economic, political and cultural context and
environment. The development and implementation of a policy can occur through negotiation,
repeated practice, decree, order or convention. Public policy refers to the policy of a government
[WHO, 2015a].
The definition of the World Health Organization of health policy as “decisions, plans, and actions that
are undertaken to achieve specific health care goals within a society [by defining] a vision for the
future which in turn helps to establish targets and points of reference for the short and medium
term, [by outlining] priorities and the expected roles of different groups and [building] consensus and
[informing] people” [WHO] also applies to nutrition policy with a focus on approaches to improve the
diet and the nutritional status of a society by preventing and eliminating one or several forms of
malnutrition.
Historically, the growing detrimental impact of unhealthy diet patterns and excessive food intake is a
very new phenomenon. The fact that, for centuries, the fight against hunger and food shortages was
the main challenge for humanity is still reflected in food policies aiming at assuring an adequate
supply of food for the population. However, in the past, costs, caloric content and shelf life were
generally considered more important than the health value of a food [Mozaffarian et al., 2018]. In
this way, nutrition policy is closely related to food and agricultural policies. Indeed, food aid to the
poor during famines is among the first actions that could be related to food and nutrition policies.
While for a long time, this was largely the domain of private and religious charity institutions like
monasteries, famines in the 19th century as well as food shortages during the two World Wars in
Europe and the United States instigated governments to intervene by regulating food prices, limit
crop exports and increase imports [Webb, 2002]. However, the supply and management of safe
drinking water was regulated since ancient times. It figures in the scriptures of all the great
civilizations and religions [Fisher-Ogden & Saxer, 2012; Raju & Manasi, 2017] and in Greek and
Roman antiquity it was governed by the State [Koutsoyiannis & Patrikiou, 2014; Bannon, 2017]. In
addition, laws regulating the composition and price of certain foods were issued to prevent food
adulteration but this was more done for economic and legal reasons than to protect the consumers’
health as the association of the latter with food quality was in most cases not known [Bush, 2002;
 15

Elmadfa & Meyer, 2012]. Moreover, legislations to protect consumer health remained limited to
regional or local control. It was not until the 20th century that universal standardised guidelines and
regulations on food composition and the control of their quality were established, not least to
facilitate trade. These efforts resulted in the creation of the Codex Alimentarius Commission under
the aegis of the Food and Agriculture Organization of the United Nations (FAO) and the World Health
Organization (WHO) in 1962 that until today is in charge of implementing the Joint FAO/WHO Food
Standards Programme [Vojir et al., 2012].
Among the first discoveries of a direct impact of nutrition on health and disease was the role of
vegetables, potatoes and fruits for the prevention of scurvy [Baly, 1843]. Another important goal of
food and nutrition policies was to ensure sufficient food supply in times of war especially to
adequately feed soldiers. This is exemplified in the enacting of the US Food and Fuel Control Act
(“Lever Act”) by President Woodrow Wilson in August 1917 that was aimed at “encouraging the
production, conserving the supply, and controlling the distribution of food products and fuel”. This
was in part achieved by including the population and appealing to their patriotism. Measures
included limiting food waste and reducing the consumption of wheat, meat and sugar through the
introduction of voluntary meatless and sweetless days and the replacement of wheat by other grains
in breadmaking as these foods were needed for the supply of the US armed forces and their allies
overseas. The recommendation to substitute these products by fresh fruit and vegetable as well as
poultry led to positive changes in the US diet, even though public health was not the primary goal
[Tunc, 2012].

2.2. International nutrition policy

At the global level, despite the emergence of foreign aid programmes, nutrition has long played a
minor role in development policies. In the beginning, until the 1970s, the focus was on single nutrient
deficiency diseases like vitamin deficiency and protein malnutrition. However, since then,
international nutrition policy has known a rapid shift of paradigms. The realization that the social,
cultural, economic and political environment is a strong determinant of food security and nutrition
and that multidimensional approaches are needed to combat malnutrition, particularly in children,
shaped nutrition policy in the following years. The 1980s and 1990s saw the advent of national and
community nutrition policies as well as the awareness of the need for nutrition surveillance. The
elimination of micronutrient malnutrition through supplementation and food-based approaches and
the provision of adequate nutrition in early life as a foundation of future health became a priorities
of this period that still persists to date [Johnsson, 2010; Nomura, 2015]. The recent renewed interest
in nutrition is mirrored in the establishment of the Scaling Up Nutrition Movement in 2010 and the
adoption of the United Nations Global Nutrition Agenda in 2015 that aim at bringing together the
 16

various stakeholders and actors involved in nutrition to end malnutrition [UNSCN, 2010; SUN, 2011;
Nomura, 2015]. Another milestone was the Rome Declaration on Nutrition, the outcome document
of the Second International Conference on Nutrition (ICN2) in 2014 that followed the first
International Conference on Nutrition (ICN) in 1992 (see chapter 3.3), together with the Framework
for Action representing a set of voluntary policy options and strategies [ICN2, 2014a; ICN2, 2014b].
Nutrition is also a central focus of the 2030 Agenda for Sustainable Development with one of the
seventeen sustainable development goals (SDGs) directly targeting nutrition (SDG 2 “Zero hunger”)
and others being influenced by nutrition in one way or the other [UNGA, 2015]. The period from
2016 to 2025 was declared the UN Decade of Action on Nutrition [WHO/FAO, 2018]. These
developments and their implications will be discussed in more detail below.
In addition to undernutrition and its established causes, the rise of obesity and the threat posed by
climate change present increasing challenges to nutrition policy. Notably, these issues affect
countries of all income levels calling for global solutions. The double burden of malnutrition, the
coexistence of undernutrition, obesity and micronutrient deficiencies and the nutrition-associated
chronic diseases, faced by transition countries require global assistance.

2.3. The make-up of a nutrition policy

The central role of nutrition and diet quality not just for individual health but also for the wellbeing
and eventually the economic performance of the population is increasingly recognized and policies
aiming at its improvement and the reduction or even elimination of the many forms of malnutrition
are pursued to various degrees in most countries of the world, not least inspired by the global
aspirations to fight malnutrition and improve nutrition and health. Unlike national or regional
approaches, international nutrition policies are of a guiding kind. They set voluntary goals and targets
and propose ways to achieve them that each country has to transform into national action plans and
to implement according to their specific situation, needs and legal context. International and
particularly regional cooperation between countries and exchange of experience is an essential
element in successful nutrition policy and the fight against malnutrition of any kind. Malnutrition in
all its forms is the result of many direct as well as underlying indirect causes. The diet of a person
does not only depend on the availability of and the access to food that are in turn influenced by
many factors, but also, among others, on socio-cultural, religious, behavioural, age- and health-
related, environmental circumstances (see also chapters 4 and 7.3). At the economic and political
level, several actors are involved in shaping the nutritional situation of a given country. Successful
nutrition policy must take into account this interplay in a multisectoral approach (fig. 1).
 17

Figure 1 The multisectoral approach to healthier diet and less malnutrition

The many determinants and influences on nutrition and the diet also require a variety of different
approaches to improve the nutritional situation including the entirety of food systems. Nutrition
policies can be implemented at different levels, international, national, regional or only in one
institution for example. They differ by their recipients or targets. They can be aimed at the individual
or consumer whose nutrition behaviour they intend to change, at the food industry or retailers to
alter the availability of and access to food or its composition as well as the marketing of foods.
Another target are institutions like schools or employers that offer food or disseminate knowledge
about food, nutrition and health.
Nutrition policies also differ by their level of implementation, and the means and mechanisms they
employ (see table 1). Moreover, when discussing nutrition policy, a distinction should be made
between health promotion and disease prevention (table 2).

Table 1 Characteristics of nutrition policies

Level National, regional, municipal, community, international agencies, organisations,
institutions (school, workplace, healthcare facilities),
Target Individuals, consumers, institutions (school, workplace), health system,
producers (farmers), industry, retailers, media
Means Population education (dietary guidelines, media campaigns), consumer
information (food labelling), food quality standards, fiscal policies, built
environment changes, research and innovation
Mechanism Altered consumer choice, food reformulation, improved food availability and
accessibility

Modified from Mozaffarian et al., 2018

 18

Table 2 Differences between disease prevention and health promotion as objectives of health and
nutrition policies
Disease prevention
Health = Objective absence of disease
symptoms
Strategies are aimed at risk groups within the
population
Specific influences – aetiology and pathogenesis
Risk minimization as starting point for
interventions
Measures are always dependent on
specialists/professionals (heteronomous)
Less disease
Health promotion
Health = Overall, versatile concept of wellbeing
Strategies are aimed at the whole population
and environment
General influences - salutogenesis
Optimization of all available resources as
starting point for interventions
Measures enable laypersons and affected
individuals to self-help (setting approach)
More health

2.4. Challenges and obstacles in nutrition policy

The implementation of nutrition policies faces a number of challenges and obstacles.
Due to its multifaceted nature, nutrition is rarely associated with a specific governmental institution
but matters that relate to it are often divided between various agencies, namely those in charge of
health matters, agriculture, trade or education. This also applies to the supranational level with
nutrition being the subject of several international agencies like the WHO, the FAO, the United
Nations Children’s Fund (UNICEF) and the World Food Programme (WFP), for instance, but also
others with less direct ties to nutrition. While this situation may ideally offer the chance to draw on a
variety of experiences and capacities, competing interests, underprioritization of nutrition and
limited financial resources among others can impede the development and implementation of
nutrition policies. This fragmentation is also found in the nutrition community itself composed of
very diverse actors and groups including scientists, public health workers, the private sector and
many more with often differing interests, views and goals [Garrett & Natalicchio, 2010; Balarajan &
Reich, 2016]. This condition results in a lack of accountability and of leadership that is further
exacerbated by a lack of political experience and expertise of nutritionists. Reconciling and
coordinating the various stakeholders and their opinions and goals can be challenging for policy
makers when capacities and institutional support are limited. The fact that the effectiveness and
success of a nutrition intervention, particularly in the short term, may be difficult to demonstrate is
another potential reason for policy decision-makers’ hesitation to prioritize nutrition policies. This
 19

emphasizes the importance of monitoring and evaluation of nutrition interventions [Garrett &
Natalicchio, 2010; Balarajan & Reich, 2016].
Moreover, there is a widespread scepticism among public health nutrition workers about the role of
private sector and what role it should play in the fight against unhealthy and malnutrition. The
cooperation between nutritionists and the food industry is overshadowed by the conflict between
public health and commercial interests. It requires transparency and strong regulation to avoid
conflicts of interest. Importantly, in the course of nutrition policy development, the private sector
should not be included in the decision-making [Balarajan & Reich, 2016; WHO, 2016a; Mozaffarian et
al., 2018].
 20

3. Recent global nutrition initiatives

3.1. Comprehensive Implementation Plan on Maternal, Infant and Young Child

Nutrition
Based on a review and analysis in 119 member states in 2009-2010 the WHO concluded that
nutrition policies and programmes are often insufficiently implemented, lacking clear goals and
targets, coordination of involved actors, timelines and outcome evaluation. In particular, it was found
that maternal and child malnutrition was not accorded sufficient priority considering the impact of
nutrition during pregnancy, lactation, infancy and childhood on foetal and child physical and
cognitive development. The findings led to the approval of the Comprehensive Implementation Plan
on Maternal, Infant and Young Child Nutrition by the WHO’s 65th World Health Assembly in 2012
with the objective to provide detailed strategies to address the double burden of malnutrition in
children, starting from the earliest stages of development. It was emphasized that focussing efforts
on the period from the conception to the completion of a child’s second year of life, the first
1000 days, would result in substantial benefits as chronic malnutrition and micronutrient deficiencies
during this phase of life result in stunting, learning deficits and lower school performance and have
repercussions on health and productivity in later life by preventing children to attain their full
physical and mental potential. Moreover, the foundations for obesity and diet-related non-
communicable diseases are also laid in early childhood [Victora et al., 2008; UNICEF, 2017].
However, to maintain good nutritional status a life-course approach is required.

Six global nutrition targets were defined:

Target 2012 2025
Stunting 40% reduction of the global number 171 million 100 million
of children under five who are
stunted by 2025 compared to the
baseline of 2010 (3.9% relative
reduction per year).
Anaemia 50% reduction of anaemia in non- 29% 15%
pregnant women of reproductive
age (15–49 years) by 2025 compared
to the baseline of 1993–2005 (5.3%
relative reduction per year)
Low birth 30% reduction of the number of 15% 10%
weight infants born with a weight lower
 21

than 2500 grams by 2025, compared

to the baseline of 2006–2010 (3.9%
relative reduction per year)
Childhood No increase in overweight. According 7% ≤7%
overweight to current trends global prevalence
of overweight in children under
5 years would rise from 6.7 (43
million) estimated for 2010 to 10.8%
(70 million) in 2025.
Breast- Increase the rate of exclusive 38% ≥50% (10
feeding breastfeeding in the first six months million more)
up to at least 50% to 50% by 2025
(2.3% relative increase per year)
Wasting Reduce childhood wasting to less 8% <5%
than 5% by 2025 and maintain it
below such levels

To achieve these targets, five priority actions were proposed:

Action 1: To create a supportive environment for the implementation of comprehensive food and
nutrition policies
This action focusses on the need for high-level policy commitment and broad societal support to
meet the nutrition goals. A revision of existing food and nutrition policies should ensure that they
comprehensively address the double burden of malnutrition with a human rights-based approach
and an official endorsement of parliament or government and that nutrition is included in overall
national development policy. The success of nutrition policies depends on their official adoption by
relevant government agencies, the setup of effective intersectoral governance mechanisms, the
engagement of development partners and the involvement of local communities. Support from the
WHO comes through improved access to policy guidelines, tools and expert networks while
international partners should strengthen cooperation to harmonize standards and policies through
intergovernmental bodies.

Action 2: To include all required effective health interventions with an impact on nutrition in
national nutrition plans
 22

Effective interventions to improve nutrition and reduce exposure to risk factors should be integrated
into existing national health-care systems and health systems be strengthened. Proposed activities
for member states are the promotion of universal health coverage and primary health care, the
control of marketing of breastmilk substitutes and the promotion of breastfeeding.

Action 3: To stimulate development policies and programmes outside the health sector that
recognize and include nutrition
The simultaneous engagement of several sectors (mainly agriculture, food processing, trade, social
protection, education, labour and public information) is required to improve supply and access to
healthier food and address underlying causes of malnutrition. Existing sectoral policies should be
reviewed with regards to their impact on nutrition. Establishing a dialogue between the health and
other sectors could address potential conflicts between policies. The recommendations on the
marketing of food and non-alcoholic beverages to children should be implemented.

Action 4: To provide sufficient human and financial resources for the implementation of nutrition
interventions
The need for increased financial and human resources and capacity building is recognized. A
comprehensive approach to capacity building should be implemented, including workforce
development as well as leadership development, academic institutional strengthening, organizational
development and partnerships. Funding must be made more efficient, local communities be
supported, and a budget line and national financial targets for nutrition be established. Resources
could be obtained from excise taxes and innovative financing mechanisms.

Action 5: To monitor and evaluate the implementation of policies and programmes

Monitoring of the progress towards the targets of the plan is required to account for the actions
implemented, resources and results. For this purpose a set of indicators is proposed by the WHO to
be adapted to the national context and requirements while enabling comparability at the global
level. These include the WHO child growth standards to monitor growth as well as prevalence of
stunting, wasting and overweight. The establishment of a database of selected indicators by the
WHO as well as the collection and exchange of information between international organizations is
encouraged to ensure global coverage of databases.
[WHO, 2014a]
 23

3.2. WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020
The rising prevalence of non-communicable diseases (NCDs) places a heavy burden particularly on
low- and middle income countries. To address this major challenge to global public health, in 2000,
the WHO developed a Global Strategy for the Prevention and Control of NCDs with the objective of
mapping the prevalence and evolution of non-communicable diseases and identifying the underlying
determinants, reducing exposure of individuals and populations to these risk factors, and promoting
health care for affected persons. This strategy was reaffirmed in the 2008-2013 Action Plan for the
Global Strategy for the Prevention and Control of Noncommunicable Diseases.

Six global objectives for the prevention of noncommunicable diseases

To raise the priority accorded to the prevention and control of noncommunicable diseases in
1. global, regional and national agendas and internationally agreed development goals, through
strengthened international cooperation and advocacy

To strengthen national capacity, leadership, governance, multisectoral action and partnerships

2.
to accelerate country response for the prevention and control of noncommunicable diseases

To reduce modifiable risk factors for noncommunicable diseases and underlying social
3.
determinants through creation of health-promoting environments

To strengthen and orient health systems to address the prevention and control of
4. noncommunicable diseases and the underlying social determinants through people-centred
primary health care and universal health coverage

To promote and support national capacity for high-quality research and development for the
5.
prevention and control of noncommunicable diseases

To monitor the trends and determinants of noncommunicable diseases and evaluate progress
6.
in their prevention and control
 24

Figure 2 Voluntary global targets for the prevention of noncommunicable diseases to be met by
2025 (within the frame of targets related to nutrition and physical activity) (modified from [WHO,
2013a])

Halt the rise in diabetes and obesity

A 30% relative reduction in mean population intake of salt/sodium

At least 10% relative reduction in the harmful use of alcohol, as appropriate, within
the national context

A 10% relative reduction in prevalence of insufficient physical activity

A 25% relative reduction in the prevalence of raised blood pressure or contain the
prevalence of raised blood pressure, according to national circumstances

A 25% relative reduction in risk of premature mortality from cardiovascular diseases,

cancer, diabetes, or chronic respiratory diseases

A 30% relative reduction in prevalence of current tobacco use in persons ≥15 years

At least 50% of eligible people receive drug therapy and counselling (including
glycaemic control) to prevent heart attacks and stroke

An 80% availability of the affordable basic technologies and essential medicines,

including generics, required to treat major NCDs in both public and private facilities

Objectives of the action plan were to raise the priority accorded to NCDs in development work and
research, reduce premature mortality from NCDs and improve care for those affected by promoting
an intersectoral and multi-level response to NCDs particularly in low and middle income countries.
Building on the achievements of the action plan and following the UN High Level Meeting on 19th
September 2011 and the Political Declaration of the High-level Meeting of the General Assembly on
the Prevention and Control of Non-communicable Diseases the Global Action Plan for the Prevention
and Control of Noncommunicable Diseases for the period 2013–2020 was developed. It defines six
 25

objectives (box) and sets nine voluntary targets to be attained by 2025 (figure 2) as a roadmap in the
fight against NCDs [WHO, 2013a].
The overarching principles are a human rights approach to health, an equity-based approach to
target the unequal distribution of social health determinants, a primary responsibility of national
governments to take action against NCDs and the need for international cooperation and solidarity.
The importance of multisectoral action and a life-course approach are emphasized as well as the
empowerment of people and communities. Strategies for the prevention and control of NCDs should
be based on recent scientific evidence and/or best practice, cost-effectiveness, affordability and
public health principles and should take cultural aspects into account. Enabling access to universal
health coverage is urged. All forms of conflict of interest have to be prevented or managed.
Member states are provided with policy options and tools to work towards the achievement of the
global targets [WHO, 2013a].

3.3. ICN2 and the Rome Declaration

The Second International Conference on Nutrition (ICN2) was co-organized by the Food and
Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) from
19th to 21st November 2014 at the FAO Headquarters in Rome, Italy, as a high-level
intergovernmental meeting to call the global attention to malnutrition in all its forms. It was
attended by more than 2200 participants, including representatives from over 160 governments,
various UN agencies, civil society and the business sector. A main objective was to assess the
progress made in scaling up nutrition since the first International Conference on Nutrition (ICN) in
1992, address new challenges and opportunities in nutrition and review policy options for fighting
malnutrition, promote intersectoral approaches and promote cooperation between institutions,
governments and various sectors and stakeholders to improve nutrition throughout the life cycle.
Specific nutrition issues were addressed in a number of pre-conference events for parliamentarians,
civil society and the private sector, round tables and side events. The ICN2 resulted in the
endorsement of two outcome documents, the Rome Declaration on Nutrition and the accompanying
Framework for Action, by the governments participating at the conference. The Rome Declaration on
Nutrition consists of ten commitments to action to eradicate hunger and malnutrition and improve
food security.
 26

Commitments of the Rome Declaration on Nutrition [modified from ICN2, 2014a]

1. Eradicate hunger and prevent all forms of malnutrition worldwide

2. Increase investments for effective interventions and actions to improve people’s diets
and nutrition, including in emergency situations
3. Enhance sustainable food systems by developing coherent public policies from
production to consumption and across relevant sectors to provide stable access to safe
and nutritious food
4. Raise the profile of nutrition within relevant national strategies, policies, action plans
and programmes and align national resources accordingly
5. Improve nutrition and fight malnutrition by strengthening human and institutional
capacities through relevant research and development, innovation and appropriate
technology transfer
6. Strengthen and facilitate contributions and action by all stakeholders and promote
collaboration within and across countries
7. Develop policies, programmes and initiatives for ensuring healthy diets throughout the
life course
8. Empower people and create an enabling environment for making informed choices
about food products for healthy dietary practices and appropriate infant and young
child feeding practices through improved health and nutrition information and
education
9. Implement the commitments of the Rome Declaration on Nutrition through the
Framework for Action which will also contribute to ensuring accountability and
monitoring progress in global nutrition targets
10. Give due consideration to integrating the vision and commitments of the Rome
Declaration on Nutrition into the post-2015 development agenda process, including a
possible related global goal

The Framework for Action offers a set of 60 policy and programme options as a voluntary guideline
for the implementation of the political commitments. These recommendations are primarily
addressed to government leaders to be adopted as appropriate for the national and regional
priorities, needs and conditions, and depending on the legal frameworks.
 27

Thematic areas of the Framework for Action

Creation of an enabling environment for effective action

Sustainable food systems promoting healthy diets

International trade and investment policies

Nutrition education and information to build capacities

Social protection

Strong and resilient health systems for the delivery of direct nutrition interventions and health
services to improve nutrition

Promotion, protection and support of breastfeeding

Addressing wasting, stunting, childhood overweight and obesity and anaemia in women

Water, sanitation and hygiene

Food safety

Improving accountability mechanisms for nutrition

3.4. The sustainable development goals

The sustainable development goals (SDGs) were adopted by the UN General Assembly on 25th
September 2015 as part of Resolution 70/1 "Transforming our World: the 2030 Agenda for
Sustainable Development". In this plan of action for people, planet and prosperity eradicating
poverty in all its forms and dimensions, including extreme poverty, is recognised as the greatest
global challenge and an indispensable requirement for sustainable development.
Seventeen goals and 169 associated targets were defined to work towards a world free of poverty,
hunger, disease and want (figure 3) [https://www.un.org/sustainabledevelopment/].
 28

Figure 3 The Sustainable Development Goals

[https://www.un.org/sustainabledevelopment/]

Nutrition plays a central role in the SDGs. It is directly targeted by goal 2 “Zero hunger” that intends
to end hunger and all forms of malnutrition, address the nutritional needs throughout the lifecourse,
and ensure universal access to sustainably produced safe, healthy, nutritious food and coverage of
essential nutrition actions.

Target 2.1. By 2030, end hunger and ensure access by all people, in particular the poor and people in
vulnerable situations, including infants, to safe, nutritious and sufficient food all year round
Target 2.2. By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally
agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional
needs of adolescent girls, pregnant and lactating women and older persons

Further targets to achieve SDG 2 focus on agricultural productivity by increasing incomes and access
to land and other resources and inputs of small scale food producers and promoting and investing in
sustainable food production and its adaptation to climate change, protection of food price stability,
proper functioning of food commodity markets and preservation and fair use of genetic diversity.
Nutrition acts as an enabler of other health-related SDGs, namely SDG 3 “Good health and
wellbeing”.
 29

Target 3.1. By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births
Target 3.2. By 2030, end preventable deaths of newborns and children under 5 years of age, with all
countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-
5 mortality to at least as low as 25 per 1,000 live births
Target 3.4. By 2030, reduce by one third premature mortality from non-communicable diseases
through prevention and treatment and promote mental health and wellbeing

Adequate nutrition improves maternal and child health and thereby contributes to the reduction
maternal, neonatal and young child mortality. In turn, malnutrition decreases the resilience to
infectious diseases and, in the form of obesity, is a major risk factor for non-communicable diseases.

Table 3 Nutrition and its interaction with the Sustainable Development Goals
Goal Effect of and on nutrition
1 No poverty Poverty is a major cause for food insecurity and unhealthy nutrition. Good
nutrition in turn, results in higher labour productivity, greater mental capacity
and longer, healthier lives.
3 Good health and Adequate nutrition reduces maternal and child health and increases resilience
wellbeing to infections; obesity is a risk factor for non-communicable diseases.
4 Quality education Adequate nutrition improves learning ability and cognitive development.
Better education is associated with better nutrition.
5 Gender equality Improving the nutrition of women, girls and children improves schooling and
reduces gender inequalities.
6 Clean water and Ensuring good nutrition requires access to safe water and sanitation.
sanitation
7 Affordable and clean Increased demand for healthy food requires clean, renewable energy sources.
energy
8 Decent work and Malnutrition in all its forms lowers economic productivity and results in
economic growth unnecessary additional healthcare costs.
9 Industrial innovation Enhanced nutrition through the lifespan supports learning and later
and infrastructure innovation potential.
Innovative technologies enable the reformulation of foods to make them
healthier.
10 Reduced inequalities Reducing current nutrition inequalities will lessen income inequalities.
11 Sustainable cities and Sustainable cities require integrated urban and rural food systems.
communities
12 Responsible Responsible food consumption and production reduces food waste and
consumption and losses.
production
13 Climate action Sustainable food systems reduce greenhouse gas emissions and limit land use.
14 Life below water Better nutrition reduces population pressure on the world’s oceans.
Oceans are an important source of nutritious food that has to be used
sustainably.
15 Life on land Soil degradation and reduced biodiversity threaten our ability to grow food.
16 Peace, justice and War and conflict are major underlying factors of nutrition insecurity.
strong institutions
17 Partnerships for the Global prioritization of nutrition has never been higher and requires
goals cooperation of all actors.
 30

Nutrition also interacts with all other SDGs: for instance, making food production systems more
sustainable has direct effects on the SDGs targeting the environment (Table 3).

3.5. United Nations Decade of Action on Nutrition

On 1st April 2016 the UN General Assembly proclaimed the period from 2016 to 2025 the United
Nations Decade of Action on Nutrition through its Resolution 70/259,4, with the aim of accelerating
the implementation of the ICN2 commitments, achieving the Global Nutrition and diet-related NCD
targets by 2025 and contributing to the realization of the SDGs by 2030. Led by the Food and
Agriculture Organization and the World Health Organization in collaboration with World Food
Programme (WFP), the International Fund for Agricultural Development (IFAD) and the United
Nations Children’s Fund (UNICEF), the UN Decade of Action on Nutrition is a commitment by United
Nations Member States to undertake ten years of sustained and coherent scale-up of
implementation of policies, programmes and increased investments to eliminate malnutrition in all
its forms, everywhere, leaving no one behind and meeting the SDGs by 2030. While clearly
supporting the achievement of Sustainable Development Goal 2 to “end hunger, achieve food
security and improved nutrition, and promote sustainable agriculture”, it is establishing a link with
many other SDGs for which improved nutrition is critical. It provides a clearly defined time-bound
cohesive framework building on existing structures and available resources and promoting alignment
among actors from multiple sectors [https://www.un.org/nutrition/about].
The Nutrition Decade is centred on six action areas derived from the ICN2 Framework for Action and
relevant to the related SDGs:
1. Sustainable, resilient food systems for healthy diets
2. Aligned health systems providing universal coverage of essential nutrition actions
3. Social protection and nutrition education
4. Trade and investment for improved nutrition
5. Safe and supportive environments for nutrition at all ages
6. Strengthened governance and accountability for nutrition.

However, these areas should not be seen as silos and policies and programmes should in practice be
linked to several areas at the same time.
To implement the Nutrition Decade, Member States and other partners are encouraged to make
SMART commitments for action on nutrition. To this end, already existing commitments should be
reviewed exist through a SMART lens (table 4) and a preliminary set of priorities for actions for the
next ten years be identified based on the ICN2 Framework for Action in order to improve food
 31

security and nutrition. For each of the prioritized actions, the implications for (1) policies and
programmes, (2) institutional requirements and delivery mechanisms and (3) costs have to be
assessed and identified.

Table 4 SMART Commitments for action on nutrition

Specific Referring to a specific action and identifying those responsible for achieving it
Measurable Including indicators to enable monitoring of progress and achievement
Achievable Realistic with regards to availability of resources and level of progress
achieved in the past
Relevant Reflecting national situation, priorities and challenges
Time-bound Key outcomes to be met within a realistic timeframe for achievement

Member States should establish nutrition targets in line with the agreed six WHA Global Nutrition
Targets and Diet-related NCD Targets by 2025, commit to implement one or more of the
recommendations made in the ICN2 Framework for Action and reflected in the six action areas of the
Nutrition Decade and allocate or mobilize adequate financial resources in support of domestic and
international action required to achieve global nutrition and diet-related NCD targets. Country-
specific commitments will reflect national priorities and depend on the country’s nutrition situation,
and current food and health systems. FAO and WHO are preparing a resource guide to assist
countries. Commitments are expected to be signed off by high-level representatives of countries and
registered in an open access commitment repository, created and managed by the joint FAO/WHO
Secretariat. For public accountability, the submitted commitments will be tracked on a regular basis
by country self-assessments. Countries will be assisted by UN system agencies and platforms.
Another means of implementation is the establishment of Action Networks that are informal
coalitions of countries aimed at accelerating and aligning efforts around specific topics linked to one
or more action areas of the Nutrition Decade. They are established at the request of one or more
countries, which can have made formal commitments and are prepared to create/implement policies
and provide leadership. Countries should define the objectives, scope and initial programme of work,
identify other partner countries, convene meetings, manage joint initiatives and decide on how to
engage with civil society organizations, academia and the private sector, as appropriate. Action
networks may be regional or global, and operate under the leadership of a government institution.
They advocate for the establishment of policies and legislation, allow the exchange of practices and
experiences, highlight successes and lessons learned, and provide mutual support to accelerate
implementation. Action networks will help countries implement their SMART commitments. They
contribute to provide solutions to global or regional problems for which cross-border/global action is
 32

needed. They offer an opportunity for peer-to-peer learning including learning from failure and for
sharing of good practices, challenges, obstacles by countries with a common interest.
Action networks have already been established on some topics in some regions (table 5).

Table 5 Examples of Action Networks

Topic Led by
Marketing of foods to children Portugal
Reduction of sodium content in foods Switzerland, Brazil
Food guidelines Brazil
Sustainable fisheries Norway
Healthy food environments Chile
Hospital nutrition Israel
Food labelling France, Australia
School food procurement Germany

Further sustained engagement of senior country leadership is needed to guarantee strong

commitment for action. Implementation to address the different forms of malnutrition has to be
urgently scaled up, investments for nutrition need to be increased, enhanced policy coherence is
required. Governments need to ensure that investments address different forms of malnutrition and
have an impact across different sectors. A greater number of SMART commitments across the
Nutrition Decade’s six action areas is called for.

Table 6 Priorities within the WHO's Ambition and Action in Nutrition 2016-2025 [WHO, 2017a]
Function Priority
Leadership Shape the narrative of the global nutrition agenda
Leverage changes in relevant non-health sectors to improve and mainstream
nutrition
Leverage the implementation of effective nutrition policies and programmes
in all settings, including in situations of emergencies and crisis
Guidance Define healthy sustainable diets and guide the identification and use of
effective nutrition actions
Improve the availability of nutrition actions in health systems
Monitoring Support the establishment of targets and monitoring systems for nutrition
 33

In the frame of the Nutrition Decade, the WHO has developed its own strategy titled Ambition and
Action in Nutrition for 2016-2025 to further enhance the priority of nutrition in its work and define
the role of WHO for advancing nutrition. The strategy builds on the six global targets to improve
maternal, infant and young child nutrition as well as the diet-related global objectives for the
prevention of noncommunicable diseases (see chapter 3.2) and sets six priorities (table 6).

In summary, within the decade since 2010, nutrition policies have evolved to put more focus on
obesity and associated NCDs while at the same time maintaining the priority of fighting
undernutrition and micronutrient deficiencies. This reflects the increasing multiple burden from
malnutrition in all its forms. A special focus is also on infants, children and women of reproductive
age who are particularly at risk of malnutrition, emphasizing the importance of a life course
approach. The first 1000 days of life, starting from conception until the second birthday, have been
recognized as a crucial period laying the foundation for health and productivity in later life. Adequate
nutrition during this time allows a child to reach its full potential, with repercussions on the
economic performance of entire countries. The promotion and protection of breastfeeding is a
priority in this context.
In light of the many influencing factors and underlying causes of malnutrition, multisectoral policies
and cooperation between various stakeholders are crucial to build sustainable and resilient food
systems and ensure access to adequate nutrition to everyone.
 34

4. Diet-related causes of morbidity and mortality

4.1. Obesity and non-communicable diseases

Obesity rates are steadily increasing worldwide regardless of country income level. Recently, the rise
in obesity prevalence has even been greater in low-income countries while reaching a high plateau in
high-income countries. In 2016, over 1.9 billion adults aged ≥18 years (corresponding to 39%) were
overweight including over 650 million obese (13%). Overweight and obesity are also increasingly
observed in children and adolescents affecting about 41 millions of <5 year-olds and about
340 millions of 5-19 year-olds [WHO, 2018a]. While in 2016 there were still more underweight than
obese children and adolescents worldwide, it has been estimated that the prevalence of obesity in 5-
19 year-olds would surpass that of underweight by 2022 if the current trends were to continue [NCD
Risk Factor Collaboration, 2017].
Obesity rates are particularly high in the Eastern Mediterranean and North Africa, reaching a
prevalence in adults of about 21% in adults aged ≥18 years (16% in men and 26% in women) and
around 8% in children and adolescents (5-19 years) in 2016 [WHO Global Health Observatory]. In the
same year, an estimated 92 million adults (≥20 years) were obese in the region [NCD Risk Factor
Collaboration, 2017].
The rise of obesity is alarming as it is a major risk factor for non-communicable diseases (NCDs).
NCDs are the most common cause of death worldwide: in 2016, 71% of the 57 million death cases
were due to NCDs. More than half of the death cases could be ascribed to four NCD types
(cardiovascular diseases 31.4%, cancer 15.8%, chronic respiratory diseases 6.7%, and diabetes
mellitus 2.8%). In turn, infectious diseases and injuries caused 14.9% and 8.6% of death cases,
respectively. The contribution of NCDs to total deaths is projected to further increase, reaching 83%
by 2060 especially for cancer-, respiratory- and diabetes-related deaths (18%, 9% and 5%,
respectively) [WHO 2018b; WHO, 2018c]. Apart from chronic respiratory diseases, all of these four
major NCDs are in part influenced by the diet and physical activity.
NCDs place a particular burden on low-income countries where financial resources and infrastructure
for health care are limited. In turn, while NCD prevalence is high in high-income countries (HICs) their
contribution to death is lower than in low-income (LICs) and lower-middle-income countries (L-MICs).
In 2016, 25% of NCD-related deaths in HICs occurred prematurely compared to 43% in LICs and 47%
in L-MICs. For adults in LICs and L-MICs the risk of dying from NCDs was almost twice as high as in
HICs (21% and 23% vs. 12%, respectively) [WHO, 2018c].
NCD prevalence is high in the EMR and it causes 1.7 million deaths per year
[http://www.emro.who.int/noncommunicable-diseases/publications/burden-of-noncommunicable-
diseases-in-the-eastern-mediterranean-region.html]. NCDs also increase the risk of premature death
 35

(i.e. before the age of 70 years). In the WHO EMR the risk of dying from NCDs at the age between 30
and 70 years was over 20%, higher than the global average of 19% and the third highest of all WHO
regions [WHO, 2014b].

4.2. Causes of under-nutrition

After a period of steady decline until 2015, the number of undernourished persons worldwide has
been increasing again and is estimated at nearly 821 million or 10.9% of the global population in
2017. A rise was especially seen on the African continent as well as in Oceania and South America
and appears mostly attributable to adverse climate events, armed conflicts and economic recession
[FAO/IFAD/UNICEF/WFP/WHO, 2018].

Undernutrition/malnutrition encompasses a number of clinical conditions in children and adults.

Generally, it is characterised as an insufficient supply of energy and/or one or several nutrients. It can
be further divided into insufficiencies of energy and macronutrients, especially protein, on one hand
and of micronutrients (vitamins, minerals and trace elements) on the other.

Acute under-/malnutrition is associated with pronounced weight loss manifesting as wasting, while
long-term deficiency also of certain micronutrients leads to impaired growth resulting in stunting
(short stature). Depending on the degree of under-nourishment, there is a classification into
moderate (MAM) and severe acute malnutrition (SAM). Both are summarized as global acute
malnutrition. In children, acute malnutrition or wasting is generally identified using the z-score (i.e.
the deviation of a given value from the mean) of the weight-for-height (WHZ) (or weight-for-length in
infants up to 2 years) based on the WHO Child Growth Standards or a corresponding validated
growth chart. Another indicator is the age-specific mid-upper arm circumference that has a high
predictive value for mortality in undernourished children. The presence of bilateral pitting oedema is
also an indicator of SAM. Stunting is diagnosed using the z-score of the height/length-for-age based
on the WHO or other validated child growth standards (table 7) [WHO, 2009; WHO, 2010a; WHO,
2013b].
Protein-energy malnutrition (PEM) manifests in two forms, marasmus and kwashiorkor that are most
commonly seen in children after weaning. Marasmus is more often associated with a general
deficiency of energy and macronutrients and kwashiorkor with a primary insufficiency of protein and
especially of essential amino acids. Both PEM forms have also been associated with differing
metabolomic changes. However, the underlying causes are still not entirely known and both forms
often co-occur (marasmic kwashiorkor) [Scrimshaw & Viteri, 2010; Di Giovanni et al., 2016].
Marasmus and kwashiorkor are generally diagnosed by their distinctive clinical symptoms that are
given in table 8.
 36

Table 7 Anthropometric criteria for the diagnosis of malnutrition

Children Wasting (acute malnutrition):
Weight-for-height z-score (WHZ) <-2
Severe wasting (severe acute malnutrition):
WHZ <-3 SD
Moderate wasting (moderate acute malnutrition)
WHZ between -2 and -3
Acute malnutrition (children of 6 to 60 months)
MUAC < 125 mm
Severe acute malnutrition
MUAC < 115 mm
Stunting (chronic malnutrition):
HAZ < –2
Severe stunting:
HAZ <-3 SD
Moderate stunting
HAZ between -2 and -3
Adults Underweight:
BMI < 18.5 kg/m2
Severe underweight:
BMI < 16.0 kg/m2
WHZ: weight-for-height z-score; MUAC: mid-upper arm circumference; HAZ: height-for-
age z-score
Sources: WHO (2010a); WHO, UNICEF (2009)

In turn, micronutrient deficiency diseases (MDDs) result from deficiencies of single or several
micronutrients, i.e. minerals, trace elements and vitamins. They are generally less apparent than
energy and macronutrient deficiencies. Moreover, they do not only occur in undernourished persons.
Inadequate supply and status of various micronutrients has frequently been observed in overweight
and obese persons that consume a diet high in energy and some macronutrients like fat and sugars
but poor in essential vitamins and minerals [Astrup & Bügel, 2018]. The most common forms of
MDDs are anaemia that is most often caused by iron deficiency, iodine deficiency diseases and
xerophthalmia or night blindness due to vitamin A deficiency.
 37

Table 8 Clinical symptoms of protein-energy malnutrition

Marasmus Kwashiorkor
Massive weight loss (weight-for-age <60%) Moderate weight loss (weight-for-age 60-80%)
Dramatic loss of adipose tissue Thin extremities
Muscle atrophy Decreased muscle mass
Prominent ribs (“skin and bones”) Peripheral oedema (decrease of oncotic pressure)
Thin “old man” face Ascites (increased capillary permeability), swollen
Loose skin abdomen
No oedema Fatty enlarged liver
Children are rather active and relatively Anaemia
alert for their condition Hair and skin changes
Anorexia
Lethargy, apathy, irritability

Malnutrition impairs the immune defence, thus lowering the resistance to diseases and increasing
the susceptibility to infections. It increases the mortality risk and impairs development and learning.
In turn, infections and other diseases are also risk factors for malnutrition.

Malnutrition is a result of inadequate dietary intake that cannot cover the body’s needs for energy
and nutrients, of infectious diseases or a combination of both. Malnutrition and infection are indeed
related in a vicious cycle as inadequate supply of energy and nutrients impairs the function of the
immune system and causes mucosal damage that increase the susceptibility to infections and are
associated with longer duration and higher severity of diseases. In turn, infections favour the
development of malnutrition as they are associated with appetite loss, altered metabolism of
nutrients and increased energy requirements and, especially in the case of diarrhoea and vomiting
cause nutrient losses and malabsorption.

The immediate causes of malnutrition, inadequate food intake and disease, are in turn the result of
insufficient household food security, a suboptimal social and care environment as well as limited
access to health care and exposure to an unhealthy environment. These underlying causes are
determined by the availability of and control over human, economic and organisational resources
that depend on economic structures, political and ideological factors and formal and informal
infrastructure.

Based on the definition formulated at the World Food Summit 1996, household food security is given
when all individuals of a household have physical and economic access to sufficient, safe and
 38

nutritious food needed for an active and healthy life at all times. Food security consists of four basic
components: food availability, food access, food utilization and stability (see table 9) [FAO, 2006].

Table 9 Components of food security

Food availability Supply of sufficient quantities of food of appropriate quality through domestic
production, stocks, trade as well as food aid
Food access Physical and economic access to adequate resources or entitlements that
enable individuals to acquire appropriate foods for a nutritious diet.
Food utilization Optimal utilization of food by the body as part of an adequate diet, enabled
by good preparation practices, access to sanitation and health care to reach a
state of nutritional well-being meeting all physiological needs.
Stability Constant availability of and access to adequate food over time

Besides food security, a healthy life environment providing access to clean water and sanitation and
promoting hygiene, access to health services (e.g. medication, immunization) and good child care
practices also are essential determinants of nutritional status and adequacy as they prevent disease.
Caring behaviours influence the feeding of infants and children. The role, status and rights of women
have an impact on their access to food and their nutrition by influencing the way food is distributed
within a community and households. Thereby they ultimately also have effects on the nutrition of
the foetus during pregnancy, the infant after delivery and children in general.

Figure 4 Causes of malnutrition (modified from [UNICEF, 2013a])

 39

Food security, health and care practices in turn depend on the socio-cultural, economic, political and
legal environment and the availability of human, economic and organizational resources (figure 4).
The respective relevance of these basic causes varies among regions and countries but also
seasonally. It is also affected by situations of conflict and emergencies. It has to be taken into
account for a successful and sustainable approach of tackling malnutrition [UNICEF, 2013a].

4.3. Common micronutrient deficiencies: hidden hunger

Deficiencies of several micronutrients, especially iron, iodine and vitamin A, are very common
worldwide. In the absence of acute undernutrition, inadequate supply of vitamins, minerals and trace
elements is often not immediately apparent and has therefore been termed as “hidden hunger”
[Ruel-Bergeron et al., 2015].

Iron deficiency most commonly manifests in the form of microcytic anaemia, i.e. a blood
haemoglobin level below 130 or 120 g/l for adult men and non-pregnant women, respectively [WHO,
2011a]. It is estimated that around 25% of the global population are affected by anaemia, with the
highest prevalence in women of child-bearing age, pregnant women and children under the age of
5 years (29.0%, 38.2% and 42.6%, respectively) and about half being attributable to iron deficiency
[WHO, 2015b]. Even the lower prevalence of iron deficiency anaemia (25% of total anaemia in
preschool children and 37% in women of reproductive age) that was suggested based on a recent
meta-analysis that also showed a high regional variability still qualifies as a public health concern in
many countries [Petry et al., 2016]. Anaemia and iron deficiency also present a major public health
concern in several countries of the Eastern Mediterranean region (EMR). For instance, anaemia
prevalence in different national nutrition surveys ranged from 7.4 to 80.4 % in children under 5 years
of age, from 14.3 to 58.4 % in pregnant women and from 21.3 to 63.0 % in women of childbearing
age. Iron deficiency based on serum ferritin levels was observed in 14.4 to 43.8 % of preschool
children, 15 to 55 % of pregnant women and 24 to 41.5 % of women of childbearing age. Iron
deficiency anaemia based on combined values on haemoglobin and serum ferritin was in up to
33.5 % of preschool children, up to 51.3 % in pregnant women and about 13 to 20 % in women of
childbearing age [Al-Jawaldeh et al., 2018].
Despite much progress in recent years, inadequate iodine intake and status remain a public
health issue in many parts of the world, including industrialized countries like Italy, Finland, Sweden,
Switzerland and Israel among others, where intake is insufficient at least in some population groups
like pregnant women [Iodine Global Network, 2017]. Salt iodization, mandatory in 108 countries as of
2018 and practised on a voluntary basis in others, has contributed so the improvement of iodine
supply in many regions but household coverage with iodised salt is still not universal [Andersson et
 40

al., 2007; Bath et al., 2013; Global Fortification Data Exchange, 2017]. Salt iodization has also resulted
in improved iodine status and lower prevalence of iodine deficiency disorders in many countries of
the EMR, but some exceptions remain. For instance, moderate to severe iodine deficiency was still
found in Afghanistan, Pakistan, Sudan, Iraq and parts of Saudi Arabia. Some countries also show an
inadequate coverage of households with iodized salt and iodization is only practised on a voluntary
basis in Saudi Arabia and the United Arab Emirates [Mohammadi et al., 2018]. Moreover, salt was
often found to be not adequately iodized [Palestinian Micronutrient Survey 2013; Ghattas et al.,
2015; Zahidi et al., 2016].
Vitamin A is another critical micronutrient in many regions of the world, especially among
preschool children and pregnant women that are considered most vulnerable to vitamin A
deficiency. According to estimates for the period of 1995 to 2005, 44 to 50 % of preschool children in
Africa and South-Asia had low serum retinol concentrations (<0.70 μmol/l) while at the global level a
third of this age group is affected. The prevalence was lower in pregnant women but still reached
15 % worldwide and 17 % in the South-Asian region. A high prevalence was also seen in the EMR
where 20 % of preschool children and 16 % of pregnant women had low serum retinol levels. Night
blindness that is a consequence of vitamin A deficiency, affected about 1 % of preschool children and
about 6 % of pregnant women globally and 1 % and 7 %, respectively, in the EMR [WHO, 2009]. In
many countries with high mortality rates in children under 5 years and where vitamin A deficiency is
considered a public health problem, the biannual distribution of high-dose vitamin A supplements to
children aged 6 to 59 months has contributed to an improvement of vitamin A status [UNICEF, 2018].
However, more recent surveys still show a notable prevalence of inadequate vitamin A status and
even an increasing trend in some countries and population groups [Pakistan National Nutrition
Survey 2011; Iran NIMS II 2012; Ministry of Public Health Afghanistan, UNICEF 2013; Gebreselassie et
al., 2013; Stevens et al., 2015; Rahman et al., 2017]. It was also reported that vitamin A
supplementation has recently declined in some regions [UNICEF, 2018a]. Vitamin A deficiency among
women and children is also common in some countries of EMR especially those with lower incomes
like Somalia, Afghanistan, Pakistan, Djibouti and Yemen with prevalence ranges from 0.5% to 72.9%
in preschool children, of 0.2 to 42.1 % in women of childbearing age and of 3 to 46 % in pregnant
women [reviewed by Al-Jawaldeh et al., 2018]. Moreover, for adult women a higher cut-off for
deficiency (<1.05 µmol/l) has been suggested as more appropriate that would entail a higher
prevalence of vitamin A deficiency in this population group [Tanumihardjo, 2012].
Other micronutrients like zinc, folic acid, vitamin B12, calcium and vitamin D have also emerged as
critical more recently [McLean et al., 2008; Beal et al., 2017; Roth et al., 2018].

Zinc is an integral part of over 3000 zinc proteins in the human body among which are enzymes
of all enzyme classes, and it is also involved in cell signalling and the regulation of the immune
 41

function [Hotz & Brown, 2004; Maret, 2013]. Zinc is contained in various food sources, but its
bioavailability is often low, particularly from unrefined foods of plant origin like wholegrain cereals,
pulses and nuts that are rich in phytic acid (an inhibitor of zinc absorption) and make up large parts
of the diet in many low-income countries [Hotz & Brown, 2004]. In light of its multiple physiological
functions, zinc deficiency results in rather unspecific symptoms. It has been associated with disturbed
immune responses manifesting as recurrent infections and intermittent diarrhoea as well as
gastrointestinal and dermal impairments. In children it causes growth disturbances that can lead to
stunting, the prevalence of which is even used as an indicator of zinc deficiency, as well as impaired
cognitive development [Hotz & Brown, 2004].
Inadequate zinc intake has been estimated for many parts of the world based on data from the FAO’s
Food Balance Sheets with an average risk for deficiency of 16% in 2011. Countries in Africa and South
Asia were most severely affected but zinc supply must also be considered as critical in Iraq, Pakistan
and Yemen [Beal et al., 2017]. The prevalence of low Zn serum or plasma levels varies between
countries and studies, a finding that is complicated by the lack of clear reference values and the
circadian variation of Zn concentration in the blood [King et al., 2016].

In a review of national surveys from 20 low- and middle-income countries reporting serum or plasma
zinc levels of preschool children and/or women of childbearing age, prevalence of zinc deficiency
ranged from 4-83% and 0-82% in the respective groups, albeit based on slightly differing cut-off
levels (<60 to <80 µg/dl), and was highest in Cameroon [Hess, 2017]. Zinc deficiency was also
common in South-East Asian countries, its prevalence ranging from 28 to 81% in preschool children
and women of childbearing age from Cambodia, Indonesia, Thailand and Vietnam [Roos et al., 2019].
While the prevalence of zinc deficiency is generally lower in high-income countries, it may still
represent a mild public health issue, especially in elderly individuals: 13.4% and 18.1% of Austrian
adult men and women (18-64 y), respectively, had plasma Zn levels below the respective IZiNCG cut-
offs for sufficiency (74 and 70 µg/dl) and the prevalence was even higher in the elderly (65-80 y;
men: 27.6%, women: 33.3%) [Elmadfa et al., 2017]. Among Spanish adults (25-60 years), 17.1% and
18.5% of men and women had plasma Zn level <70 µg/dl and serum levels <60 µg/dl were reported
in 15.6% of 18-60 year-old Greek adults [Sánchez et al., 2009; Kouremenou-Dona et al., 2006].
Although data on zinc status from countries of the EMR are scarce, high rates of deficiency have been
reported: In the Pakistani National Nutrition Survey from 2011, 41.3% of non-pregnant and 47.6% of
pregnant women aged 15-49 years were zinc-deficient (defined by serum Zn levels < 60 µg/dl). The
prevalence in children aged 6-59 months was 39.2% based on the same cut-off level [National
Nutrition Survey Pakistan, 2011]. Lower prevalence was observed in Iran with 19.1% of infants aged
15-23 months, 13.6% of 6-year-old school children and 11.4% of adolescents (14-20 years) showing
serum Zn levels <70 µg/dl <65 µg/dl and 28.0% of pregnant women showing serum Zn levels
 42

<65 µg/dl [Pouraram et al., 2018]. In Afghanistan, 15.1 % of children aged 6-59 months and 23.4% of
women aged 15-49 years had serum Zn levels <60 µg/dl [Ministry of Public Health Afghanistan,
UNICEF 2013]. Zinc deficiency was also observed in 55% of children aged 6-59 months, 59 and 70% of
adolescent boys and girls, respectively, in 59-75% of the pregnant women and 83% of the lactating
women participating in the Palestinian Micronutrient Survey 2013. Across all population groups
tested, the prevalence of deficiency was higher in the Gaza Strip than in the West Bank [State of
Palestine, 2014].

Folic acid, together with other vitamins of the B group, is essential for DNA replication and cell
proliferation and plays an important role in foetal development. Its deficiency causes megaloblastic
anaemia and during pregnancy, increases the risk of birth defects especially of the neural system.
Folic acid is also associated with a lower risk of cardiovascular disease, particularly stroke, and may
possibly be protective against age-related cognitive decline. These effects have been ascribed to the
reduction of homocysteine concentration in the blood. Folic acid intake was also inversely correlated
to some types of cancer (breast and colon) [EFSA, 2014; Li et al., 2016].
Considering the fact that the consumption of good dietary folate sources, namely leafy green
vegetables, pulses, offal and citrus fruits is low in many population groups, deficiency of folic acid is
common and low-and middle-income countries are particularly affected [McLean et al., 2008; Rogers
et al., 2018]. In a study compiling data from representative national surveys in 45 countries, folic acid
deficiency prevalence in women of child-bearing age ranged from 7 to 79% in low-income countries
and from 1 to 88% in middle-income countries but was <5% in most high-income countries although
insufficiency was more common [Rogers et al., 2018]. Fortification of flour that is now practised in a
number of countries has been shown to improve the folate status at the population level and was
also associated with a decreased incidence of neural tube defects. However, its implementation is
often insufficient with high percentages of flour not adequately fortified [Aaron et al., 2017; Garrett
& Bailey, 2018].
Inadequate status of folic acid has also been reported from countries of the EMR even though data
are not abundant. Among women of child-bearing age, 13.6% were deficient in Jordan [Ministry of
Health Amman, Jordan, 2011], 24.9% in Iran and 19.0% in Iraq [Al-Jawaldeh et al., 2018]. In
Afghanistan, the prevalence was 7.4% in adolescent girls (10-19 years) [Ministry of Public Health
Afghanistan, UNICEF 2013]. The Palestinian Micronutrient Study 2013 revealed suboptimal or
deficient folic acid plasma levels in about 20 % of the included lactating women (18-48 years) and in
10.1 to 31.9% of adolescents (15-18 years). Overall, the status was worse in the Gaza Strip where
deficiencies were more common than in the West Bank. However, in all subgroups, the prevalence of
deficient plasma folic acid levels was under 5 %. Adolescent girls showed a better status than boys. In
turn, a satisfactory status was found in infants and children aged 6 to 59 months and pregnant
 43

women (18-43 years). Of the latter, the majority (86.8 %) supplemented folic acid during the first
trimester of pregnancy, but only 24 % had done so before conception. In both cases,
supplementation frequency was lower in the Gaza Strip [State of Palestine, 2014].

Vitamin D deficiency – a global health issue?

Vitamin D is unique among micronutrients in being synthesized by the body from the conversion of
7-dehydrocholesterol to cholecalciferol under the influence of UV light in the skin. However, this
reaction requires adequate sun exposure and its activity declines with age. Epidemiological evidence
points to a high prevalence of insufficient vitamin D status (defined by serum levels of 25-OH-
cholecalciferol <50 nmol/l or 20 ng/ml) worldwide. Various causes have been suggested for this
“pandemic” as it has been termed by some experts, including low sun exposure at high geographic
latitudes or due to clothing, pollution, increasing rates of indoor activities, use of sun screen or high
skin pigmentation. Paradoxically, populations of sunny countries have repeatedly been found to be
highly affected while residents of northern regions like Scandinavian countries or Canada generally
show better status [Hilger et al., 2014; Spiro & Buttriss, 2014; Saraf et al., 2016; Roth et al., 2018].
However, in these latter, in addition to higher fish consumption, supplementation is rather common
and some of these countries also have a long-standing history of food fortification with vitamin D
[Raulio et al., 2017; Itkonen et al., 2018]. Natural dietary sources for vitamin D are limited to fatty
fish and some seafood and small amounts in mushrooms.

Considering the involvement of vitamin D in many physiological functions beyond skeletal health and
its association with a number of non-communicable and immunological diseases, action to address
global vitamin D deficiency is warranted [Pilz et al., 2018].
 44

5. Working together towards good nutrition and health

5.1. Health in all Policies

Health in All Policies” (HiAPs) are based on the understanding that multiple sectors affect and
contribute to the health status of a society (figure 5). The concept aims at the social determinants
and drivers of health that affect health outcomes and health inequities, by facilitating action in and
collaboration between sectors that are not primarily concerned with health. HiAP incorporates
health considerations into decision-making across sectors and policy areas to improve the health of
all individuals [Leppo et al., 2013].
The importance to include other related sectors beyond the actual health sector into primary health
care was first acknowledged in the Declaration of Alma-Ata in 1978 [WHO, 1978] and its role for
health promotion is stated in the Ottawa Charta for Health Promotion from 1986 [WHO, 1986].

The Helsinki Statement on Health in All Policies at the 8th Global

Conference on Health Promotion, Helsinki, Finland, 10-14 June 2013
Health in All Policies is an approach to public policies across sectors that
systematically takes into account the health implications of decisions,
seeks synergies, and avoids harmful health impacts in order to improve
population health and health equity. It improves accountability of
policymakers for health impacts at all levels of policy-making. It includes
an emphasis on the consequences of public policies on health systems,
determinants of health and well-being.

Figure 5 Causes and underlying determinants of health issues

 45

HiAP systematically takes into account the implications of decisions for health and health systems,
seeking synergies and aiming at avoiding harmful impacts on health impacts with the final goal to
improve population health and health equity.
HiAP approaches are founded on human and health-related rights and obligations and on social
justice. They focus on the consequences of public policies on health determinants aiming at
enhancing health and other crucial societal goals and improving the accountability of policy-makers
for health impacts at all levels of policy-making. Strategic public health goals and efforts are aligned
across sectors and the whole nation to improve population health.

Objectives of HiAPs
1. Promotion of health, elimination of equities
2. Support of collaboration between sectors
3. Mutual benefit of all involved partners, obtain commitment of stakeholders
4. Avoiding negative health effects of public policies
5. Sustainable change of the health environment

The concept of HiAP is to incorporate health in various policies and actions and ensure that health
considerations are part of government decision-making processes. Considering that inequity is a
strong determinant of poor health, HiAP also aims at promoting equity. Besides health, other
objectives are pursued to varying degrees depending on the situation [Olilla, 2011].
HiAP fosters collaboration between sectors and across all levels by including areas that are not
typically associated with health but act as determinants of the economic, social and physical
environments. This interaction also increases the efficiency of the approach.
Collaboration is further encouraged by the generation of mutual benefits for all involved
stakeholders resulting in “win–win” effects. By achieving not only the goals of the health sector but
also of other government agencies and community stakeholders, efficiency and use of resources are
improved across sectors. Effectiveness is also enhanced through the commitment of stakeholders
from non-government areas such as members of the community or the private sector and funders.
Involvement of various stakeholders helps to obtain the necessary information and feedback to
adapt policies to the needs of the target community as well as for fundraising.
Exchange and collaboration between sectors allows to identify and address potential negative health
effects resulting from policies of non-health-related sectors with diverging interests and goals.
By creating new partnerships, raising awareness of health issues and building sustainable and
coordinated intersectoral collaboration, HiAP will result in permanent changes of the health
 46

environment and also ensure that health becomes a constant goal in public policies [Olilla, 2011;
Rudolph et al., 2013].
In the end, HiAP aims at achieving the best possible results within the given circumstances and the
available resources [Leppo et al., 2006].

A HiAP approach is particularly favoured by three general policy situations:

1. Complex health challenges
The most common situation where a HiAP approach should be considered is the existence of
complex health challenges concerning population health, health equity or health systems that
require intersectoral policy solutions. A strong evidence of the problem is essential: its causes,
potential solutions involving other sectors, especially their technical feasibility, and finally the
potential costs and benefits of action from the perspective of health and society as a whole have to
be identified. The prevention and control of NCDs falls into this category.

2. A high impact on health from non-health sector policies

A HiAP approach should also be considered if policy proposals originating from non-health sectors
are likely to have a significant effect on health or health equity. This is the case of many government
policies but engagement of the health sector with other sectors requires significant resources and
time and so priorities have to be set. A HiAP approach can help focus and legitimize the health
sector’s engagement in policy decisions that have significant (indirect) impacts on health. This policy
situation can equally apply to international declarations or agreements. Free trade agreements and
environmental protection laws are examples of this scenario.

3. Government priority affecting many sectors

This policy situation can arise when the government has a high priority goal that both requires
intersectoral collaboration and affects the health sector. This situation offers a good opportunity to
the health sector to advance its own agenda while at the same time contributing to the achievement
of an important government objective via intersectoral action. Through this proactive engagement
ties with other sectors can be strengthened. It also helps establish a reputation of expertise and
reliability, which can be called upon when needed later. Improving early childhood development or
responding to food insecurity belong into this category [WHO, 2015a].

Strategies for the implementation of HiAPs

HiAP actions and groups can take many forms. It can be implemented through its application to
existing processes such as strategic planning, individual initiatives and grant-making or the creation
of a new structure or group, e.g. a task force, or a combination of both.
 47

Many options exist for how to consider health in decision-making, from using formal health impact
assessment tools to an informal application of a health lens. Partners, leaders, and focus areas will
vary, depending upon political support, community needs, and resources.
Challenges to the implementation of HiAP arise from deficits in a country’s political and public health
structures, limited economic and human resources and existing inequalities especially in low and
middle income countries.

Challenges to Health in All policies

 Weak public health structures

 Political instability  Lifestyle change and
 Lack of integrated multisectoral
 Lack of transparency, industry interference
collaboration
accountability and  Weak regulatory
 Inadequate domestic funding and high
knowledge sharing mechanism for the private
out-of-pocket expenses
 Ongoing humanitarian crises sector
 Weak Health Information System
 Climate change and  Lack of human resources
hindering surveillance, monitoring and
environmental hazards  Gender discrimination
evaluation

5.2. Key partners involved in international nutrition policies

Various UN agencies are involved in programmes to improve nutrition and fight against malnutrition
and NCDs in accordance with the SDGs. Consistent with the multisectoral approach, cooperation
between these organizations and other stakeholders like governmental public health institutes, bi-
and multilateral organizations, NGOs, foundations and others, will enhance the impact on nutrition
and health (figure 6).
 48

Figure 6 Cooperative network of UN agencies and other stakeholders for the achievement of the
SDGs

5.2.1. UN System Standing Committee on Nutrition (UNSCN)

UNSCN was created in 1977 as the Subcommittee on Nutrition of the Administrative Committee on
Coordination of the UN (ACC) through an UN Economic and Social Council (ECOSOC) resolution. It
continued its functions as the United Nations System Standing Committee on Nutrition (UNSCN) after
the UN Reform of the ACC and its renaming as Chief Executives Board for Coordination (CEB). The
mandate and responsibility of the UNSCN falls within the UN system and it reports to the CEB. Its
Secretariat is hosted by FAO in Rome. Its task is to promote cooperation and exchange between UN
agencies and also with partner organizations in support of community, national, regional, and
international efforts to end malnutrition in all of its forms by offering a framework for dialogue,
guiding, magnifying and enhancing the coherence and impact of actions against malnutrition across
the world. It also seeks to raise awareness of nutrition issues and obtain commitment to their
resolving.
UNSCN uses a mode of plenary talks (as face-to-face meetings, phone or video conferences,
electronic consultations and debates), open to all its members, to foster communication and for any
other substantive work. Another important functioning principle is a delegation of responsibility to
its members to lead or conduct research and policy work on nutrition, on behalf of UNSCN. To raise
 49

awareness on the impact of other sectors on nutrition such as climate and trade, UNSCN will also
selectively engage in global “non-nutrition” forums.
The efficiency and effectiveness of these processes and the focus on results are ensured by the
UNSCN steering committee, including a representative of each constituent member, the UNSCN
Secretariat and the UNSCN Chair that is a senior UN official, appointed by consensus amongst the
principals of the constituent member agencies for a term of two years that is renewable once. The
UNSCN Secretariat oversees the implementation of the annual work plan and the funding
management and coordinates tasks delegated to members or other partners as well as the plenary
talks, the UNSCN website and its products, and it produces an annual activity report.
Membership to UNSCN is open to all UN agencies that have a significant interest or engagement in
nutrition-related issues. Besides the five UN agencies with an explicit mandate to improve the global
nutrition situation in the world, FAO, IFAD, UNICEF, WFP and WHO, the UN Department of Economic
and Social Affairs (DESA), the International Atomic Energy Agency (IAEA), the UN Environmental
Programme (UNEP) and others are also associated to the UNSCN [UNSCN, 2017;
https://www.unscn.org/].

Tasks of the UNSCN are

 to provide global strategic guidance and advocacy in nutrition to ensure engagement and
investment at the highest level and to ensure progress towards nutrition security for all;
 to enhance dialogue and linkages, fostering joint nutrition action, partnerships and mutual
accountability between UN agencies;
 to harmonize concepts, including methodologies and guidelines, policies and strategies in
response to the nutritional needs of countries;
 to facilitate knowledge exchange of practices, tools and needs, enhancing coherence of the
global nutrition public goods agenda and identifying emerging issues;
 to communicate on global trends, progress and results and to enhance global advocacy
through networks and platforms;
 to engage in and facilitate dialogue with stakeholders across health, food security, water and
sanitation and social protection constituencies for strengthening nutrition action and
mainstreaming nutrition into development policies.

To contribute to the achievement of the Agenda 2030 and the SDGs, the UNSCN has set a number of
strategic objectives for the period of 2016-2020:
 50

 Strategic Objective 1: Maximize UN policy coherence and advocacy on nutrition

(strengthening of policy coherence on nutrition across the UN system, enhancing advocacy
on nutrition, promoting exchange between stakeholders)
 Strategic Objective 2: Support consistent and accountable delivery by the UN system
(harmonization of UN methodologies, guidelines, policies and strategies, mobilisation of
other relevant UN agencies to ensure a robust and coherent response and engagement of
the UN system in implementing and monitoring of the outcomes of the 2025 WHA and ICN2)
 Strategic Objective 3: Explore new and emerging nutrition-related issues
(provision of information on global trends, progress and results in relation to nutrition in the
context of the 2030 Agenda, identification of critical emerging issues and proposal of
strategies to investigate them and address knowledge gaps
 Strategic Objective 4: Promote knowledge sharing across the UN System
(analysis and discussion of key topics by time-bound communities of practice or working
groups, facilitation of networking and joint research within the UN system) [UNSCN, 2017].

5.2.2. UN Interagency Taskforce on NCDs (UN IATF)

The UN Interagency Taskforce on NCDs (UNIATF) was established by ECOSOC in 2013 in response to
the 2011 Political Declaration of the high-level meeting of the UN General Assembly on the
prevention and control of non-communicable diseases. Its purpose is to coordinate the activities of
the relevant United Nations funds, programmes and specialized agencies and other
intergovernmental organizations and thereby support the achievement of the goals reached at the
High level Meeting of the General Assembly on the Prevention and Control of Non-communicable
Diseases and the implementation of the World Health Organization Global Action Plan for the
Prevention and Control of Non-communicable Diseases 2013-2020 [WHO, 2013a]. In 2016, activities
were extended to include NCD-related SDGs. The UNIATF reports to the Council through the UN
Secretary-General. It has about 40 members, including the World Bank and regional development
banks. Sustainability is ensured through UN Country Teams.

Specific objectives of the task force are:

 to enhance and coordinate systematic support to Member States in their efforts to prevent
and control non-communicable diseases and mitigate their impacts;
 to facilitate systematic and timely information exchange among entities of the United
Nations system and intergovernmental organizations about existing and planned strategies,
programmes and activities to prevent and control non-communicable diseases and mitigate
their impacts, at the global, regional and national levels;
 51

 to facilitate information on available resources to support national efforts to prevent and

control noncommunicable diseases and mitigate their impacts, and to undertake resource
mobilization for the implementation of agreed activities, including for joint programmes in
accordance with guidelines of the United Nations Development Group;
 to strengthen advocacy and raise the priority accorded to the prevention and control of non-
communicable diseases on the international development agenda and sustain the interest of
Governments in realizing their commitments through statements, reports and participation
in panels by high-level United Nations officials;
 to incorporate the work of the Ad Hoc Inter-Agency Task Force on Tobacco Control and to
ensure that tobacco control continues to be duly addressed and prioritized in the new task
force mandate;
 to strengthen international cooperation in the prevention and control of non-communicable
diseases (e.g. through exchange of best practices in the areas of health promotion,
legislation, regulation and health systems strengthening, training of health personnel,
development of appropriate health-care infrastructure and diagnostics, transfer of
technology, production of affordable, safe, effective and quality medicines and vaccines)
[WHO, 2015c].

The task force has developed a set of policy briefs available in the six UN languages providing
decision makers across government with information about how NCDs affect their sector and on how
to respond to the challenge of NCDs. Considering the increasing burden exerted by NCDs on public
health care systems of low and middle income countries, the task force offers guidance on how to
integrate NCDs into the UN Development Assistance Framework (UNDAF).
To reach its strategic priority for 2018 and 2019 of supporting member countries in their efforts
towards achieving the NCD-related SDGs 3.4 and 3.8 by 2030, the UNIATF focusses on:
 building national investment cases
 establishing national multisectoral mechanisms for NCDs
 enhancing the capacity and mandates of relevant authorities in facilitating and ensuring
action across governmental sectors for NCDs
 mobilizing action in sectors beyond health to support countries in responding to NCDs within
the context of UHC, including addressing cancer, use of information and communication
technologies (ICTs) for better health outcomes, and good governance
 integrating NCDs and NCD-related SDGs into national SDG responses
 52

5.2.3. Global Coordination Mechanism on NCDs

The Global Coordination Mechanism on NCDs (GCM/NCD) is a global Member State-led coordinating
and engagement platform. It was established in 2014 by the World Health Assembly to help
counteract the growing global health threat of noncommunicable diseases. The GCM/NCD
contributes to the implementation of the WHO Global Action Plan for the Prevention and Control of
Noncommunicable Diseases 2013-2020 [WHO, 2013a] and the NCD-related Sustainable Development
Goal (SDG) targets by fostering high-level NCD commitments by facilitating and enhancing the
coordination of activities and multi-stakeholder engagement and action across sectors at the local,
national, regional and global levels. It connects and convenes a diverse group of over 300
participants comprising WHO Member States, United Nations organizations and non-State actors
around a shared goal to support countries to reduce premature mortality and unnecessary suffering
from NCDs and to address its five functions:
1. Advocating and raising awareness
2. Disseminating knowledge and information
3. Encouraging innovation and identifying barriers
4. Advancing multisectoral action
5. Advocating for mobilization of resources [WHO https://www.who.int/activities/gcm]

To foster results-oriented work related to the five functions of the GCM/NCD and in line with the
principles and six objectives of the WHO Global NCD Action Plan 2013–2020, the WHO Director
General established Working Groups as appropriate to produce reports with recommendations to
enhance national actions against NCDs. Working Groups composed of leading technical experts
nominated by Member States and co-chaired by high-level Member State representatives appointed
by the WHO Director-General in consultation with Member States (table 10) [WHO
https://www.who.int/activities/gcm].
GCM/NCD key activities include promoting dialogue on NCDs, poverty and development and on
cooperation, organising webinars, communications campaigns such as the Global Communications
Campaign on NCDs, Global Dialogue Meetings, and providing a Web-based Platform for the exchange
of information and best practices. GCM/NCD regularly launches Communities of practice (CoPs) that
are closed networks from a diverse range of stakeholders with expertise in a certain area of the
prevention and control of noncommunicable diseases (NCDs). CoPs are not open to the general
public. The discussions conducted or resources shared on the platform are accessible only to
members of the CoP. A General Meeting of the GCM took place in 2018.
 53

The Global Dialogue meetings respond to one of the GCM/NCD’s key objectives, which is to advocate
for and raise awareness of the urgency of implementing the Global Action Plan for the prevention
and control of noncommunicable diseases, 2013-2020 [WHO https://www.who.int/activities/gcm].

Table 10 Working Groups of the WHO GCM/NCD

Working Group Term Related function
WHO GCM/NCD Working Group on how to realize 2015 3
governments’ commitments to engage with the private sector
for the prevention and control of NCDs
GCM/NCD Working Group on how to realize governments’ 2015 5
commitment to provide financing for NCDs
WHO GCM/NCD Working Group on health education and 2016-2017 3
health literacy for NCDs
WHO GCM/NCD Working Group on the alignment of 2016-2017 3
international cooperation with national plans on NCDs
WHO GCM/NCD Working Group on the inclusion of NCDs in 2016-2017 3
other programmatic areas

The Global Dialogue meetings are multistakeholder events, with participants drawn from Member
States, United Nations and all its Specialized Agencies, and non-State actors such as non-
governmental organizations, academic institutions, philanthropic foundations and eligible private
sector business associations [WHO https://www.who.int/activities/gcm].

5.2.4. Committee on World Food Security (CFS)

The Committee on World Food Security (CFS) was established in 1974 as an intergovernmental body
to serve as a forum for review and follow up of food security policies [FAO http://www.fao.org/3/a-
au831e.pdf].
In 2009 the Committee went through a reform process to increase its legitimacy as a decision-making
body for global governance of food security and ensure that the global debate on food security and
nutrition be focused, results orientated and inclusive. The vision of the reformed CFS is to be the
most inclusive international and intergovernmental platform for all stakeholders to work together in
a coordinated way to ensure food security and nutrition for all. The Committee reports annually to
the ECOSOC [FAO http://www.fao.org/3/a-au831e.pdf].
CFS is made up of Members, Participants and Observers. The membership of the Committee is open
to all Member States of the FAO, the IFAD or the WFP and non-Member States of FAO that are
 54

Member States of the United Nations. Currently members of the CFS include 130 countries and
several hundred civil society organizations, eleven international private sector association and about
500 other companies are independently engaged. The CFS Bureau is the executive arm of CFS. It is
made up of a Chairperson and representatives of twelve member countries. Recognizing the
importance of inclusiveness in decision-making processes is conceived as a global multi-stakeholder
platform, promoting dialogue, joint ownership and responsibility. The Advisory group of the CFS is
made up of representatives from CFS Participants including UN agencies and other UN bodies, civil
society and non-governmental organizations, international agricultural research institutions,
international and regional financial institutions, private sector associations and philanthropic
foundations as well as prominent individuals [FAO http://www.fao.org/3/a-au831e.pdf].
The permanent CFS Secretariat hosted at the FAO in Rome includes staff from the FAO, the IFAD and
the WFP and supports the Plenary, the Bureau and Advisory Group and the HLPE in their work.
CFS holds an annual plenary session which informs, debates and recommends actions to be taken by
CFS stakeholders on food security and nutrition issues [FAO http://www.fao.org/3/a-au831e.pdf].
A key function of the CFS is to address the knowledge gap by defining the nature, causes and
magnitude of food security issues to enable the formulation of policy recommendations. The High
Level Panel of Experts on Food Security and Nutrition (HLPE) was created in October 2009 as an
essential part of the CFS reform. It has since produced a number of evidence-based reports on some
of the most crucial issues related to food security and nutrition such as price volatility, land tenure
and international investments in agriculture, investing in smallholder agriculture, climate change,
biofuels, sustainable food systems and others. It also publishes policy tools to assist stakeholders in
their own strategies and activities and provides technical assistance through its multi-agency
secretariat. Promoting policy convergence is the most important role of the CFS. Two notable
outputs of the CFS are the Voluntary Guidelines on Responsible Governance of Tenure of Land,
Fisheries and Forest (2012) and the Principles for Responsible Investment in Agriculture and Food
System (2014) [FAO http://www.fao.org/3/a-au831e.pdf].

5.2.5. Scaling Up Nutrition (SUN) Movement

The Scaling Up Nutrition (SUN) Movement started in September 2010 by the UN Secretary-General at
the 65th Session of the UN General Assembly with the objective to bring together national
governments, United Nations agencies, donors and various other stakeholders like businesses and
civil society and development organizations in a collective fight against malnutrition. Its ultimate goal
is the achievement of the nutrition targets defined by the World Health Assembly in its
Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition in 2012 (see
below). Special focus is on maternal and child undernutrition, a reduction of stunting and the rights
 55

and an empowerment of girls and women. Creating an alliance between various actors involved in
nutrition, the movement helps countries to develop, coordinate and implement multisectoral
nutrition policies, to raise and mobilise resources for nutrition programmes and evaluate outcomes
and progress. Countries also receive technical assistance and advice on engaging with the private
sector [SUN BN, 2015; SUN Secretariat, 2016].
The movement is led by the SUN Movement Coordinator and a Lead Group, made up of
representatives of governments, the civil society, international organizations, donor agencies,
businesses and foundations that were appointed by the United Nations Secretary General in 2012. To
date (2018), 60 countries (40 from the African, 15 from the Asian-Pacific and 5 from the Latin-
American-Caribbean region) and three Indian States (Jharkhand, Maharashtra and Uttar Pradesh)
have joined the movement, including three countries from the WHO EMR (Afghanistan, Pakistan and
Yemen). The non-governmental actors are grouped into self-organised networks (United Nations,
Civil Society, Donor and Business Networks). The SUN Movement Executive Committee oversees the
development and implementation of the SUN Movement strategy with the support of the SUN
Movement Secretariat based in Geneva that also coordinates the cooperation between the Country
Focal Points and the Networks [SUN Secretariat, 2016].
A roadmap was developed in 2010 and revised in 2012, followed by the first SUN Movement Strategy
2012-2015. In 2014, the Lead Group commissioned an independent comprehensive evaluation by the
international development consultancy group Mokoro Ltd. to assess the Movement’s efficiency,
relevance and effectiveness. The findings of this evaluation provided the basis for the second SUN
Movement Strategy and Roadmap 2016-2020 outlining four key areas for future efforts to tackle
identified weaknesses [Mokoro, 2014; SUN Secretariat, 2016].

Strategic objectives of the SUN Movement

1. Expand and sustain an enabling political environment
2. Prioritise and institutionalise effective actions that contribute to good nutrition
3. Implement effective actions aligned with Common Results
4. Effectively use, and significantly increase, financial resources for nutrition
 56

Four key areas of the SUN Movement Strategy and Roadmap 2016-2020
1. Continuously improving country planning and implementation to end malnutrition
2. Mobilising, advocating and communicating for impact
3. Strengthening the capacity for multi-sectoral and multi-stakeholder collaboration at all levels
4. Equity, equality and non-discrimination for all – with women and girls at the centre
 57

6. From theory to practice: implementing nutrition policy

6.1. Translation of nutritional epidemiology findings into dietary guidelines and

health policy
The objective of dietary guidelines, including food-based guidelines and nutrient-based reference
intake levels, is to provide guidance on the composition of a healthy diet ensuring the supply of
adequate amounts energy, essential nutrients and other health-promoting food components and to
prevent negative effects arising from certain other diet components.
Dietary guidelines are based on the knowledge of associations between food consumption, intake of
nutrients and certain health effects or diseases. They are developed using an evidence-based
approach involving a systematic review of the scientific evidence of nutrition research to make
practice decisions by integrating best available evidence with professional expertise and client values
to improve outcomes. A critical requisite for making recommendations is the proof of a causal
relationship. In general, randomized controlled trials (RCTs) are considered the best approach to
study causal relationships because they reduce bias and allow better control of confounders (figure
7). Even stronger evidence is obtained from systematic reviews or meta-analyses of RCTs that
combine the results from several studies. In this regard, some aspects that are unique to the field of
nutritional science and nutritional epidemiology have to be considered [Tapsell et al., 2016].

Figure 7 Determinants of the quality of evidence

Studying the effects of dietary factors and patterns on health differs in many ways from
pharmaceutical trials. The greatest difference arises from the fact that food and even more so an
entire diet is made up of many diverse components, which all have their effects on health. The
identification of single active agents is much more difficult than for clinical drug trials. The use of
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RCTs in nutritional studies is constrained by a number of factors that do not apply to drug trials (table
11). For this and other reasons, nutritional data are more often obtained from observational studies
that are more applicable to the large sample sizes required for insights into the diet at population
level [Satija et al., 2015].

Table 11 Comparison of RCTs of drugs and RCTs of nutrients or foods (modified from Satija et al.,
2015)
Design criterion RCTs of drugs RCTs of nutrients or foods
Exposure Well-defined, individual, isolated Complex, interacting network of
chemical compounds nutrients and food components
Choice of control Placebo Depending on prior evidence,
feasibility and ethical aspects
Endpoint Clinical events, adverse effects Disease prognosis and management,
intermediate outcomes
Blinding Easy Not possible with whole food and
dietary pattern approach
Compliance High to moderate over follow-up Often decreases substantially over
(depending on side effects) long period of follow-up
Dropout rate Low to moderate (depending on Moderate to high depending on
side effects) duration and type of intervention

Dietary assessment methods are either prospective or retrospective. Prospective assessment uses
food records that can be weighed for more accuracy even though this is more laborious for the
participants and of limited applicability to large samples. Moreover, the recording may cause a
change in the consumption pattern of the participants. The most common retrospective methods are
24h dietary recalls and food frequency questionnaires (FFQs) and these are also the most widely
used methods altogether. Disadvantages are the reliance on the participants’ memory, the difficulty
to correctly estimate portion sizes and the fact that foods may also be misreported deliberately. To
account for intraindividual variability and atypical food consumption, the collection of multiple 24h
recalls is advised [Elmadfa & Meyer, 2014]. Both, prospective and retrospective methods depend on
the availability of reliable food composition data. There is still a lack of data for certain food
components like many trace elements, some vitamins, fatty acids and non-nutritive secondary plant
compounds as well as for ethnic or regional foods and prepared dishes. Moreover, the composition
of food varies widely so that the intake of nutrients can only be estimated even if the recording of
 59

food consumption is very exact [Elmadfa & Meyer, 2010]. Biomarkers allow a more accurate
determination of an individual’s nutritional status but their applicability to large samples and in field
studies is limited. In addition, specific markers are not available for every nutrient [Elmadfa & Meyer,
2014].
Besides these issues concerning the collection of data on food and nutrient intake, the effect of a
given food component also shows individual and genetic diversity. Nevertheless, causal relationships
can be inferred from data obtained from nutritional epidemiology [Satija et al., 2015]. The general
criteria for causality also apply to nutritional epidemiology: the consistency of an observed
association across studies and trials, the strength of an association, the existence of a dose effect, the
biological plausibility and the temporality of a relationship between a food or a nutrient and an
outcome, coherence between experimental and epidemiological evidence [Hill, 1965; Potischman &
Weed, 1999]. Consistency corresponds to the replicability of results. Observed effects/associations
have to be consistent across (similar) populations, study designs, and statistical methods. However,
instruments for epidemiological nutritional assessment such as FFQs and dietary recalls are usually
not comparable between studies with regards to the applied cut-off points, the selection of food
groups, the estimation of portion sizes etc. There are also differences concerning the choice of
subgroups (by gender, age groups). The strength of association is another issue in nutritional
epidemiology. Associations between nutritional factors and health effects are generally weak.
However, when exposure is high and/or the health effect has major public health relevance, even a
weak effect may be important. Surrogate biomarkers can minimise errors arising from self-reported
data [Satija et al., 2015]. The observation of effects of certain diets is corroborated if these effects
can be traced back to foods, nutrients or components that are abundant in this diet. Taking the
example of the cardioprotective effect of the Mediterranean diet, this effect was also found for olive
oil, nuts, fruits and vegetables that are main components of this dietary pattern and also for
unsaturated fatty acids and polyphenols that occur in these foods [Satija et al., 2015].
Causality is supported by the existence of biological explanations for the observed effects
(plausibility).
Nutrient-based dietary guidelines assure the adequate supply of energy, nutrients and dietary fibre
to the vast majority (97.5%) of healthy persons over the life course. They take into account the
specific needs of different age groups including the requirements for growth and development
during childhood and adolescence, of older adults and during pregnancy and lactation to assure
optimal performance and health.
The availability of data on the average requirement differs between nutrients. This is taken into
account by formulating different types of dietary reference intakes. If the average requirement (AR),
defined as the level of a nutrient that is adequate for 50% of a given population, is known a
 60

recommended daily allowance (RDA) or population reference intake (PRI) value can be derived by
adding 2 standard deviations to cover the needs of 97.5% of the population. This is the case for
protein, many vitamins and some minerals like calcium, magnesium and iron. If the available data is
not sufficient to determine the average requirement of a population or population group, an
approximate value is derived from observed or experimentally determined levels of nutrient intake
by apparently healthy persons that are assumed to be adequate (adequate intake, AI). This is the
case of n-3 fatty acids, some vitamins like vitamins D, E and K and some trace elements like selenium
and copper. For fat and carbohydrates, acceptable macronutrient distribution ranges (AMDR) or
reference intake ranges (RI) are given as a percentage contribution to total energy intake that is
adequate for maintaining health and associated with a low risk for some related chronic diseases. For
certain nutrients like saturated fatty acids and added sugars as well as for cholesterol maximum
intake levels are indicated that should not be exceeded for better health [Otten et al., 2006; EFSA,
2010a].
There are different ways to determine nutrient requirements:
If a nutrient is associated with specific functions in the body, its deficiency will lead to functional or
structural changes or disease states that can serve as clinical endpoints. However, such an approach
is limited for ethical reasons. The association of a nutrient with the activity of a specific enzyme, the
immune response or the expression of certain genes also offers potential functional biomarkers.
Concentrations in the plasma, serum or tissue can be used to determine the status when reference
values are known. For nutrients with a known constant metabolism in the body and urinary excretion
rate, the minimum requirements can be deduced from balance assessments by finding the
equilibrium between intake and the sum of excretion, losses and utilization using a factorial method.
If no other data are available, the intake of apparently healthy subjects can provide an estimate for
adequate intake amounts and requirements. These data should be obtained from large
epidemiological surveys to be representative. However, nutritional assessment suffers from
confounding and food composition databases are often incomplete especially with regard to trace
elements and some vitamins, polyunsaturated (n-6/n-3) fatty acids, trans fatty acids, dietary fibre
and health-related secondary food components, only allowing an estimation of nutrient intake.
Moreover, misreporting is common whether intentional or not. Although data from experimental or
clinical trials are generally considered of higher quality, data from epidemiological or ecologic studies
contribute substantially to the derivation of recommendations and guidelines by covering larger
samples and reflecting the actual situation at population level especially if data on food consumption
are complemented by biochemical data [Otten et al., 2006; Satija et al., 2015].
The evidence from nutritional epidemiology also provides the basis for food-based dietary guidelines
(FBDG) that give advice on the composition of a healthy diet, taking into account specific national
 61

public health and nutrition priorities, the sociocultural background, consumption patterns and
aspects of food production among others. Often recommendations about other lifestyle factors like
physical activity are also included. Food-based dietary guidelines target a wider audience than
nutrient-based recommendations including the general population. To be easily understandable even
for persons with a lower education level or illiterate persons, FBDGs are often complemented by
pictographic form showing the different food groups in their respective recommended amounts
[EFSA, 2010b]. Examples are the plate formats used in the USA, the UK, Mexico or in Oman, the
pyramids used in the German-speaking countries, in Iran and other less common formats like the
shell used in Qatar, the Healthy Food Palm in Saudi Arabia or the Cedar Food Guide from Lebanon
(figure 8).

Figure 8 Graphic representations of food-based dietary guidelines from various countries

6.2. Partnership, resource mobilization and key actors in nutrition

The effectiveness of nutrition policy is increased by the existence of a central governance body acting
as a leader of policy initiatives that can also sign other high-level stakeholders. Transparency and
accountability can be improved by the inclusion of national and sub-national government officials,
representatives of civil society and other participants. The development of policies, the coordination
of actions and their evaluation is ideally committed to a central coordinating agency. The efficiency
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of such an agency is enhanced by its being located centrally within the government. It should possess
sufficient authority, capacities, financial resources and leadership. Its long-term survival may depend
on the extent to which agency staff advocate for ongoing attention and resources. In addition to the
governance body and coordinating agency sectoral agencies (such as the departments of health,
agriculture, education, welfare and trade) may be included in a nutrition policy. Sub-national
activities can be confided to regional and local food and nutrition bodies resulting in a multi-sector/-
level institutional framework with clearly defined roles and responsibilities. Institutional
accountability, monitoring and performance are enhanced by the existence of data-sharing and
communication systems that can enable institutional responsiveness and induce adaptation of
centralized policies in response to feedback on changing on-the-ground conditions, challenges and
demands [WHO/FAO, 2018].

Figure 9 Forms of commitment for nutrition and their reinforcement (adapted from [WHO/FAO,
2018])
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6.3. Guiding principles for developing WHO guidelines

Guidelines are a fundamental means through which the WHO fulfils its technical leadership in health
and other core functions as stated in its 12th General Programme of Work [WHO, 2014c] (see box).

Core functions of the WHO

1. Providing leadership on matters critical to health and engaging in partnerships where joint
action is needed

2. Shaping the research agenda, and stimulating the generation, dissemination and
application of valuable knowledge

3. Setting norms and standards, and promoting and monitoring their implementation

4. Articulating ethical and evidence-based policy options

5. Providing technical support, catalysing change and building sustainable institutional

capacity

6. Monitoring the health situation and assessing health trends

WHO guidelines contain recommendations for clinical practice or public health policy developed by
the WHO upon request from member states, WHO country offices, external experts or other
stakeholders. They advise the intended user of the guideline on how to act in specific situations to
achieve the best health outcomes possible, enabling informed choices of different interventions or
measures with an anticipated positive impact on health and implications for the use of resources.
The development of these guidelines is based on internationally recognized methods and standards
to ensure that they are of the highest quality, through a process that is explicit and transparent,
multidisciplinary and inclusive, aiming at minimizing the risk of bias in the recommendations.
Recommendations are made following a systematic and comprehensive assessment of potential
benefits and harms and explicit consideration of other relevant factors, and they can be
implemented in, and adapted to, local settings and contexts. Audiences for WHO guidelines include
public health policy-makers, health programme managers, health-care providers, patients,
caregivers, the general public and other stakeholders.
The WHO is committed to ensuring that its health care recommendations are based on the best
available research evidence and are developed in ways consistent with best practice and through
appropriate use of the available evidence.
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In 2010, a nutrition guideline development group, the WHO Nutrition Guidance Expert Advisory
Group (NUGAG) was established by the WHO Department of Nutrition for Health and Development
(NHD) in accordance with the new WHO guideline development process. It is guided by the WHO
Steering Committee for Nutrition Guidelines Development composed of representatives from all
WHO Departments interested in the provision of nutrition-related recommendations and includes
experts from various WHO Expert Advisory Panels as well as external experts from multiple areas of
expertise from all WHO Regions. Currently, it comprises three subgroups, Diet and health, Nutrition
actions and Policy actions, focussing on different topics (for more details see
https://www.who.int/nutrition/topics/guideline-development/en/).
In 2010, a Global Network of Institutions for Scientific Advice on Nutrition was established with the
aim of bringing together major public institutions that set guidelines related to diet and nutrition,
creating synergy and avoiding duplicate work.
The process of developing a WHO nutrition guideline follows the general principles described in the
WHO Handbook for guideline development [WHO, 2014d] (figure 10).
At the beginning of any guideline development, it has to be clarified whether there is a real need for
that specific guideline, if guidelines on the topic already exist, who wants the guideline, who should
produce it and who should be involved in its development (e.g. WHO departments and external
experts). Target audiences and recipients of the intervention have to be identified and the timeframe
for the development process be decided on. These questions are discussed by the WHO technical
unit of the WHO Organization that initiated the development of the guideline.
 65

Figure 10 Process of developing a WHO Guideline [WHO, 2014d]

GRC: Guidelines Review Committee; GRADE: Grading of Recommendations Assessment,
Development and Evaluation

If the need for a guideline is confirmed, the groups involved in its development have to be
established. These include:
 the steering group
consists of 4-10 members from all WHO departments and regional offices directly related to the
topic of the guideline and is in charge of identifying members of the Guideline Development
Group (GDG) and external review group, overseeing and administrating the development
process and the conduct of the systematic review, and drafting the scope as well as the final
guideline.

 the Guideline Development Group (GDG)

is a multidisciplinary group composed of 10-20 (or more depending on the guideline scope)
external experts from all WHO regions to use the guideline. Members include i.a. relevant
technical experts, experts in evidence assessment and guideline development, end-users of the
 66

guideline and representatives of groups most affected by the guideline recommendations. The
GDG’s primary task is the formulation of recommendations, the general scope and content of
the guideline. It also contributes to formulating the scope and key (PICO) questions and reviews
the final guideline document.

 the external review group

includes 5-20 persons with interest in the subject of the guideline (e.g. technical experts, end-
users, advocacy groups and individuals affected by the condition addressed in the guideline).
The group provides diverse and real-world perspectives, reviews the draft final guideline and
may also have input into the scope and key questions.

 the systematic review team

a team of 2-6 or more persons with the required expertise for systematic reviews and without
conflicts of interest commissioned with the provision of a comprehensive, objective synthesis of
the evidence to inform each recommendation, the assessment of the quality of the evidence
and the development of evidence profiles. It also has input into the key questions.

The formulation of the key questions addressed by the guideline is of great importance as it
determines the systematic review and influences the final recommendations. Usually, two basic
types of questions can be distinguished: background and foreground questions. Background
questions provide context and rationale for the guideline and can pertain to definitions, the
prevalence and distribution of a disease or problem or underlying pathophysiologic mechanisms.
Foreground questions directly inform and underpin recommendations. They are the most important
questions for a guideline as they are used to inform the recommendations. Answering these
questions usually requires a systematic review and quality assessment of the evidence.
Example:
Background question: How is salt intake associated with hypertension?
Foreground question: What impact does reduced salt intake in adults have on CVD mortality?

Because the answers to foreground questions will form the evidence base upon which the
recommendations will be made, these questions should be formulated so as to enable a systematic
literature search. This is generally done by using the PICO format (table 12).
Recommendations are made to achieve a net benefit, making the choice of the most important
outcome critical to producing a useful guideline. However, the value attributed to different outcomes
varies between populations. Therefore, the GDG that should include end-users, implementers and
policymakers, as well as technical experts, is required to identify the key outcomes that are critical
for making the recommendations.
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Table 12 Elements of the PICO format for the formulation of key questions
Population What group or population is targeted by the intervention or exposure under
consideration?
Describe members of the target population (relevant demographic
characteristics, age, sex and other social, geographic and environmental
characteristics relevant to the guideline topic)
What is the setting (e.g. hospitals, communities, workplaces or schools)?

Intervention What intervention or exposure is under consideration? Can also be an exposure,

a diagnostic test or other technology or a public health measure

Comparator What are alternative courses of action or exposures compared to those

recommended in the guideline?
Can be a placebo, a standard practice or no treatment. Comparisons can also
involve settings or treatment level.

Outcomes What are the outcomes of the intervention or exposure that matter most to the
individuals and populations affected by the guideline? In the context of clinical
interventions, these are sometimes referred to as patient-oriented or patient-
centred outcomes. What are the potential benefits of the intervention or
exposure? What are its potential harms? What impact will it have on equity
(distribution of health)?

Timing Sometimes the timing of the measurement of outcomes or for the duration of the
intervention or exposure is also added.

Recommendations in WHO guidelines are generally based on a systematic review of the scientific
literature guided by the specific key questions about the considered intervention or exposure. This
can include the use of existing systematic reviews of adequate quality on the subject. Otherwise, a
new systematic review is performed. In most cases, it is commissioned from external contractors
with the necessary expertise, forming the systematic review team. After finalizing the key questions
in PICO format and defining the study eligibility criteria, information sources and bibliographic
databases are identified and original research articles are searched. Relevant studies are selected on
the basis of their titles and abstract using the inclusion and exclusion criteria and full texts are
obtained. Selected studies are then assessed for risk of bias. Among others, the design of a study is a
strong determinant of bias. Randomized controlled trials are generally less prone to bias than
observational studies or expert opinions (figure 8). The estimates of effect on the selected critical
and important outcomes are assessed for confidence using the GRADE approach (see below) and the
 68

results are presented to the GDG to formulate recommendations. Data extracted from the
systematic review that meet certain requirements, namely a high level of homogeneity of effect
measures across studies, can be combined in meta-analyses. Through the use of statistical methods
to combine the results of independent studies a summary estimate of effect with a confidence
interval is obtained, allowing more precise estimates of the effects of an intervention.
The evidence gained in the systematic review has to be assessed for its quality. Quality of evidence is
defined as the “extent to which one can be confident that an estimate of the effect or association is
correct [Balshem et al., 2011].” The WHO uses the GRADE (Grading of Recommendations,
Assessment, Development and Evaluation) approach to assess the quality of a body of evidence,
develop and report recommendations. The quality of the evidence is assessed for each important or
critical outcome and each key question and findings are summarized across studies to generate a
GRADE evidence profile. These summaries are the basis for the formulation of recommendations by
the GDG. Outcomes are presented in rows and for each outcome, the judgements made about the
factors that determine the quality of the body of evidence are described briefly together with a
summary of the effect (Figure 11).
GRADE distinguishes between four levels of quality of evidence depending on the design of the
included studies and other factors that can either lower or raise the level of quality (table 13).
Lowering factors include limitations in study design and execution, indirectness, imprecision
inconsistency and publication bias. In the presence of these limitations, the quality of the evidence
should be downgraded by one or two levels depending on the seriousness of the issue (e.g.
downgrade by one level for serious limitations in study design and by two levels for very serious
limitations). Factors raising the level of quality are the presence of a dose−response gradient, lack of
adjustment for plausible confounders and the presence of a large effect.

Figure 11 Format of a GRADE evidence profile

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Table 13 Significance of the four levels of quality of evidence in GRADE

Quality Definition
The GDG is very confident that the true effect lies
High
close to that of the estimate of the effect.
The GDG is moderately confident in the effect
estimate: the true effect is likely to be close to the
Moderate
estimate of the effect, but there is a possibility that
it is substantially different.
Confidence in the effect estimate is limited: the
Low true effect may be substantially different from the
estimate of the effect.
The GDG has very little confidence in the effect
Very low estimate: the true effect is likely to be substantially
different from the estimate of the effect.
Implications
Further research is very unlikely to change
confidence in the estimate of effect.
Further research is likely to have an
important impact on confidence in the
estimate of effect and may change the
estimate.
Further research is very likely to have an
important impact on confidence in the
estimate of effect and is unlikely to
change the estimate.
Any estimate of effect is very uncertain.

Based on the obtained evidence and its quality, recommendations are formulated by the GDG. A
framework is provided by GRADE taken into account specific factors affecting the direction and
strength of each recommendation. Recommendations are formulated from a particular perspective,
in most cases that of the health systems, WHO acting as a global public health agency.
The direction and strength of the recommendations is determined by four major factors:

 the quality of the evidence

 values and preferences assigned to health outcomes by those affected
 the balance of benefits and harms
 resource implications (i.e. cost effectiveness).

Additional aspects that must be considered when formulating public health, health system and
health policy recommendations are the importance or priority of the problem being addressed,
equity and human rights aspects, acceptability and feasibility of the intervention. Even though some
of these aspects overlap with the main four factors, particularly with values and preferences, they
may be treated separately.
Recommendations are either strong or conditional depending on the quality of evidence. A strong
recommendation can be made if there is sufficient confidence that following the recommendation
has more desirable effects than undesirable consequences. Strong recommendations can be adopted
as policies in most situations. A conditional or weak recommendation is made when the balance
between the benefits and harms or disadvantages resulting from its implementation is less certain.
This type of recommendation can apply to certain conditions. Translating conditional
 70

recommendations into policy action will typically require considerable debate and support from
various stakeholders.
The standard format of a WHO guideline comprises the following sections: executive summary,
purpose or justification of the guideline, background, scope of the Guideline (content and questions),
Review Groups involved (Technical Consultation), recommendations, a summary of the WHO
Statement Development, a declaration of interests, plans for update, acknowledgments and
references.
Examples of recent WHO nutrition guidelines include the Guideline on sugars intake for adults and
children [WHO, 2015d], on Potassium intake for adults and children [WHO, 2012a] and on Sodium
intake for adults and children [WHO, 2012b].
 71

7. “Cost effective” nutrition interventions to combat the double burden

of malnutrition

7.1. The costs of malnutrition and NCDs

In addition to physical and psychological suffering, malnutrition in all its forms results in high
economic costs, not only for the people affected by it but also to entire communities and even
countries. In part, such costs are directly associated with health. This is particularly true for the
expenses resulting from NCDs caused by overweight and obesity like cardiovascular diseases and
diabetes mellitus type II, for instance. The effective treatment of these diseases including regular
medical care and drug supply places a heavy burden on health care systems and individuals.
Especially in low- and middle-income countries without a functioning health insurance system, the
costs associated with NCDs can cause financial hardship and even poverty to affected persons
[Saksena et al., 2011]. In the case of diabetes, the total global healthcare expenditure was estimated
to amount to USD 727 billion for the age group of 20-79 years in 2017, an 8% increase since 2015. For
the age group of 18 to 99 years, the estimated costs were even higher with USD 850 billion. While
much of these costs are spent in Western high-income countries, high expenditures also arise in
middle-income countries from other parts of the World including the Eastern Mediterranean and
North-African region. This region even has the highest percentage of the total healthcare budget
spent on diabetes, amounting to nearly 17% [IDF, 2017].
Moreover, unhealthy nutrition resulting in nutrient deficiencies, infections, NCDs and overall poor
health reduces the work performance of individuals leading to income losses that will eventually
affect whole communities or countries with a high rate of malnutrition and high NCD incidence. The
economic toll due to the principal diet-related NCDs, CVDs, diabetes and cancer, for the period of
2011-2030 has been estimated to around USD 26 trillion of which 61% are due to CVDs. The costs
were projected to double between 2010 and 2030 [Bloom et al., 2011].
Of the 39.5 million global deaths caused by NCDs in 2015, 38% were premature i.e. occurring before
the age of 70 years [Cao et al., 2018]. This is associated with a great loss of working force and
productivity. Lower socioeconomic status and poverty confer a higher risk for obesity and NCDs. By
causing a decline in income, NCDs further exacerbate poverty and are in turn furthered by poverty,
leading to a vicious cycle [WHO, 2011b].
Economic burden also arises from undernutrition and micronutrient deficiencies that are associated
with growth retardation, impaired development, lower work capacity and higher disease risk [Bailey
et al., 2015]. Iron deficiency as a major cause of anaemia is associated with fatigue and low
productivity and impaired cognitive and motor development in children. Iron deficiency anaemia
during pregnancy may result in low birth weight and a higher risk of maternal and perinatal mortality
 72

[Haas & Brownlie, 2001; Lozoff et al., 2013; WHO, 2015b]. Negative economic effects of iron
deficiency are not limited to low-income countries. In a survey from Switzerland, 29% of the
participants suffering from symptomatic iron deficiency stated that they were not able to fully
comply with their work due to exhaustion, fatigue and loss of concentration. This was estimated to
result in annual indirect costs of up to CHF 33 million (about USD 33.1 million) [Blank et al., 2019].
In children, chronic malnutrition and deficiencies of micronutrients like iron, zinc and iodine have
permanent effects by causing delays in development and growth that are associated with lower
income and productivity in adult life [Rivera et al., 2003; Oot et al., 2016]. A number of studies
suggest that stunting has a negative impact on adult income and that greater adult height is
associated with higher wages. In low and middle-income countries undernutrition leads to reductions
in annual GDP of up to 12% [McGovern et al., 2017].
In light of the long-lasting effects of malnutrition in all of its forms, its prevention should start at early
childhood and even before birth.

7.2. Interventions addressing child and maternal malnutrition

The first 1000 days of life starting from conception have been recognized as a critical time not only
for the immediate health and development of a child but also as a determinant of later disease risk
and overall performance and potential. Adequate nutrition providing optimal amounts of energy,
macronutrients, vitamins, minerals and trace elements plays a crucial role during this time window
[Elmadfa & Meyer, 2012; Schwarzenberg & Georgieff, 2018].
Intrauterine growth lays the foundation of all body and organ functions and its retardation and
impairment has permanent effects on the structure of organs and tissues that increase the
susceptibility for certain NCDs. The development of chronic diseases is determined by various factors
over the entire life course, including the diet, physical activity and environmental aspects, and early
exposures during critical or sensitive periods in development can have significant effects on adult and
old-age health. There is strong evidence for an association of intrauterine growth retardation,
manifesting as small birth size, with a higher risk of coronary heart disease, stroke, impaired glucose
tolerance and diabetes. Excessive weight gain during childhood, also related to catch-up growth after
intrauterine malnutrition also confers a higher risk for NCDs in later life. Foetal nutrition and
environmental factors during pregnancy also act on the genetic programming via epigenetic
mechanisms. Moreover, dietary habits that are acquired during childhood and adolescence are often
kept by adults, providing an opportunity for disease prevention if healthy nutrition is promoted
[Darnton-Hill et al., 2004].
Exposure to various stresses in early life does not only have detrimental consequences for health.
Physical manifestations like stunting and retardation of cognitive development limit an individual’s
 73

working potential and professional advancement. Data from a number of countries underline the
significant impact of nutritional status on work capacity and performance. Especially a person’s
height is positively associated with his or her income [Haddad & Bouis, 1991; Thomas & Strauss,
1997]. In a rural Philippine population, 1% increase in adult height was associated with a 4% increase
in agricultural wages [Haddad & Bouis, 1991]. Inadequate supply of micronutrients like iron or zinc
further aggravates this issue. It has been estimated that eliminating anaemia would lead to an
increase of 5% to 17% in adult productivity [WHO, 2014a]. Moreover, height was found to be
positively associated with higher cognitive abilities that are in turn promoted by better nutrition
[Case & Paxson, 2008].
Malnutrition is an impediment to the progress towards achieving Millennium Development Goals 1
(Eradicate extreme poverty and hunger), 2 (Achieve universal primary education), 3 (Promote gender
equality and empower women), 4 (Reduce child mortality), 5 (Improve maternal health) and 6
(Combat HIV/AIDS, malaria and other diseases).
Recent evidence based on the WHO Growth Standards provides support for the importance of
adequate nutrition during the first two years of life as growth failure occurs predominantly during
this phase and can have permanent effects on later life. The issue of early malnutrition is therefore
larger than assumed so far, underscoring the importance of prenatal and early-life interventions to
enable adequate nutrition and promote appropriate infant feeding practices [Victora et al., 2008;
Victora et al., 2010; WHO, 2013c]
However, malnutrition in utero and during infancy is not limited to deficiencies in energy and
nutrients but also includes overnutrition. Indeed, it has been shown that newborns with excessive
weight also have a higher risk for NCDs like diabetes mellitus type 2 and CVD in later life [Marciniak
et al., 2017].
Ensuring the optimal nutrition and development of children and their mothers is therefore a key to
combating the double burden of malnutrition and the rise in NCDs.

7.2.1. Nutrition of women of child-bearing age and during pregnancy and lactation
The prevention of child malnutrition starts before birth by targeting the nutritional situation of
women of child-bearing age. This population group is particularly vulnerable to malnutrition for a
number of factors. The increased requirements for some micronutrients like iron are often not met
by nutrition, resulting in a high prevalence of anaemia in premenopausal women (also see chapter
4.3). In some cultural environments, particularly in the South-Asian region, girls and women face
discrimination in terms of access to nutrient-rich food. Moreover, some traditional beliefs about
properties of certain foods and their suitability for pregnant and/or lactating
Table 14 Critical nutrients during pregnancy and lactation
Nutrient Role
Protein (amino acids) Required for tissue building, maintenance Pregnancy (by trimester):
and repair, as well as for the production of +1/+10/+13 g/da
enzymes, hormones, neurotransmitters,
antibodies etc.
Essential fatty acids Components of cell membranes and as
(linoleic acid (LA), α- such involved in signal transduction,
linolenic acid (ALA), neural and cognitive functions, foetal
EPA+DHA) brain development
Vitamin A Growth, development, function and
maintenance of the skin, vision (retinal is
part of the light receptor rhodopsin),
immune function
Vitamin D Promotes calcium absorption, required for
bone formation and maintenance,
modulator of the immune function
Vitamin E Protection from oxidative stress and
damage in the lipophilic milieu
Vitamin K Required for blood clotting and bone
formation and maintenance
Folic acid Essential for cell replication. Deficiency
during pregnancy is associated with
congenital anomalies particularly of the
neural system like spina bifida or
anencephaly.
Iron Required for oxygen transport and as co-
Increase in RDI during pregnancy
/lactation
Lactation:
1st 6 months: +19 g/da
After 6 months: +13 g/da
Fat requirements increase
proportionally with higher energy
requirements only.
ANR for EPA+DHA: 300 mg/d
Pregnancy: +300 µg/d
Lactation: +350 µg/d
Not increasedb
Pregnancy: not increasedc
Lactation: +4 mg/d α-tocopherolc
Not increased
Pregnancy: +200 µg/d
Adequate intake should be achieved
before conception.
Lactation: +100 µg/d
Pregnancy: depending on pre-
Food sources
Lean meat, fish, eggs and dairy products
for high-quality animal protein; pulses,
cereals and nuts for plant proteins.
Combining proteins from different
sources generally enhances their quality
(e.g. cereal + pulses).
High-quality plant oils for LA; flax seed,
rapeseed, soybean and walnut oil for
ALA; fat fish/fish oil for EPA and DHA
Preformed: animal liver and other organ
meat, egg yolk, (full-fat) dairy products
Provitamin: green leafy vegetables,
yellow/orange vegetables,
yellow/orange non-citrus fruits,
unrefined red palm oil
Fat fish, fish oil, mushrooms
Plant oils, nuts and seeds, leafy
vegetables
Leafy vegetables, some plant oils
Leafy vegetables, broccoli, pulses,
wholegrain cereal
Red meat, organ meat, pulsesd,
 75

factor of enzymes (cytochromes etc.) pregnancy iron status amaranthd, quinoad, oil seedsd
Lactation: decreased due to
cessation of menstrual losses
Calcium Required for the formation and Pregnancy (3rd trim.): +200 mg/d Dairy products, sesame and chia seedsd,
maintenance of bones and teeth, blood Lactation: not increased amaranthd, kaled, spinachd
coagulation and signal transduction in
muscles, nerves and immune cells
Zinc Co-factor of >3000 enzymes, required for Pregnancy (by trim.): +0.4-1.2/+1.2- Red and organ meat, oil seedsd,
growth (deficiency causes stunting) and a 4.2/+3.0-10.2 mg/de wholegrain cereald, pulsesd
functioning immune defence Lactation (0-3/3-6/6-12mo): +2.8-
9.2/+2.3-7.7/+1.3-4.6 mg/de
Iodine Growth, foetal brain development Pregnancy/lactation: +1.5 µg/kg/d Marine fish, algae, iodised salt, dairy
products if iodine is added to the feed.
a
Safe level of intake
b
The major part of vitamin D is supplied by dermal synthesis upon exposure to UV light. Additional supply through food or supplements is only needed
when exposure to sunlight is inadequate.
c
WHO considers that the evidence is insufficient for estimating recommended intakes. Instead, the IOM RDIs [IOM, 2000] are given.
d
low bioavailability from plant foods containing absorption inhibitors like oxalic acid, phytate, tannins and others. In the case of iron, plant foods
contain the less available Fe(III) that is reduced to Fe(II) by the addition of reducing agents like vitamin C.
e
for high/moderate/low bioavailability
women may also negatively affect nutritional adequacy [Walker, 1997; Harris-Fry, 2017; Kavle &
Landry, 2018]. Therefore, women are often already suffering from nutritional deficiencies when they
enter pregnancy and the problem is further aggravated as nutrient requirements increase over the
course of gestation.
Some nutrients are particularly important during pregnancy and lactation as they play special roles in
child development and growth (see table 14).
A diverse diet composed of a wide selection of nutrient-rich foods including fresh vegetables and
fruits complemented by animal foods but low in salt, sugar and saturated and trans fatty acids is the
best way to achieve nutritional adequacy. However, especially in low-income settings, the diet is
mostly composed of staple or highly refined foods with low micronutrient contents [Arimond et al.,
2010; Torheim et al., 2010; Hong Nguyen et al., 2018].

Table 15 Nutrition-sensitive strategies increase the impact of nutrition-specific actions (modified

from [Arnold, 2016]

Specific actions for nutrition Nutrition-sensitive strategies

Infant feeding practices and behaviours: Agriculture:

Encouraging exclusive breastfeeding in the
first six months and continued
breastfeeding together with appropriate
and nutritious complementary food until
up to two and more years of age
Making nutritious food more accessible
to everyone and supporting small farms
as a source of income for families

Food fortification: Improving access to clean water and

Improve nutrient supply through sanitation to reduce infections and
incorporating them into foods diseases

Micronutrient supplementation: Education and employment:

Direct provision of supplemental nutrients Making sure children have the nutrition
needed to learn and earn a decent
income as adults

Treatment of acute malnutrition: Health care:

Providing effective treatment to persons Access to services that improve health
with moderate and severe malnutrition

Support for resilience:

Establishing a stronger, healthier
population and sustained prosperity to
better endure emergencies and
conflicts

Different approaches have proven successful in improving the nutritional situation of women of
reproductive age. Education and training enhances the knowledge about healthy nutrition of the
 77

women themselves and also the optimal feeding of infants and young children and can also improve
the social status of women and increase their influence on their family’s diet. Interventions involving
the introduction or promotion of home gardening of nutrient-rich crops and small-scale animal
husbandry can also contribute to higher food security and improve the diet of households. However,
the impact of such approaches on the nutritional status of women and children again is highly
variable, depending on many factors, and has been shown to be largest when complemented by
educational measures [Webb Girard et al., 2012].
In general, the impact of nutrition-specific interventions that are directly aimed at malnutrition is
increased when they are accompanied by nutrition-sensitive strategies. These latter target the
underlying causes of malnutrition by improving the availability of and access to food through
agricultural interventions, increasing food safety and hygiene as well as creating a supportive food
and health environment (see table 15) [Shekar et al., 2013].
On the other hand, supplementation of critical micronutrients has a more immediate effect although
it requires a functioning health care infrastructure. Considering the high prevalence of suboptimal
iron and folic acid status and anaemia in women of child-bearing age, the status of these
micronutrients should be optimised in all menstruating women before they become pregnant to
enable a healthy pregnancy, adequate nourishment of the child and safe delivery at term.
Intermittent iron and folic acid supplementation serves as an effective preventive strategy at
population level. This type of intervention takes into account the limited intestinal iron absorption
capacity, allowing similar amounts of iron to reach the blood and tissues while being associated with
less side effects. However, women diagnosed with anaemia require a daily supplementation (see
table 16) [WHO, 2013c].
Intermittent iron supplementation is ideally preceded and accompanied by a nutritional status
assessment to ensure daily needs are being met and can be integrated into national programmes for
adolescent and reproductive health. Well-conducted social marketing and educational campaigns
informing about the harmful effects of anaemia, the benefits of supplementation, and how to
respond to potential side effects campaigns can increase the acceptability and adherence to the
intervention. Campaigns promoting dietary diversity and measures to improve iron absorption can
also improve iron status. The risk of inadequate iron intake is particularly great for women and girls
living in resource-limited environments. In such settings, cooperation with and between industry and
government can improve the availability and the access to high-quality, low-cost supplements [WHO,
2013c].
 78

Table 16 Supplementation schemes for iron, folic acid and iodine in non-pregnant women of child-
bearing age (15-49 y.) [modif. from WHO, 2013c]
Iron + Folic acid Iodine
Dose Iron: 60 mg of elemental Iron: 120 mg of 150 µg/d
iron, elemental iron, Or
Folic acid: 2800 μg Folic acid: 400 μg 400 mg/y
Frequency Once per week Daily Daily or once per year
Duration 3 months of Until normal Until the salt iodization
supplementation haemoglobin programme is scaled up
alternating with 3 months concentration is
without, continuing attained
throughout the school or
calendar year as feasible
Target group All menstruating Anaemic Women of reproductive
adolescent girls and adult menstruating age (15-49 y.)
women adolescent girls and
adult women
Settings Populations with anaemia Countries where <20% of
prevalence in non- households have access
pregnant women of to iodized salt when it is
reproductive age ≥20% difficult to reach pregnant
women

A general supplementation of women of child-bearing age may also be advisable in the case of iodine
when it is difficult to specifically reach pregnant women. Adequate supply of this nutrient during
pregnancy and early childhood is important for the optimal brain development of the foetus and
young child but there are still countries where universal salt iodization is not fully implemented.
Moreover, persons in emergency situations or living in geographically remote areas may also not
have access to iodized salt [WHO, 2013c].
During pregnancy, the WHO recommends daily supplementation of iron and folic acid to prevent iron
deficiency and anaemia in the mother and the neonate as well as low birth weight. Moderate or
severe anaemia during pregnancy increases the risk of premature delivery, maternal and child
mortality as well as for infectious diseases. Even in the absence of anaemia, intermittent
supplementation of iron and folic acid is advisable to prevent the development of anaemia and
improve gestational outcomes. Daily iron supplementation has shown a protective effect against low
 79

birth [WHO, 2013c]. Supplementing other micronutrients may also be required at least in certain at-
risk groups or settings. For instance, vitamin A deficiency is very common worldwide especially in the
African and South-East Asian regions, and is a major cause of night blindness. Vitamin A plays a
central role in cell division, visual function and the development of vision in the foetus, the
maintenance of the immune response, the growth and maturation of foetal organs and skeleton. This
makes pregnant women and young children under the age of 5 years particularly vulnerable for
vitamin A deficiency. Supplementing pregnant women with vitamin A reduced the risk of maternal
night blindness. However, as overdoses of vitamin A present a health hazard, supplementation is not
advised as a routine measure but only in settings with a prevalence of night blindness of ≥5% in
pregnant women or 2-5 year-old children [WHO, 2013c].
In regions where universal salt iodization is not fully implemented, pregnant and lactating women
may not be adequately supplied with iodine that is required for foetal brain development and growth
in general. The WHO recommends supplementation for pregnant and lactating women in countries
where less than 20% of households have access to iodized salt. Countries with 20 to 90% of
households covered are advised to improve their salt iodization programme or to consider providing
vulnerable population groups with supplements or other fortified foods as appropriate [WHO,
2013c].
The mineral calcium is not only required for bone mineralization but is also involved in many body
functions such as signal transduction, muscle contraction and neuronal signalling through its effects
on cell membrane potential and the actions of enzymes and hormones. Inadequate calcium supply
has been associated with hypertension and its supplementation may lower blood pressure by
reducing vasoconstriction [WHO, 2013c]. Hypertensive disorders occurring during pregnancy, like
pre-eclampsia and eclampsia, are the second most common cause of maternal death, accounting for
14% of global cases [Say et al., 2014], and lead to severe pregnancy complications, morbidity and
long-term disability. Despite some inconsistencies between studies, calcium supplementation was
found to lower the risk of developing pre-eclampsia that affects about 5% of pregnant women
beginning at mid-gestation, and through its actions on uterine muscle contractions may prevent
preterm labour and delivery and improve utero-placental blood flow [Hofmeyr et al., 2018]. The
WHO recommends a daily supplementation of 1.5 to 2.0 g of elemental calcium to pregnant women
with low dietary calcium intake and at high risk of developing hypertensive disorders during
pregnancy. This amount is well above the reference intake level for pregnant women ranging from
1000 to 1300 mg per day and difficult to meet through the diet alone. Supplements should be
divided into three smaller doses taken preferably at meal times and not together with iron
supplements to improve absorption and prevent interactions between the two nutrients [WHO,
2018d].
 80

An overview of supplementation with micronutrients during pregnancy and lactation as

recommended by the WHO is given in table 17.

Table 17 WHO recommendations on supplementation with micronutrients during pregnancy

and/or lactation [WHO, 2013c]
Iron + Folic acid Vitamin A Iodine Calcium
Daily Intermittent
Dose 30-60 mg 120 mg Up to 250 µg/d or 1500 to 2000 mg
elemental Fe elemental Fe, 10000 IU*/d 400 mg/y elemental Ca
and 400 µg 2800 µg folic or up to
folic acid acid 25000 IU*/w
Frequency Once daily Once weekly Daily or Daily or once Daily (in 3
weekly per year portions)
Duration Throughout Throughout Min. 12 weeks
pregnancy pregnancy
Target All pregnant Non-anaemic Pregnant Pregnant and Pregnant women,
group adolescent pregnant women lactating especially with
and adult adolescent women high risk of
women and adult hypertension
women
Setting All Countries with Prevalence of Countries Areas where Ca
anaemia night where <20% of intake is low
prevalence blindness ≥5% household
<20% in pregnant have access to
women or 2-5 iodized salt
y-old children
* 1 IU = 0.3 µg retinol equivalents

In turn, the other face of malnutrition, obesity, also has a negative impact on pregnancy outcome
and predisposes the child to overweight, obesity and associated metabolic disorders. Children of
obese mothers have a higher risk of macrosomia (i.e. being large for gestational age (LGA)). LGA
children are in turn predisposed to obesity and have a higher risk to develop hypertension, impaired
glucose tolerance, diabetes mellitus type II or even metabolic syndrome and also certain types of
cancer during their childhood and in later life [Boney et al., 2005].
 81

Optimal nutrition of children starting in utero is therefore critical and one of the best investments in
public health. After birth, breastfeeding offers the best nutrition to the infant and should therefore
be promoted.

7.2.2. Promotion of breastfeeding and limiting the marketing of breast-milk

substitutes
Breastfeeding is the best way to ensure the optimal nutrition and development of a child. The WHO
recommends that during the first six months of life, breast-milk should be the only food given to a
child. As long as the mother’s diet is adequate, breast-milk provides all the energy, nutrients and
fluids needed by the infant during the first six months [PAHO/WHO, 2003; WHO, 2009]. Rising the
rate of breastfeeding in the first six months of life to at least 50% by 2025 is one of the six global
targets of the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition
[WHO, 2014a]. Exclusive breastfeeding is associated with lower infant mortality and lower incidence
of diarrhoea and respiratory infections [WHO, 2009]. This protective effect of breastfeeding is
underlined by a meta-analysis of thirteen studies conducted in low and middle-income countries:
Non-breastfed infants under six months had a 14-fold increased all-cause mortality risk compared to
exclusively breastfed infants and even predominant or partial breastfeeding was associated with
lower all-cause mortality than no breastfeeding. The risk of infection-related mortality was almost 9-
fold higher in non-breastfed infants than in exclusively breastfed infants aged 0 to 5 months.
Continuing breastfeeding between 6 and 23 months of age reduced the risk of all-cause and
infection-related mortality by about half [Sankar et al., 2015]. In older children that already receive
complementary food, breast-milk still contributes a large part of energy to the infant, up to 50% in
the first year of life, and is a critical source of nutrients like essential fatty acids, vitamin A and
calcium [PAHO/WHO, 2003].
In turn, infants that are not breastfed are also more likely to suffer from autoimmune or atopic
diseases. There is evidence to suggest that breastfeeding is associated with lower rates of obesity in
later childhood and adolescence and may protect from cardiovascular diseases. Moreover,
breastfeeding also beneficially affects cognitive development [WHO, 2009]. In the lactating mother,
breastfeeding has also shown a number of positive health effects like a lower incidence of certain
cancer types (breast and ovary) and of type 2 diabetes mellitus and a prevention of a new pregnancy
[Chowdhury et al., 2015; Aune et al., 2014].
Therefore, optimal infant and young child feeding according to the recommendations of the WHO
and the UNICEF consists of:
1. early initiation of breastfeeding (within one hour of birth),
2. exclusive breastfeeding for the first six months of life,
 82

3. continued breastfeeding for two years or beyond,

4. introduction of adequate and appropriate complementary foods from six months onwards.

In 1989, WHO and UNICEF proposed Ten Steps to Successful Breastfeeding consisting of a number of
policies and procedures to promote and protect breastfeeding (table 18). In 1991, the two agencies
introduced the Baby-friendly Hospital Initiative (BFHI) to motivate facilities providing maternity and
newborn care to implement the Ten Steps and an accompanying guidance.

Table 18 Ten steps to successful breastfeeding [https://www.who.int/nutrition/bfhi/ten-

steps/en/]

Critical management procedures

1a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant
World Health Assembly resolutions.
1b. Have a written infant feeding policy that is routinely communicated to staff and parents.
1c. Establish ongoing monitoring and data-management systems.
2. Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding.

Key clinical practices

3. Discuss the importance and management of breastfeeding with pregnant women and their
families.
4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate
breastfeeding as soon as possible after birth.
5. Support mothers to initiate and maintain breastfeeding and manage common difficulties.
6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically
indicated.
7. Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day.
8. Support mothers to recognize and respond to their infants’ cues for feeding.
9. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.
10. Coordinate discharge so that parents and their infants have timely access to ongoing support and
care.

The guidance offers strategies to reach universal and sustainable coverage of care facilities and
achieve a better integration of the BFHI into national health-care systems. A revision of the Ten Steps
and the guidance were started in 2015 resulting in the publication of the updated versions in 2018.
Notably, full compliance with the International Code of Marketing of Breast-milk Substitutes (see
 83

below) was included in step 1 as it had not been explicitly mentioned in the original version.
Additionally, the need for continuous monitoring of adherence to the programme is stressed. There
was an attempt to simplify the steps and make them more feasible and applicable. Moreover, the
prohibition to use feeding equipment like bottles, teats as well as pacifiers was replaced by the
request to counsel mothers on their use due to a lack of good evidence on effects on breastfeeding
rates. Implementation of the Ten Steps has a demonstrated positive effect on breastfeeding
including its early initiation, exclusivity and total duration [UNICEF/WHO, 2018].
Despite the large evidence for its beneficial effects, breastfeeding is not commonly practised in many
countries and is especially impeded by the availability and promotion of various industrial breast-milk
substitutes (BMS) like infant formula. While BMS may be needed in certain cases when mothers are
unable to breastfeed they should not undermine breastfeeding by being advertised as equal or even
superior to breast-milk and by being aggressively promoted. The use of BMS is particularly
problematic in low-income countries when a clean safe water supply needed for the preparation of
the formula is not guaranteed and the costs for qualitative products place a high financial burden on
families and aggravate poverty. Expensive substitutes may be used in a diluted form to save costs
leading to infant malnutrition and financial straits limit the access to good health care. Nevertheless,
the sales of BMS are rising having amounted to almost 45 billion US $ in 2014 and projected to
increase further (over 70 billion US $ in 2019). While the highest consumption of infant formula is
observed in Western Europe and Australasia, followed by the North American region, numbers are
stagnating in these parts of the World and the largest increase is forecast for the Asia-Pacific and
Middle Eastern-African regions [Rollins et al., 2016; Changing Markets Foundation, 2017].
The sales of BMS are supported by various marketing strategies used by the manufacturers and to
some extent, importers, distributors, and retailers. These include direct marketing to the consumers
through media advertisements, the distribution of free samples and other brand-related gifts, and
counselling and information material. However, marketing also involves health care workers in
maternity wards and paediatric care units receiving financial support, free training, and other
incentives for promoting BMS products as well as policy makers. All these tactics have been shown to
influence infant feeding behaviour and the attitude about breastfeeding on the one hand and about
BMS on the other. For example, marketing BMS as equal or even superior to breast-milk to support
healthy child growth and development is a strong determinant for choosing BMS. Marketing may
also aim at diminishing the mothers’ self-confidence in their ability to adequately breastfeed their
children. In turn, incentives to promote breastfeeding by providing counselling and creating an
encouraging environment have shown the opposite effect resulting in higher breastfeeding rates
[Piwoz & Huffmann, 2015].
 84

Against this background, the World Health Assembly already in the 1970s recognised the need for a
proper regulation of the marketing of BMS to protect breastfeeding and ensure that every infant is
adequately nourished, leading to the release of the International Code of Marketing of Breast-milk
Substitutes in 1981.
The Code applies to the marketing of breast-milk substitutes, including infant formula, other milk
products and foods and beverages, including bottle-fed complementary foods that are marketed as a
suitable, partial or total replacement of breast milk as well as the quality and availability of such
products and to information about their use. It does not prohibit the use of breastmilk substitutes or
restrict their availability and that of feeding bottles or teats, but only regulates their marketing. In
article 3 of the Code breast-milk substitutes are defined as “any food being marketed or otherwise
presented as a partial or total replacement for breast milk, whether or not suitable for that purpose”
[WHO, 1981]. At this time, no upper age specification was given for the products covered by the
Code. In this context, it is important to distinguish between breast-milk substitutes in the narrow
sense acting as a replacement of breast-milk, and those that complement to breast-milk when it is no
longer sufficient alone. Thus, the Code also covers milk formula products intended for children over
six months like follow-up formula and growing-up milk for which the Codex Alimentarius sets slightly
different composition standards compared to those for infant formula to account for the changing
nutritional requirements of children. In the Codex standard of 1987, these were not defined as
breast-milk substitutes. However, considering that follow-up milk products are often cross-promoted
with and labelled like infant formula, both product types interfere with breastfeeding and replace
breast-milk. The use of follow-up formula is associated with a reduced frequency of daily breast-milk
feedings or even its complete termination, thus counteracting the WHO’s recommendation to
breastfeed for at least 24 months.
Following a mandate of the 65th World Health Assembly in 2012, a Guidance on ending the
inappropriate promotion of foods for infants and young children was prepared by the WHO and
approved by the 69th World Health Assembly in 2016 (resolution WHA 69/9). It aims at assisting
Member States in protecting breastfeeding, preventing obesity and chronic diseases, and promoting
a healthy diet for young children. It covers all commercially produced food or beverage products that
are specifically marketed as suitable for feeding infants and children from 6 months up to 36 months
of age, including solid complementary foods. Marketing such products as suitable for the defined age
group includes labelling with the words baby/babe/infant/toddler/young child, recommendations of
introduction to children aged less than three years; use of images of children of that age or being
bottle-fed. The guidance specifies the definition of breast-milk substitutes “to include any milks (or
products that could be used to replace milk, such as fortified soy milk), in either liquid or powdered
form, that are specifically marketed for feeding infants and young children up to the age of three
 85

years (including follow-up formula and growing-up milks)”. Such products should not be promoted to
protect breastfeeding. Particularly, complementary food should not be marketed for introduction to
infants younger than six months. Moreover, preference should be given to home-made
complementary food from fresh local products and commercial products should not be marketed as
superior to home-made food. Messages to promote foods for infants and young children should
advert to the importance of continued breastfeeding for at least 24 months [WHO, 2017b].
Therefore, a revision of the Codex Alimentarius standard for follow-up formula became necessary
that would align the standard with the WHO Guidance. A draft for the revised standard was
proposed at the 40th session of the Codex Committee on Nutrition and Foods for Special Dietary Uses
(CCNFSDU) held in Berlin from 26th to 30th November 2018 and is currently further discussed and
revised. A distinction is made between products for older infants aged between six and twelve
months and for young children aged over one up to three years that are regulated differently, with
the latter no longer referred to a “formula”. While only follow-up is strictly defined as breast-milk
substitutes, both categories are submitted to labelling restrictions according to the Code and the
WHO Guidance [Joint FAO/WHO CAC, 2019].
However, the Code is not legally binding and its incorporation into national legislation, the
enforcement, control and monitoring of respective laws are the responsibility of the Member States
that may collaborate with other parties like the WHO, NGOs and relevant institutions and
professional groups as appropriate [WHO, 1981].
To facilitate this process and to build capacities of Member States and civil society to monitor the
Code a Network for Global Monitoring and Support for Implementation of the International Code of
Marketing of Breast-milk Substitutes and Subsequent relevant World Health Assembly Resolutions
(NetCode) was established in 2014 by the WHO and UNICEF as a partnership of UN system
organizations, WHO Collaborating Centres, NGOs (Action Against Hunger, Emergency Nutrition
Network, Helen Keller International, International Baby Food Action Network (IBFAN), World Alliance
for Breastfeeding Action and others), and a number of Member States. NetCode pursues the vision of
“a world in which all sectors of society are protected from the inappropriate and unethical marketing
of breast-milk substitutes and other products covered by the scope of the Code” [WHO/UNICEF,
2017a,b]. The NetCode members developed a protocol and a Monitoring Framework Toolkit to
support Member States in their efforts to monitor and enforce the Code, identify violations and take
appropriate national measures. The NetCode Toolkit is composed of two protocols, the Ongoing
Monitoring System Protocol and the Periodic Protocol that are complementary with differing
objectives and can be used simultaneously or exclusively. The ongoing assessment is intended to
continuously monitor the compliance with the Code and detect, report and act upon violations of the
Code and respective national laws. Further objectives are the establishment of an enforcement
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mechanism to stop violations and prevent them in the future, and ensuring the accountability of
manufacturers, distributors, retail outlets, the health-care system and health-care workers for any
breeches of the Code and/or related national laws. The protocol contains a stepwise approach to
setting up a national monitoring system (see table 19) [WHO/UNICEF, 2017a].

Table 19 Steps in setting up a national Code monitoring system (based on [WHO/UNICEF, 2017a]
Step Procedures
1. Negotiating the
political and bureaucratic
environment
2. Determining the
coverage and extent of
monitoring based on
national laws
3. Building a national
monitoring team
4. Costing and budgeting
for monitoring
5. Developing standard
monitoring tools and a
database
Training of the monitors, awareness raising on the importance of
6. Capacity building of
monitors
7. Monitoring and
enforcing
8. Evaluation of the
system
 Obtaining high-level commitment
 Engaging relevant offices
 Identifying external supporters
 Anticipating and addressing opposition
Establishing
 what to monitor
 where to monitor
 when to monitor
 Identifying existing monitoring mechanisms and processes
 Building a national monitoring team, designating a lead agency
 Team building and allocation of roles and responsibilities
 Identifying available human and financial resources that can be
allocated for monitoring the Code and/or national laws
 Estimating resources that need to be requested and/or
advocated for at national and/or sub-national levels
 Reviewing systems and plans for their sustainability and
efficiency
 Using a standard monitoring form (provided in the protocol)
 Developing data collection tools
 Setting up a database for monitoring activities
breastfeeding, familiarization with the provisions of the national
laws
 Identifying violations
 Reporting on violations
 Verifying and acting on violations
 Disseminating findings of the monitoring
 Verifying the relevance, efficiency, effectiveness, impact and
sustainability of the system
 Qualitative and quantitative information collection
 Every three to five years

Key settings for ongoing monitoring are customs and borders, media channels (broadcast and print)
and social networks, public and private health facilities, points of sale and public areas where breast-
milk substitutes can be promoted. Considering that marketing and promotional are daily activities
that occur in various settings, Code monitoring should be integrated into existing control processes
such as product registration, customs and border control, food and drug inspection activities at
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points of sale, media monitoring, health facility assessments, and monitoring of health and nutrition
programmes at community level [WHO/UNICEF, 2017a].
On the other hand, the objective of the periodic assessment is to quantify the level of compliance
with the Code and the respective national laws, study trends and changes over time, uncover
shortcomings and define priorities for the implementation and enforcement of the Code. The
recommended interval between the assessments is three to five years. Four key groups or settings
are targeted in the assessment [WHO/UNICEF, 2017b]:
 Mothers of children under 24 months
 Health facilities
 Retail and product labelling
 Media (TV and internet)

Health and adequate nutrition are basic rights of every child and infant figuring in the "Convention
on the Rights of the Child" [UNGA, 1989]. In its General comment No. 15 on the right of the child to
the enjoyment of the highest attainable standard of health (2013) and its General comment No. 16 on
State obligations regarding the impact of the business sector on children’s rights (2013), the
Committee on the Rights of the Child recognizes exclusive breastfeeding during the first six months
of life, its continuation until the age of two years or beyond alongside appropriate complementary
foods as the optimal nutrition for young children and urges its promotion and protection as well as
the implementation of the Code [UNCRC, 2013a,b]. The UN Special Rapporteurs on the Right to Food,
Right to Health, the Working Group on Discrimination against Women in law and in practice and the
Committee on the Rights of the Child expressed their support of increased efforts to promote,
support and protect breast-feeding in a Joint statement in 2016. Protecting infants and their mothers
from harmful, inappropriate marketing of breast-milk substitutes and other commercial products
undermining breastfeeding by adopting legal measures in accordance with International Code and
the WHO Guidance was considered part of States’ core obligations under the Convention on the
Rights of the Child and other relevant UN human rights instruments [Joint Statement, 2016].
Despite the general recognition of the need to promote and protect breastfeeding and the fact that
184 countries voted for the adoption of the Code in 1981, the level of national implementation of the
latter is still insufficient as shown by the regularly published status reports. In 2018, while 136 out of
194 Member states had some form of legal measure in place covering at least a few provisions of the
Code, only 35 had it fully implemented. Of these countries, twelve were located in the African region,
six in each, the regions of the Americas and the Eastern Mediterranean, and five in South-East Asia.
In turn, the European region had the lowest rate of implementation (see table 20) [WHO, 2018e].
With regard to the latter region, it must be noted that Member states of the European Union within
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this region are subject to EU regulation no. 609/2013 of 12 June 2013, that includes only few rather
general provisions on the marketing of breast-milk substitutes and commercial complementary foods
[Regulation EU No 609/2013].

Table 20 Legal status of the International Code of Marketing of Breast-Milk Substitutes by WHO
region in 2018 [WHO, 2018e] (given as number of countries)
Law WHO Region
categories Africa Americas Eastern Europe South- Western Global
Mediter- East Asia Pacific
ranean
Full provisions 12 6 6 3 5 3 35
in law
Many 12 5 4 4 3 3 31
provisions in
law
Few 6 9 7 43 - 5 70
provisions in
law
No legal 17 15 4 3 3 16 58
measures
Total 47 35 21 53 11 27 194

New Code-related legislation was enacted in three countries (Chile, Thailand and Mongolia) and
additional legal measures strengthening the legislative frameworks for Code implementation were
adopted in Albania, Bahrain and Bangladesh. However, Fiji and China repealed provisions of laws
related to the Codex. Globally, about 60% of children are not exclusively breastfed during the first six
months. Products for children up to 36 months are only covered in 22 Member states, mostly in the
Western-Pacific and African regions, and 59 countries include complementary foods in their legal
measures [WHO, 2018e].
Overall, the promotion and protection of breastfeeding is still a matter of concern in most countries
of the world.

7.2.3. Food marketing and advertising to children

Exposure of children and adolescents to marketing of foods and beverages high in saturated fats,
trans fats, sugars and salt (HFSS foods) is widely acknowledged as a risk factor for obesity and
 89

associated NCDs. According to reports mostly from industrialized countries, covering the period from
2003 to 2013, most of the food marketing to children and adolescents was in the form of
advertisements via TV and online channels of foods high in energy, fats, sugars and/or salt but low in
other, essential nutrients. The majority of these foods belonged to the categories of sugar-
sweetened breakfast cereals, confectionary, high fat savoury snacks, soft drinks and fast food. In turn
advertisement of fruits and vegetables was underrepresented or completely inexistent [FSA 2003;
OfCom, 2004; IoM, 2006; WHO, 2009; WHO EUR, 2013]. A high exposure of children to marketing of
unhealthy food is also reported from the Eastern Mediterranean Region where the expenditures for
the marketing of HFSS foods have markedly increased from 2009 to 2012. Most marketing of HFSS
foods occurs on television and particularly through regional channels rather than national ones,
underscoring the cross-border effects of food marketing to children [WHO EMRO, 2018]. A recent
report from Turkey found that 78.8% of foods advertised on television across all viewing time did not
comply with the nutrient profiling model developed by the WHO EURO. Considering only children’s
peak viewing time of 15:00 to 19:00, this was the case of 46.2% of the advertised products. Of the
foods marketed through the internet only about a quarter could be classified as healthy (25.6%).
Confectionary, cakes, biscuits and sugar-sweetened beverages were the most common categories
[WHO EURO, 2018].
The importance of controlling the marketing of foods and beverages to children to promote healthy
diets was emphasized in the WHO Global Action Plans for the Prevention and Control of NCDs 2008-
2013 and 2013-2020 and the implementation of policies to reduce the impact on children of
marketing of HFSS foods and non-alcoholic beverages is one of the 25 indicators to monitor the
progress towards attainment of the voluntary global targets suggested in the Action Plan 2013-2020
[WHO, 2013a].
In 2010, WHO issued a set of twelve recommendations to guide Member States in their efforts to set
up policies to reduce the marketing of HFSS foods high to children (table 21) [WHO, 2010b]. These
recommendations were complemented in 2012 by an implementation framework, giving advice on
policy development, implementation, monitoring and evaluation.

Table 21 Recommendations on the marketing of foods and non-alcoholic beverages to children

Section Recommendations
Rationale Recommendation 1: The policy aim should be to reduce the impact on
children of marketing of foods high in saturated fats, trans-fatty acids, free
sugars, or salt.
Recommendation 2: Given that the effectiveness of marketing is a function
of exposure and power, the overall policy objective should be to reduce both
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the exposure of children to, and power of, marketing of foods high in
saturated fats, trans-fatty acids, free sugars, or salt.
Policy development Recommendation 3: To achieve the policy aim and objective, Member States
should consider different approaches, i.e. stepwise or comprehensive, to
reduce marketing of foods high in saturated fats, trans-fatty acids, free
sugars, or salt, to children.
Recommendation 4: Governments should set clear definitions for the key
components of the policy, thereby allowing for a standard implementation
process. The setting of clear definitions would facilitate uniform
implementation, irrespective of the implementing body. When setting the
key definitions Member States need to identify and address any specific
national challenges so as to derive the maximal impact of the policy.
Recommendation 5: Settings where children gather should be free from all
forms of marketing of foods high in saturated fats, trans-fatty acids, free
sugars, or salt. Such settings include, but are not limited to, nurseries,
schools, school grounds and pre-school centres, playgrounds, family and
child clinics and paediatric services and during any sporting and cultural
activities that are held on these premises.
Recommendation 6: Governments should be the key stakeholders in the
development of policy and provide leadership, through a multistakeholder
platform, for implementation, monitoring and evaluation. In setting the
national policy framework, governments may choose to allocate defined
roles to other stakeholders, while protecting the public interest and avoiding
conflict of interest.
Policy Recommendation 7: Considering resources, benefits and burdens of all
implementation stakeholders involved, Member States should consider the most effective
approach to reduce marketing to children of foods high in saturated fats,
trans-fatty acids, free sugars, or salt. Any approach selected should be set
within a framework developed to achieve the policy objective.
Recommendation 8: Member States should cooperate to put in place the
means necessary to reduce the impact of cross-border marketing (in-flowing
and out-flowing) of foods high in saturated fats, trans-fatty acids, free
sugars, or salt to children in order to achieve the highest possible impact of
any national policy.
Recommendation 9: The policy framework should specify enforcement
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mechanisms and establish systems for their implementation. In this respect,

the framework should include clear definitions of sanctions and could
include a system for reporting complaints.
Policy monitoring Recommendation 10: All policy frameworks should include a monitoring
and evaluation system to ensure compliance with the objectives set out in the national
policy, using clearly defined indicators.
Recommendation 11: The policy frameworks should also include a system to
evaluate the impact and effectiveness of the policy on the overall aim, using
clearly defined indicators.
Research Recommendation 12: Member States are encouraged to identify existing
information on the extent, nature and effects of food marketing to children
in their country. They are also encouraged to support further research in this
area, especially research focused on implementation and evaluation of
policies to reduce the impact on children of marketing of foods high in
saturated fats, trans-fatty acids, free sugars, or salt.

Marketing of food to children comes in many guises of which advertisement in broadcast, print and
other media is only one part. It further includes direct marketing strategies like promotions and
product vouchers, point-of-sale marketing, product placement and branding as well as sponsoring of
events, broadcasting programmes, school food campaigns and educational materials. Besides,
children are increasingly exposed to digital forms of marketing using social media, mobile apps,
online games etc. that are gaining importance at the expense of more traditional forms like television
advertising [WHO EUR, 2013; Kelly et al., 2015; WHO EUR, 2016]. This wide range is taken into
account in the broad definition of marketing by the WHO as “any form of commercial communication
or message that is designed to, or has the effect of, increasing the recognition, appeal and/or
consumption of particular products and services. It comprises anything that acts to advertise or
otherwise promote a product or service” [WHO, 2010b].
Nevertheless, in many countries the focus of exposure assessment as well as policies continues to be
predominantly on traditional media, especially television. There is therefore a need to extend
measures on advertisements in new media that have a wider reach, appear to have a larger impact
on children and to be more difficult to recognise but are, however, much more difficult to monitor
and control [WHO EUR, 2016; Kelly et al., 2015].
The impact of marketing is determined by its power and the exposure to it. The power of marketing
depends on its creative contents, the design and execution, while the exposure is composed of the
reach (the share of the target population exposed to the marketing) and the frequency (figure 12).
 92

Both determinants should ideally be addressed by policies to restrict the marketing of HFSS to
children. A regulation of food marketing to children concerns not only the health-related government
agencies but also many others like among others ministries and agencies in charge of business and
industry, trade, commerce, consumer affairs, family affairs, child protection, media and
communications, all with their own interests, responsibilities and point of views on the matter.
Achieving consensus among these actors and resolving disagreement increases the political support
for the adoption of a policy. This can be accomplished through the establishment of a working group.
Policies should be led by the government but include public health and consumer organizations,
academics and lawyers to counteract legal arguments raised by the food industry. The private sector
should be included

Figure 12 Actors in the development and dissemination of marketing and determinants of its
impact

An important point concerns the definition of HFSS foods. This is best done using a nutrient profiling
model that should be objective and based on scientific evidence to include nutrients relevant for the
prevention of NCDs, taking into account regional consumption habits and local food supply. A
number of systems exist like the model developed by the UK Food Standards Agency for the Office of
Communications (OfCom model) consisting of a score that is determined by points given for nutrients
that should be limited and points for beneficial components (figure 13). This system has more
 93

recently also provided a basis for front-of-pack labelling. In turn, the model developed by the WHO
regional office for the EMR sets specific nutrient thresholds for different food categories. This model
is based on the nutrient profile model of the WHO Regional Office for Europe that was adapted to
the requirements of the countries of the region [WHO EMRO, 2017a]. The use of a uniform model
also facilitates the cooperation between the countries of a region and the development and
implementation of cross-border regulations to address the impact of global trading and the
propagation of media and internet content across borders.
The implementation of policies to reduce the impact of HFSS foods on children can be
comprehensive or step-wise. While a comprehensive model is more effective in covering all forms of
marketing across all media, most countries have taken step-wise approaches by focussing their
actions on a specific age group (mostly younger or school age children), certain product groups, types
of media, forms of marketing and/or defined settings. Furthermore, legally binding statutory
regulations to restrict marketing of HFSS foods to children are also rather the exception than the
rule. Notable exceptions include policies restricting advertisements of HFSS foods to children in
broadcast and/or non-broadcast media in the UK, Ireland, Norway, Sweden, Turkey, Chile, Mexico,
South Korea and Taiwan. Brazil, Peru as well as the Canadian Province of Québec ban commercial
advertising to children in any media. In the EMR, the Islamic Republic of Iran imposed a ban on the
advertisement of soft drinks on broadcast media in 2004 and intends to include other food groups. A
ban on broadcasting advertisements of unhealthy food through state television and radio also exists
in Egypt. Other countries are currently developing policies [WHO EMRO, 2018].
Brazil, Chile, Peru, South Korea Taiwan also prohibit the use of gifts, free toys and games, cartoon or
licensed characters for marketing purposes. In San Francisco and Santa Clara County, California,
restaurants are forbidden to use such marketing techniques on meals not meeting certain standards
[WCRF NOURISHING Framework database].
A greater number of countries use a system of voluntary self-regulation established by the food
industry. Examples for such initiatives include the EU Pledge, the US Children Food and Beverage
Advertising Initiative (CFBAI) and the Global Policy on Advertising and Marketing Communications to
Children of the International Food and Beverage Association among others. Although regrouping
some of the largest food and beverage manufacturers and fast-food restaurants, these models suffer
from many weaknesses: They are generally based on self-defined criteria for classifying foods and
setting target groups and media that vary widely and they lack appropriate enforcement and
monitoring mechanisms [EPHA, 2016; Boyland & Harris, 2017].
 94

Figure 13 The UK Food Standards Agency (FSA) nutrient profiling model developed for OfCom to
classify foods in the context of television advertising to children
This model is also the basis of the Nutri-Score front-of-pack label (see chapter 7.4.2)

It has been stated that the irresponsible marketing of unhealthy food infringes several children’s
rights as defined by the Convention on the Rights of the Child including the right to health, access to
nutritious food, information and privacy and that governments have a responsibility to protect
children from the harmful influence of such marketing. The adoption of a child rights-based approach
to restrict marketing of unhealthy foods to children has the potential to increase the accountability
by strengthening commitments of the involved stakeholders and enabling effective measures against
violations. The universality of children’s rights lends legitimacy to measures undertaken to their
protection and it empowers policies by making them legal obligations of governments. A child rights-
based approach gains more advocacy and support and invites strategic alliances between various
actors with similar visions and common goals [UNICEF, 2018b].

7.3. The Food Systems Approach to ensuring sustainable food and nutrition security
Food and nutrition security are not only determined by the mere production and availability of food,
but also require a stable access to and utilization of safe, nutritious and healthy food for everyone
[FAO, 2006] (also see chapter 4.2.). Climate change, political and economic crises and recent
sociodemographic developments pose an increasing challenge to food and nutrition security. What
and how we eat is influenced by a wide variety of interrelated factors and actors. In turn, our dietary
 95

habits have themselves significant impacts on the environment. Interventions aiming at changing the
nutrition situation can have unpredictable and even adverse effects. To successfully combat hunger
and malnutrition and make healthy wholesome food available to everyone the whole system of food
production, processing, distribution and consumption from “farm to fork” must be targeted taking
into account environmental and socioeconomic aspects and trying to predict their outcomes.

7.3.1. The concept of food system

Food systems are variable and specific for the environment in which they are set. They are also
changing over time with the appearance of new actors and situations. However, at the centre of each
food system is a set of activities that constitute the food supply chain ranging from production,
processing and transforming, storage and transport to retail and consumption.
These activities lead to various outcomes that in the context of food security can be assigned to three
groups. Besides food availability, access to and utilization of food that are the components of food
security in the narrow sense, socioeconomic outcomes of food activities like income, employment
and health also have effects on food security. The same applies to the environmental outcomes of
food activities. Environmental factors like changes in land use, water availability and quality,
biodiversity, climate and weather, and socioeconomic factors like demographic trends, the political,
economic and cultural context, also act as drivers of food activities. The fact that they are in turn
influenced by the food system – its activities and its outcomes – creates feedback and multiplier
effects. Environmental feedbacks arise for example from soil erosion, declining water quality and
greenhouse gas emissions due to unsustainable food production and processing that cause changes
in the ecosystem with consequences for the food system.
The decisions of consumers on what, how and when they eat, i.e. their interaction with the food
system, are determined by the food environment that sets the physical, political and socio-cultural
conditions under which food supply and consumers’ demands concur. Places were food is acquired
and eaten like markets, stores, restaurants etc. are as much elements of the food environment as
laws regulating food quality, labelling and food prices among others. Infrastructure, regulations and
institutions constitute an enabling environment for food system activities. An overview of the
complex interactions within the food system is given by figure 14.

Figure 14 A model of the activities and outcomes of the food system and their drivers
At the centre of every food system are a number of activities (production, processing/transforming,
distribution and consumption) the outcomes of which contribute to food security, but also have effects on the
environment and on socioeconomic aspects. Food activities and food outcomes are set within the food
 96

environment that determines the dietary choices of consumers, and the enabling environment made up by the
conditions under which the food supply system operates (represented by the grey shade in the diagram). Food
system activities and outcomes are themselves influenced by different environmental and socioeconomic
drivers that interact with each other and in turn receive feedbacks from various food system activities and
outcomes.
Based on [Ingram, 2011; UNEP, 2016; Ingram, 2016; van Berkum et al., 2018]

Various actors are involved in the food system and play different roles in its shaping and functioning.
On the on hand, there are producers including individual farmers and fishers but also large
agribusiness enterprises, multinational food companies and retail chains. On the other end of the
food value chain are the consumers. However, individuals involved in all other sectors are also
consumers buying, preparing and eating foods. Governments in turn, provide the regulatory and
legislative framework in which the food supply chain is embedded, as well as the infrastructure and
determine the socioeconomic environment. Civil society and non-governmental organizations
(NGOs) can also have an influence on the food system by acting as counsellors and/or lobbyists
thereby influencing the government’s decision-making and policies and by raising awareness of
specific issues.
The way the actors of a given food system operate and interact is determined by a number of
circumstances, notably the physical environment (the availability of and access to natural resources,
the infrastructure etc.), the social, economic and technical setting (food and labour prices, education
and training, gender and equity aspects, research and technology etc.), the institutional and
regulatory environment (property and tenure rights, laws concerning food safety and the
 97

environment etc.), and cultural aspects (religion, traditions, norms, values etc.). These circumstances
vary between countries, regions, communities and even between individual actors [UNEP, 2016].
Taking a food systems approach to address nutrition problems and make diets healthier and more
sustainable is a key to success as it allows a broader view on activities, outcomes and actors of food
production and consumption and the interactions between them. It opens ways to improve
outcomes across the full set of food system activities rather than focussing on just one, also taking
into account synergies and potential trade-offs of interventions. Moreover, it helps including all
relevant actors in interventions [Ingram, 2016].

7.3.2. Sustainable food systems to improve food security and support development
Traditionally, increasing food production through crop production, livestock rearing and fishing is
often considered the primary approach to increase food security and fight hunger. While food
production is essential for food security by supplying the raw material for the rest of the food chain,
the recent large increase in total food production was not accompanied by a corresponding decline
of undernourishment [UNEP, 2016]. Of the food system activities, food production is most directly
affected by environmental and climate change, but it has its own negative effects on the
environment and contributes to resource degradation and biodiversity loss. In light of global climate
change and the threats for food security resulting from it, sustainable food systems are needed to
provide sufficient food of good quality to the growing global population. Such a food system has
been defined as “ensur[ing] food security and nutrition for all in such a way that the economic, social
and environmental bases to generate food security and nutrition of future generations are not
compromised” [HLPE, 2014].
From a natural resource perspective, this implies three main basic principles:
1. the sustainable use of renewable resources avoiding degradation,
2. the efficient use of all resources, renewable and non-renewable,
3. low environmental impacts from the food system activities [UNEP, 2016].

Sustainability refers not only the environmental impact of the food system but also its economic and
social outcomes that are determinants of food security, health and livelihoods. While the relevance
that is accorded to each of these three pillars varies across regions and between actors, they all have
to be included in a sustainable food system. It should provide a viable basis for food supply,
livelihood and incomes, ensure the equal distribution of the generated value among the population
including vulnerable groups and support socio-cultural values and animal welfare, and it should have
no negative effects on the natural environment (see figure 15) [FAO, 2018a].
 98

Figure 15 Sustainability in food systems (modified from [FAO, 2018a])

SFS: sustainable food systems

Changing agricultural systems so that they enable sustainable increases in productivity, while at the
same time enhancing adaptation and resilience to climate change and contributing to the mitigation
of greenhouse gas emissions to achieve food security and development goals is the objective of the
FAO’s concept of “climate-smart agriculture” [FAO, 2013].
While food production can be increased through a more efficient use of land and resources this
needs technological inputs and an enabling environment. Social support and adequate incomes allow
farmers and fishers to make the necessary changes in their practices and invest in new technologies
[FAO, 2013; UNEP, 2016; FAO, 2018b].
Another crucial approach to making food systems more sustainable is the reduction of food losses
and waste considering that over 30% of foods produced are lost before they reach the consumer
(food loss) or are discarded (food waste). Highly nutritious foods like fresh fruits and vegetables and
animal products are also the most perishable. Preventing food loss and spoilage through improved
post-harvest management (better storage, transport, more efficient processing) at the producer and
processor level are one strategy. This can for example be achieved by improving manufacture and
hygienic practices or by investing in road infrastructure to facilitate transport or in technical
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equipment for storage. However, especially in high-income countries, food wasting by consumers
contributes significantly to overall food losses. Food waste is also increased by multipack
promotional offers from retailers. This indicates the need to raise awareness in consumers about
food storage and shelf life as well as to guide food purchasing [HLPE, 2014].
Consumers’ food choices are influenced by the availability and offer of foods on the market, but their
food preferences and purchasing behaviour in turn act as drivers of food demand and thereby food
production. This gives them the power to actively change their food environments and food systems
[FAO, 2018b]. Determinants of food preferences and choices offer entry points for policies to make
consumption more sustainable. Urbanization and globalization make it more difficult for consumers
to know about the environmental and social impacts of the foods they consume. More transparency
is needed to inform customers about the origins and production conditions of foods and justify
higher prices for more sustainable products [Wognum et al., 2011]. Minimum standards, labelling
rules and education of consumers can all contribute to this goal.

7.3.3. A food systems approach to make diets healthier and fight NCDs
Besides food security and environmental aspects, food systems approaches can also help in
addressing problems of overconsumption and unhealthy diets. Indeed, limiting the environmental
impact of food systems can have positive effects on diet health as well. Notably, reducing the high
consumption level of animal products as well as the excessive overall food and energy intake in high-
income countries would contribute to the prevention and reduction of obesity and associated NCDs.
Making diets healthier involves all activities and actors of the food system beginning at the level of
production/supplying of diverse, healthy and nutritious food that is accessible to everyone. A recent
analysis of data from the FAO Food Balance Sheets showed that the global production of fruits and
vegetables would not suffice to supply the recommended five servings per day (set at 600 g/d for
adults in this model) to the total global population. On average, only 78% of the amount needed was
available and just 42% in low-income countries [Siegel et al., 2014]. Making diets healthier therefore
requires adaptation of the agricultural production or importations. This can be achieved through
policies aiming at promoting the production nutritious foods like fruits and vegetables and
influencing the price of these products through subsidies. In most countries, health, agriculture and
environmental matters fall under the responsibility of different government departments or agencies
presenting a barrier to the alignment of policies. A food systems approach can help intersectoral
collaboration.
In modern, increasingly urbanized food systems, private actors have a growing impact on consumer
food choices and diets through food marketing and supply. Highly processed foods are cheap to
produce, well storable and offer high profits and are therefore intensively promoted. Excessive
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consumption of these products containing high levels of undesirable nutrients like added sugars, salt,
saturated or trans-fatty acids is a risk factor for NCDs. A way to help consumers make healthier food
choices is the use of nutrition labelling. Front-of-pack labels provide information about the nutrient
contents of food in a form that is easy to understand. This measure has already been adopted in
many countries around the globe on a mandatory or voluntary base. In the latter case, the
cooperation of the food industry is required, and a number of food manufacturers has already taken
steps towards better information of consumers. Some have also developed their own schemes.
However, reactions from the food industry are mixed and there is a need for regulation (see chapter
7.4.2 for more detail). Information on healthy nutrition can also be imparted in schools as part of the
curriculum. Another approach is the reformulation of products to make them healthier. A survey
from the UK showed that in the case of salt this was mainly done by retailers with their own brands
but less so by food producers [Public Health England, 2018].
Some countries have also decided to levy taxes on products rich in sugar, salt, saturated or trans fatty
acids (see chapter 7.4.1).

Regardless of the measure taken, a stepwise approach to planning and implementing policies to
make food systems nutrition-sensitive is advisable. At the beginning, a country situational analysis
should be conducted to understand a country’s food systems and their contribution to problems in
nutrition. In a second step, the policy landscape shaping the food system should be analysed to
identify existing gaps and policy instruments in place. This step should be followed by a search for
policy options that that could be applied as levers at various entry points throughout food systems to
enable healthier diets. In a final step, opportunities for policy change are identified and initiated
[FAO, 2018b].

7.4. Diet-related NCD interventions

7.4.1. Limiting the intake of salt, saturated and trans fatty acids and sugars
Some dietary factors are directly associated with known risk factors for disease providing a target for
dietary interventions. Most attention in this regard has been on salt, saturated fatty acids (SFAs) and
especially trans fatty acids (TFAs) as well as sugars. A high intake of foods rich in one or several of
these nutrients is associated with the development of obesity and physiological disturbances like
hypertension, dyslipidaemia and insulin resistance that in turn are major risk factors for NCDs. The
problem is further aggravated by the wide availability of foods rich in unhealthy components that are
generally cheap, palatable and easy to store, so that they can be sold in vending machines at any
time. In addition, they are often cleverly and aggressively advertised especially to children. For
manufacturers, the use of salt, sugars, SFAs and TFAs presents a number of advantages. Salt and
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sugars increase the shelf life of foods and add to their taste. They also bind water, thereby increasing
the weight of a food for the benefit of the producer. Regular consumers of fatty, salty and sweet
foods get used to the taste and develop a liking for it, resulting in even higher intake. Moreover, salt,
sugars and fats are hidden in many foods, leaving consumers unaware of their high consumption.
Reducing the intake of unhealthy nutrients improves the diet and reduces the risk for obesity and
NCDs. While food manufacturers, retailers, caterers and other actors in the food business have a
responsibility to offer healthy, wholesome foods, the government must contribute to lead the way by
setting objectives and rules and enabling a healthy food and living environment [WHO-Euro, 2014].
Evidence for the effectiveness of a collaborative multifaceted approach to tackle NCDs through
improvement of an unhealthy diet comes from the earliest community-based intervention to prevent
CVD, the North Karelia Project started in 1972 in the Finnish province of North Karelia that was
affected by very high CVD mortality rates. This community-based intervention aimed at the
improvement of the diet through lower intake of saturated fats especially from dairy sources and salt
and higher consumption of fruits, vegetables and whole grain products together with a reduction of
tobacco use and changes in other lifestyle factors through behavioural changes, health
communication, food product reformulation, improved access to healthy foods and environmental
changes. The project resulted in significant improvements including lower smoking rates, decreased
prevalence of hypertension and hypercholesterolaemia as well as a reduction of cardiovascular
mortality [Puska et al., 2016].
A central part of the North Karelia Project was the reduction of dietary sodium intake that occurs
most commonly in the form of table salt and it is still a high priority of current policies to improve the
diet [Laatikainen et al., 2016]. High intake of sodium or salt is directly correlated with hypertension
and dietary interventions leading to a reduction in salt intake in the North Karelia Project entailed a
reduction in average blood pressure [Laatikainen et al., 2016].
Hypertension is one of the most important risk factors of the cardiovascular system and currently the
leading health risk factor accounting for 10.4 million (95% UI 9.39–11.5) global deaths, corresponding
to about 19%, and 218 million (198–237) disability-adjusted life years (DALYs) in 2017 (figure 16)
[GBD, 2018]. Dietary salt intake has also been related to the risk of certain types of cancer,
particularly of the stomach [WCRF/AICR, 2018]. Hypertension has a high prevalence globally.
 102

Figure 16 Global deaths from all causes in 2017 by associated risk factor [GBD, 2018]

Data from 844 studies from 154 countries taken from the Global Burden of Disease, Injuries, and Risk
Factor study 2015 (GBD 2015) suggest that between 1990 and 2015 the prevalence of systolic
hypertension defined as systolic blood pressure (SBP) ≥ 140 mm Hg increased from 17.3% to 20.5%,
amounting to a projected number of 874 million affected persons in 2015. In 2015, an estimated
143 million DALYs and 14% of total global deaths were attributable to SBP ≥ 140 mm Hg. It is
noteworthy that 29% of the DALYs related to SBP ≥ 110-115 mm Hg occurred in persons with SBP
between 110 and 140 mm Hg. Cardiovascular diseases including ischaemic heart disease and stroke
were the major causes of death related to SBP ≥ 140 mm Hg. A high disease and death burden from
hypertension was observed in the Eastern Mediterranean and North-African region with Afghanistan
showing the highest age-standardized rate of deaths associated with SBP ≥ 140 mm Hg of all
participating countries (456 per 100,000) (figure 17) [Forounzar et al., 2017].
High intake of sodium or table salt has been associated with higher blood pressure and a higher risk
for some cardiovascular diseases, particularly stroke. Limiting sodium intake to 2 g/d or even less
results in lower blood pressure and less hypertension [WHO, 2012b]. Reducing dietary sodium intake
has also been associated with lower risks for cardiovascular disease and death although the evidence
for this effect is weaker calling for more high quality research on this subject [Tuomilehto et al.,
2001; WHO, 2012b; Cobb et al., 2014; He et al., 2014; Wong et al., 2016].
 103

Figure 17 Age-standardized death rates per 100,000 attributable to systolic blood pressure
≥140 mm Hg in 2015 by region and socio-demographic index (SDI)
SDI is based on lag-dependent income per capita, average educational attainment in the population
older than age 15 years, and the total fertility rate. [Forounzar et al., 2017]

The reduction of sodium and salt intake in the general population by 30% by the year 2025 is
therefore one of the targets of the WHO Global Action Plan for the Prevention and Control of NCDs
2013-2020 [WHO, 2013a]. The WHO strongly recommends a sodium intake of less than 2 g/d
corresponding to less than 5 g/d of table salt from all sources. For children, this level should be
further reduced based on the energy requirements of children relative to those of adults [WHO,
2012b].
Reducing salt intake is considered a highly efficient and cost-effective approach to combat NCDs
especially when interventions are set at population level. This approach has a high prevention
potential. Cost effectiveness was particularly high for mandatory or voluntary reduction of salt
contents in processed foods by setting targets for the food manufacturers or by imposing a tax on
salty foods. These measures may even result in cost savings due to benefits from lower health care
expenditures and lower productivity losses that exceeded the costs of the intervention. In turn,
individual interventions targeting high-risk patients were found to be less cost-effective [Cobiac et
al., 2013; Schorling et al., 2018]. However, interventions aimed at behavioural changes like
educational campaigns have also shown effects when implemented at whole population level or at
work sites [Trieu et al., 2017].
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A number of surveys from across the globe reveal a high salt intake in most countries that markedly
exceeds the recommended amount [Brown et al., 2009; Powles et al., 2013]. Based on data from 66
countries, global mean sodium intake in adults in 2010 was 3.95 g/d corresponding to about 10 g of
table salt and ranging from 1.6 to 5.98 g/d (4 to 15 g of salt). Across all regions, men had higher
intakes than women (mean 4.14 g/d vs 3.77 g/d, respectively. Apart from the Sub-Saharan region and
some countries of Latin America, the Caribbean and Oceania, all countries had mean sodium intakes
exceeding 3 g/d. Particularly high intakes were observed in Central Asia and Eastern Asia, Eastern
Europe and North Africa. Intakes for the Eastern Mediterranean and North Africa ranged from 2.1 to
5.4 g/d of sodium (5.2 to 13.5 g/d of salt), the lowest levels being reported from Sudan, Somalia and
Djibouti, the highest from Bahrain and Tunisia [Powles et al., 2013]. Data from the European Salt
Framework reported mean intakes of 5-17 g/d of salt [EC Framework, 2014]. Based on a recent
assessment of urinary sodium excretion in US adults in the frame of the NHANES 2013-2014, a mean
sodium intake of 4 g/d was estimated (4.7 g/d in men and 3.4 g/d in women) [Cogswell et al., 2018].
The reliability of data on sodium intake depends on the method used for assessment. The estimation
from dietary records is hampered by the lack of reliable data on salt content of many processed
foods or prepared meals as well as by underreporting. Urinary sodium excretion provides a better
way of assessment considering that about 90% of the ingested sodium is excreted through the
kidneys. However, excretion shows seasonal and diurnal variation with lower values being observed
in overnight urine samples and under hot climate due to losses via sweat. Therefore, 24h urine
samples are generally regarded as the gold standard to assess sodium intake. Assessment of spot
urine samples provides a more convenient alternative both for investigators and probands that is
applicable to larger samples and increases the accuracy and completeness of collection. Different
formulae have been developed to estimate 24h sodium excretion from spot urine samples but the
correlation with the sodium amount measured in full 24h samples is generally low in individuals. In
turn, better accuracy was found at the population level when mean concentrations were compared
[McLean, 2014]. In turn, the estimation of sodium intake using dietary assessment is generally not
very reliable [McLean et al., 2018]. However, this method is required to identify the major sources of
sodium and salt in the diet. In this regard, it is important to ensure that data on sodium contents of
food especially of processed foods and highly consumed dishes is made available and kept up-to-date
[WHO-EMRO, 2017b].
In industrialized countries with a Western-style diet (75-80%) and increasingly in developing
countries, the majority of sodium in the diet comes from processed foods, the rest being added
during cooking and at table whereas only small amounts occur in natural unprocessed foods [Brown
et al., 2009; Baker & Friel, 2014; Klose et al., 2015]. Processed foods also contribute highly to sodium
intake in the countries of the Eastern Mediterranean Region (EMR) as evidenced by data from
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Lebanon reporting a share of 67% [Nasreddine et al., 2014]. While the importance of single food
groups varies between regions and even countries depending on cultural and dietary habits, bread
and cereal products play a major role in many countries, followed by processed meats, cheese and
ready meals [Nasreddine et al., 2014; Klose et al., 2015]. In the EMR, consumption of bread is
generally high making it a major source of salt even at lower salt contents. A recent survey in
different countries of the region found that salt content in diverse bread types ranged from 0.28 to
1.55 g per 100 wet weight with a mean of 0.76 g/100 [Al-Jawaldeh & Al-Khamaiseh, 2018].
Against this background and the increasing burden from NCDs, the WHO has formulated the SHAKE
package, a set of key measures to develop, implement and monitor salt reduction strategies to assist
member states in their efforts to reduce salt intake (figure 18) [WHO, 2016b].

Figure 18 The SHAKE package of measures to develop, implement and monitor salt reduction
strategies (adapted from [WHO, 2016b])

To date, the implementation of salt reduction policies and its progress varies between countries.
Among the first to take action was the United Kingdom that began its salt reduction programme in
2003 following a report by the Committee on Medical Aspects on Food Policy (COMA) on Nutritional
Aspects of Cardiovascular Disease in 1994 that identified excessive sodium and salt intake as a major
contributor to hypertension. The target for salt intake in the adult population was set to 6 g/d down
from an average of 9 g/d. Voluntary reformulation of processed foods was a central part of the
programme and was achieved through a close cooperation with the food industry. This was
complemented by the promotion of food labelling and intensive media campaigns to raise consumer
awareness. To achieve an incremental reduction of salt content, thresholds were set a four time
points (2006, 2009, 2011 and 2014) for around 80 different product categories [Public Health
England, 2018]. Taking the example of bread, a major contributor to salt intake, the target was
 106

reduced to 0.9 g/100g from previously 1.0 g/100g. A reduction of 30% was achieved until 2008
[Wyness et al., 2011]. Since the launching of the intervention, salt intake measured by urinary
analysis declined by 11% to 8.0 g/d in 2014. An assessment in 2017 showed that cereals and cereal
products including bread were still the main contributors to salt intake (29.5%) followed by meat
products (27.3%). 89% of breads and rolls from manufacturers and retailers met the target but only
41% of products from the out of home sector. Room for improvement was also found in the meat
product category. Across all product groups, more products from retailers than from brand
manufacturers met the targets (73% vs. 37%) [Public Health England, 2018].
Other countries have also set targets for salt levels in foods including the USA, Canada and Australia
as well as Brazil, Chile, Argentina and Mexico. In Australia, 81% of breads met the agreed targets in
2017. In Europe, the WHO Action Network on Salt Reduction in the Population in the European
Region (ESAN) has planned a reduction of the salt content of various food categories by 16% over 4
years. It includes 23 countries of the WHO European Region of which 17 are EU member states. Of
these, Finland has the longest programme for salt reduction in existence, dating back to the 1970s
when it was started as part of the North Karelia project. There has also been some progress in the
reduction of salt contents of food in other countries such as Ireland, the Netherlands, Belgium and
France [Trieu et al., 2015; WHO-Euro ESAN, 2017].
The reduction of salt intake is considered a high priority by the WHO Regional Office for the Eastern
Mediterranean (EMRO) and a number of initiatives are currently being undertaken to achieve this
goal. In a series of multi-stakeholder technical meetings focusing on population salt reduction
strategies, policy guidance was developed with actions for a progressive and sustainable reduction of
national salt intake by 25% within 3–4 years recommended to member states and a monitoring
mechanism and a regional protocol on 24-hour urinary sodium measurements was set up [Al-
Jawaldeh et al., 2018].
Despite a number of achievements in many countries, further efforts are needed to obtain a
permanent reduction of salt intake and of salt contents in processed foods.
Another established dietary influencing factor of NCDs is fat quality. The negative effect of
SFAs on cardiovascular health is widely recognized. High intake of SFAs has been repeatedly
associated with a higher risk for cardiovascular disease and mortality. The primary mechanism
behind this effect is the increase in total cholesterol and particularly its low-density fraction leading
to atherosclerosis. SFAs have also shown proinflammatory effects, promoting LDL cholesterol
oxidation and may contribute to insulin resistance [Calder, 2015]. In turn, unsaturated fatty acids are
protective against CVDs. In that, they are also superior to carbohydrates that increase triglycerides
when excessively consumed in the form of free sugars [Calder, 2015; Briggs et al., 2017].
 107

Even more negative effects on cardiovascular health have been shown for trans fatty acids (TFAs),
unsaturated fatty acids that have one or more double bonds in the trans configuration as opposed to
the cis configurated fatty acids normally occurring in the mammalian organism. Most TFAs in the diet
come from industrially processed sources, mainly from partially hydrogenated vegetable oils in which
they are formed during the hydrogenation process. Only a small part is contributed by TFAs occurring
naturally in milk and milk products as well as meat from ruminants. In turn, in processed foods like
fast foods, some bakery goods including biscuits, cakes and pastries, and deep-fried products TFAs
can constitute up to 60% of the total fat content [Stender et al., 2008]. Partial hydrogenation is used
to turn liquid oils into solid or semi-solid fats with increased tolerance, extended shelf-life, specific
sensoric properties and low costs that are useful for the industrial processing of foods. Partially
hydrogenated oils were increasingly used in the 1950s to 1970s as a cheap replacement for animal
fats following the discovery of the negative health effects of saturated fatty acids [Stender et al.,
2008; WHO, 2018f].
Trans fatty acids especially increase the risk of coronary heart disease and cause hyper- and
dyslipidaemia. A possible contribution of TFAs to inflammatory reactions, endothelial dysfunction,
insulin resistance, diabetes mellitus type II and cancer is less clear [Gebauer & Baer, 2013]. According
to a metaanalysis of four prospective cohort studies, a 2% increase in energy intake from TFAs
corresponded to a 23% higher incidence of myocardial infarction and CHD death and to a 29%
increase in three retrospective case-control studies [Micha & Mozaffarian, 2009]. The evidence for an
increasing risk of coronary heart disease from TFAs from partially hydrogenated vegetable oils was
considered convincing by the WHO [Uauy et al., 2009]. The earlier recommendation to keep their
intake as low as possible and preferably below 1% of total energy (corresponding to 2 g/d for a total
energy intake of 2000 kcal) issued by the WHO/FAO in its technical report series 916 from 2003
[WHO/FAO, 2003] was retained and adopted by many other nutrition and public health entities. At
the national level, Denmark was the first country worldwide to impose a limit on industrially
produced TFAs in all foods including those for out-of-home consumption to 2 g/100 g fat in 2003.
This measure was followed by other European countries. In the European Union, regulations to limit
industrially produced TFAs to 2% of total fat in all food products were adopted in April 2019 that will
come into effect in 2021 and be applicable in all the EU Member States as well as countries of the
European Economic Area. Mandatory limitation of TFA content in fats and oils has also been
implemented in Argentina, Canada, Chile, Colombia, Ecuador, India, Peru, Singapore and South
Africa, Thailand, Uruguay, the USA. In the Eastern Mediterranean region, Iran, Bahrain and Saudi
Arabia have mandatory limits of 2% for TFAs in oils and margarines as well as of 5 g/100 g fat in other
foods in place. Other countries of Gulf Cooperation Council countries have yet to finally adopt the
regulations. In total, by 2019, 53 countries had set mandatory limits for industrial TFAs or bans on
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partially hydrogenated oils that were fully implemented in 28 countries. However, only three of the
countries are lower-middle-income countries and none is a low-income country (table 22) [WHO,
2019a]. Another approach is the prohibition to use partially hydrogenated oils in foods that has been
imposed in Canada (2017), the USA and Brazil. Furthermore, the US Food and Drug Administration
(FDA) has revoked the GRAS (Generally regarded as safe) status of TFAs so that they can no longer be
added to foods [FDA, 2018
https://www.fda.gov/Food/IngredientsPackagingLabeling/FoodAdditivesIngredients/ucm449162.ht
m]. Earlier, in 2008, the City of New York had restricted the use of partially hydrogenated oils with
≥0.5 g of TFA per serving by food service establishments (restaurants, caterers). In addition, in many
countries (the Netherlands, Germany, Belgium, Czech Republic, France, Poland and the UK), the
reduction of TFAs in processed foods is performed on a voluntary basis in collaboration with food
manufacturers [WHO Europe, 2015]. A number of countries also require labelling of TFAs on food
such as Jordan, Kuwait and Saudi Arabia in the EMR [WHO, 2019a].

Table 22 Mandatory limits, bans and labelling of trans-fats in foods in 2019 [WHO, 2019a]
Approach Targets Countries
Austria, Chile, Denmark, Ecuador,
Hungary, Iceland, Latvia, Norway,
2% of fat in all foods
Slovenia, European Union (effective in
2021), South Africa
2% in vegetable oils and
Argentina, Colombia, Peru, Bahrain, Iran,
Limitation of TFAs margarines
Saudi Arabia, Belarus,
5% in all other food
2% in vegetable oils and Armenia, Kazakhstan, Kyrgysztan, Russian
margarines Federation, Switzerland, Singapore
4% in all foods Uzbekistan
5% in fats, oils and emulsions India
Nationwide ban on
the use of partially
Canada, USA, Thailand
hydrogenated
vegetable oils
Labelling of TFAs on Bolivia, Brazil, Canada, China, India, Israel, Jordan, Kuwait, Paraguay,
foods Philippines, Saudi Arabia, Singapore, South Korea, Turkey, Uruguay, USA
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To assist its member states in the reduction of TFA intake and contents in foods, the WHO has
released the REPLACE package, a set of six multisectoral strategic actions to assess the intake of TFAs
in the population and identify major sources, to impose regulations to limit their contents in foods
and to raise awareness on the negative health effects of TFA intake (figure 19).

Figure 19 The REPLACE action package of the WHO [WHO, 2018f]

Following these approaches, a reduction of the contents of TFAs in foods and of their consumption
level was reported in countries having implemented either mandatory or voluntary policies. In
Denmark, the percentage of products containing more than 2 g TFAs per 100 g of fat fell from 26% in
2002/2003 to 6% in 2012/2013. Transgressions in 2012/2013 were only found in cookies and biscuits
[Ministry of Food, Agriculture and Fisheries of Denmark, 2014]. Decreases in the contents of TFAs in
dietary fats and other foods following the introduction of regulation were also observed in Austria,
New York, Canada and Argentina [Restrepo & Rieger, 2016b; Hyseni et al., 2017; Grabovac et al.,
2018; Kakisu et al., 2018]. Even voluntary approaches led to significant reductions in TFA contents in
major food sources in different European countries [Stender et al., 2012]. Studies in Denmark and
New York City showed that TFA reductions were accompanied by declines in cardiovascular mortality
even though this could not be confirmed for the Austrian population [Restrepo & Rieger, 2016a;
Restrepo & Rieger, 2016b; Grabovac et al., 2018].
However, with the existence of different approaches to limit TFAs in foods and their lack in many
countries, TFA intake varies across regions and countries. For instance, analyses of TFA contents in
industrially produced biscuits, wafers and cakes on the market in countries of the European Union
and neighbouring countries of the Balkan region showed that TFA content in foods from Western-
and Northern-European countries decreased between 2005 and 2013 and that no products
containing partially hydrogenated oils were discovered in 2013. In turn, only minor changes if at all
occurred in Eastern-European countries during the same period. Moreover, imported products with
 110

high contents of TFAs were found in ethnic food shops in Western and Northern-European countries,
highlighting the need for mandatory legislation of all foods sold in a given country, including
imported ones [Stender et al., 2012; Stender et al., 2014].
A systematic review of fat consumption patterns in 113 countries in 2010 revealed a high TFA intake
level in many countries of the EMR with Egypt showing the highest intake (6.5% of energy) followed
by Pakistan (5.8% of energy), and Bahrain in the fifth place (3.2% of energy). The region also showed
the highest increase in TFA intake (by 7%) between 1990 and 2010 [Micha et al., 2014].
Surveys in Canada showed that the elimination of TFAs did not entail marked increases in the SFA
content of foods but was associated with higher contents of cis-unsaturated fatty acids [Ratnayake et
al., 2009]. In turn, in Denmark and Argentina, SFAs were found to be the main replacements for TFAs
in foods [Ministry of Food, Agriculture and Fisheries of Denmark, 2014; Kakisu et al., 2018]. This
underscores the importance to guide manufacturers through the reformulation process and to make
healthy alternatives to partially hydrogenated oils like high oleic canola oil that has a higher stability
than other oils rich in polyunsaturated fatty acids available. Approaches include technical support to
producers and agricultural and trade policies to increase the availability of suitable oil alternatives at
affordable prices [Skeaff, 2009; WHO, 2018f].
In addition to salt, SFAs and TFAs, sugars have come into the focus of public health. Diets rich
in free or added sugars, especially in the form of sugar-sweetened beverages, have a high energy
density, tend to have a lower nutrient density and contribute to obesity and associated NCDs [WHO,
2015d]. High intake of fructose in particular, has been associated with a number of metabolic
disturbances like hypertriglyceridaemia, impaired glucose tolerance and non-alcoholic fatty liver
disease. Free fructose is increasingly consumed as high-fructose syrup that is used as a cost-effective
and easy-to-handle sweetener in a wide range of processed foods [Tappy & Lê, 2010]. Furthermore,
sugars are also a direct cause of dental caries [WHO, 2015d]. Therefore, the WHO strongly
recommends to limit the intake of free sugars to less than 10% of total energy intake for adults and
children and conditionally suggests a further reduction to below 5% of total energy intake for
additional health benefits [WHO, 2015d]. This limit has been adopted by many national nutrition
societies [NNR, 2012; CNS, 2013; SACN, 2015; USDHHS/USDA 2015; Health Canada, 2019]. The term
free sugars includes all monosaccharides and disaccharides added to foods by the manufacturer,
cook or consumer, plus sugars naturally present in honey, syrups and fruit juices [WHO, 2015d]. In
turn, lactose naturally occurring in milk and milk products and sugars enclosed within the cellular
structure of foods like fruits are excluded [SACN, 2015].
With the rise in consumption of industrially processed foods, high intake of free sugar has been
observed in many countries and populations across the world. Children are particularly at risk of high
consumption levels. Major contributors vary between countries and age groups, but sugar-
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sweetened non-alcoholic beverages are one the most important sources even though a decline in
their intake has been observed in the USA [Robinson et al., 2018; Marriott et al., 2019]. Many
countries worldwide have committed to reduce sugar intake in their population. The WHO Regional
Office of the Eastern Mediterranean Region has issued a Policy statement and recommended actions
for lowering sugar intake and reducing prevalence of type 2 diabetes and obesity in the Eastern
Mediterranean Region, noting that sugar intake would have to be substantially reduced (by at least
50%) to reach the WHO targets on NCDs by 2025 and suggesting actions to achieve an annual
reduction by 10% [WHO-EMRO].
While the importance of reducing free sugar intake at the population level has been widely
recognized, different approaches have been taken that target major determinants of sugar intake,
namely the availability of sugar and sweetened foods, their affordability, the acceptability of sugar
and of alternatives, and the awareness of consumers on the sugar content of foods (4 A’s concept)
[WCRF, 2015]. An assessment of evidence-based actions by Public Health England identified three
major areas on which actions should focus: Influencers that drive food choice like advertisement,
pricing and retail price promotions, the food supply and the knowledge about diet and health (figure
20) [PHE, 2015].

Figure 20 Key actions to reduce sugar intake at population level (based on [PHE, 2015])

Generally, a multifaceted approach targeting several or all of these factors is required to efficiently
reduce sugars intake at population level. In the case of sugar, food taxes on sugar-sweetened
beverages and/or sugar-rich foods have been suggested as an option. The number of countries that
levy taxes on sugar-sweetened beverages has been rising, reaching 36 as of early 2019 as well as
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eight US and one UK communities and the region of Catalonia in Spain [WCRF, 2018]. These taxes are
most often excise taxes of which there are different types (table 23) that should be chosen
depending on the local context. However, taking nutrient i.e. sugars content as a basis has the most
direct effect and also covers cheaper products. Benefits from taxes are further enhanced by
earmarking the revenues for the funding of health promotion such as programmes to combat obesity
in children or to subsidize healthy foods. Earmarking revenues also contributes to the societal
acceptance of the tax and gains public and political support [WCRF, 2018]. Taxes collected from the
producer generally entail price increases that would result in lower purchases of the taxed product.
However, such taxes are also an incentive for manufacturers to reformulate their products to make
them comply with the criteria exempting them from being taxed.

Table 23 Types of taxes on sugar-sweetened beverages (modified from [WCRF, 2018])

Volumetric tax levied per volume of beverage sold (e.g. per litre)

Nutrient content-based tax levied per sugar content of the beverage (per g of sugar)

corresponds to a percentage of the value of goods (e.g. 10% of

Ad valorem tax
the pre-tax product price)

Value added tax charged on each production stage that adds value to the product

Custom or import duty tax levied on imported products

collected from consumers at sales point as a percentage of the

Sales tax
price

The experience from countries having implemented taxes on sugar-sweetened beverages like Mexico
and Barbados suggests that they are an effective approach to reduce purchases and thereby,
consumption of these products [WCRF, 2018]. A modelling study from Mexico estimated that a 10%
lower consumption of sugar-sweetened beverages resulting from taxation could prevent about
189,300 incident type 2 diabetes cases, 20,400 incident strokes and myocardial infarctions and
18,900 deaths in 35 to 94 year old adults between 2013 and 2022, especially among those aged 35–
44 years. This could save 983 million international dollars of healthcare costs [Sánchez-Romero et al.,
2016].
The implementation of these taxes has generally been faced with significant opposition from
stakeholders like the beverage industry for instance. In the USA, taxes on beverages were blocked in
some states and this has also been observed in other countries [Backholer et al., 2018]. To
counteract industry interference, a strong engagement of civil society and governmental
stakeholders is advised as well as the involvement of the all government departments. It is also
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important to base the measure on strong evidence concerning the negative effects of high sugar
intake, the national consumption level and its drivers and on the effectiveness of comparable
approaches. Public campaigns can inform the public on the taxes and obtain support for it [WCRF,
2018].
In summary, diet-related policies to counteract NCDs share some common approaches to
change the diet by reducing the consumption of foods rich in sugars, salt, SFAs and TFAs and increase
the consumption of healthy foods. Referring to the NOURISHING Framework of the World Cancer
Research Fund, dietary choice is determined by the food environment, the food system and the
dietary behaviour offering various targets for policies (figure 21) [WCRF, 2015].

Figure 21 The NOURISHING Framework of the World Cancer Research Fund to promote healthy
diets and reduce obesity [WCRF, 2018]

Reformulation of food products is an effective approach to sustainable improve the diet at

population level because it does not require any changes in the consumption habits and food choices
of individuals. Moreover, with processed foods being the main sources of salt, sugar, SFA and TFA in
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the diet, the food industry has a responsibility to counteract the negative trends and also acts as an
influencer of consumption patterns. It is therefore essential to involve the food production sector
into processes while at the same time preventing any influence on decision-making. Potential
conflicts and rejection of measures also from consumers arise from technological reasons, costs,
changed properties and taste of the modified products calling for support as well as technological
innovation and research. However, fiscal incentives for healthier products can make compliance
more attractive to manufacturers. Mandatory, government-led approaches have proven more
efficient than voluntary industry-borne initiatives. Even though especially some major retailers have
pledged to markedly improve the health value of their own brands and even begun to set the
necessary steps, such approaches are hampered by conflicts of interest and generally lack
transparency, evaluation and often also clear targets [von Philipsborn et al., 2018].
Aside from food reformulation, modifying the dietary behaviour of the target population is also an
effective way in the prevention of NCDs and consumer education and information are important
elements of this approach. These will be considered more closely in the following.

7.4.2. Consumer education and information: Front-of-package labelling as an

effective way to healthier nutrition
Informing and educating consumers about the relationship between the diet, health in general and
the risk for NCDs in particular, is essential to enable healthier food choices and reduce the intake of
nutrients contributing to obesity and NCDs. Food labelling is a means to provide such information
and is currently (as of 2018) practised in 73 countries, of which the majority (60) use a mandatory
scheme [EUFIC, 2018]. Most frequently, labelling takes the form of a predefined list of nutrients of
which the contents per 100 g/ml and/or serving are indicated on the back of packaged foods.
However, evidence suggests that this type of label is difficult to understand for many consumers,
especially those with a lower education level, and that is may be easily overlooked. This has
prompted the development of simplified nutrition labels that are displayed in a salient form on the
front of the package. Such front-of-pack (FOP) labels are now being introduced in an increasing
number of countries, either on a mandatory or a voluntary basis. Moreover, they are counted among
the “best buys” to address NCDs proposed by the WHO [WHO, 2017c] and are recommended by
many other institutions and civil society organizations.
Providing consumers with nutrition information in an understandable format thereby facilitating
healthier food choices as well as stimulating food manufacturers to innovate and reformulate their
products to make shared objectives of all FOP labels. Additionally, they may also help consumers
understand the links between the nutrient composition of foods and health, particularly in the
context of NCD prevention, support advice on nutrition and healthy nutrition by health professionals
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and reduce consumer confusion about food quality and deception by misleading health and nutrition
claims.
The evidence that FOP labelling can have a positive influence on consumers’ food choice and
facilitate the distinction between healthier and less healthy options is growing [Cecchini & Warin,
2016; Ducrot et al., 2016; Kelly & Jewell, 2018]. Research also shows that consumers prefer this type
of labelling to nutritional information panels on the back or side of the package, are more likely to
look at them and understand them [Cecchini & Warin, 2016; Talati et al., 2016; Neal et al., 2017;
Egnell et al., 2018; Kelly & Jewell, 2018]. Interpretative labels that facilitate interpretation through
colour coding or a graphic symbol are particularly effective. The introduction of FOP labels has also
motivated food manufacturers to reformulate their products to make them healthier [Vyth et al.,
2010; Mhurchu et al., 2017].
Generally, FOP labels are based on a nutrient profile allowing the classification of foods depending on
their nutritional composition. The results of this rating are presented in a graphical form.
There is currently a wide variety of FOP labels that differ in their design and the underlying nutrient
profile used. This prompted the FAO/WHO Codex Committee on Food Labelling to address the
subject and prepare a discussion paper on the different FOP labelling systems currently available,
their defining criteria and the evidence on their use and effects. The need for updated guidelines on
nutrition labelling considering FOP labelling was recognized and the fact that the lack of global
consistency might lead to problems for export and trade. The Committee identified 16 different
systems implemented in 23 countries and ten systems that have been proposed in eleven countries.
Of these latter, the Nutri-Score system in France and the Healthy Living (Živjeti zdravo) symbol in
Croatia have in the meantime been implemented [Croatian Institute of Public Health, 2016; Ministère
des Solidarités et de la Santé, 2017].
The various types of FOP labels can be categorised by some key criteria (table 24).
A major distinction is between labels displaying several single nutrients and those consisting of a
summary score that is calculated from different nutrients and/or ingredients. An example of the first
type is the traffic light system used in the UK since 2012 that is a hybrid label, showing the contents
of total and saturated fat, total sugars and salt in the indicated serving size of the food and their
contribution to the reference intake (in %). The interpretive part of the label consists of the colour
coding (red, amber, green) based on the contents in 100g/ml (or in a serving if it is larger than 100 g).
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Table 24 Classification criteria for front-of-pack nutrition labels

Criterion Options Characteristics Example
Kind of information Informative provides factual information GDAs
provided (reductive) without judgement or
guidance on a food’s
nutritional quality
Interpretive provides guidance on the Nutri-Score, Health
relative healthiness of a Star, Key hole
food, often through use of
colour, graphic symbols or
interpretive wording
Hybrid provides both, factual and Traffic light with GDA
interpretive information
Base of rating Nutrient-based Provides information on a Traffic light
selection of nutrients
Summary-based Combines a defined set of Nutri-Score, Health
nutrients/ingredients into an Star, Key hole
overall indicator of food
healthiness
Legal form Mandatory Labelling is compulsory. Can
apply to all food categories
or just specific ones.
Voluntary Include government-led
schemes with dictated label
type and format but optional
use and labels led by
industry or other
stakeholders
Range of Varies from only one
nutrients/ingredients nutrient/ingredient to a
included large range. Sodium/salt,
total/added sugars,
total/saturated fats and
trans fatty acids and energy
are commonly included.
Reference amount for Per 100 g/ml or per
nutrients serving
Tone of judgement Positive Identify only foods of higher
(for interpretive nutritional quality
types) (endorsement schemes,
rather a health claim)
Negative Identify only foods with high
content of one or several
nutrients of which intake
should be limited (warning
labels)
Graded Provide a graded indicator of
both healthier
nutrients/ingredients and
those that should be
consumed less
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The thresholds for “low” (green) and “medium” (amber) levels correspond to the values of the EU
Nutrition and Health Claims Regulation, that for the “high” (red) category is set at 25% of the
Reference Intake value [Dep. of Health/FSA, 2016]. In turn, the Nutri-Score system, introduced in
France in 2017, is a summary label, based on a score made up of components to limit (calories, total
sugars, saturated fat and sodium) and beneficial components (fruits, vegetables, pulses, nuts, fibre
and protein) in 100 g/ml of the food. The score uses the nutrient profiling model of the UK Food
Standards Agency and Ofcom that was originally developed to identify foods high in fats, sugars or
salt that should not be advertised to children [Julia & Hercberg, 2017].

Figure 22 Examples of front-of-pack labels used in different countries

Clockwise from upper left: Nutri-Score (France, Belgium, Spain), Health Star Rating (Australia, New
Zealand), Guideline Daily Amounts (GDAs) (industry standard in the EU), combined Traffic Light (UK),
Traffic Light (Saudi Arabia), Traffic Light (Iran), warning labels (Chile).
Centre (from left to right): Heart Symbol (Finland), Key Hole (Sweden, Norway, Denmark, Iceland),
Weqaya (Abu Dhabi)

A combination of several nutrients including total and saturated fat, sugars and salt, also provides
the basis for health logos like the Nordic Key hole that was introduced in Sweden in 1989 and has
since been adopted by other Scandinavian countries and Iceland as well. The cut off values for the
nutrients are specifically set for different food categories. Unlike the Nutri-Score label, the Key hole is
only displayed on foods meeting certain criteria that qualify them as healthier choice within their
category. It does not warn about less healthy foods [Livsmedelverket, 2015].
A disadvantage of all composite systems is that they do not provide information on single nutrients.
However, systems providing information on more than one nutrient may be experienced as too
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complex particularly for people with limited nutritional literacy. When products have positive and
negative aspects it may be difficult to recognize the healthier options (e.g. a product high in salt but
low in fat vs. one low in salt but high in fat). It was shown that consumers tend to focus on just one
or a few nutrients that they consider of special relevance [Hieke & Wilczynski, 2011]. In a study
including participants from twelve countries, summary labels were better understood than nutrient-
based ones [Egnell et al., 2018].
The choice of the nutrients included in the score varies but in accordance with the purpose of
labelling to improve health, mostly comprises nutrients and ingredients that either promote or
reduce the risk for obesity and NCDs. Composite scores often include a wider range of positive and
negative aspects than the traffic light with a focus on nutrients that should be limited. However,
labels that identify less healthy foods, not just those that should be preferably consumed, have been
shown to be more effective. This was particularly the case with red warning signs indicating high
contents of saturated fats, sugar or salt in a food [Scarborough et al., 2015; Goodman et al., 2018]. In
addition, consumers were reported to be more concerned about avoiding less healthy foods than
finding healthier options [Scarborough et al., 2015].
To assist member states in the introduction of FOP labelling, the WHO has prepared a Guiding
Principles and Framework Manual for front-of-pack labelling that defines 15 principles for
developing, implementing and evaluating a front-of-pack labelling system (table 25).
Front-of-package labelling is also considered an important tool to improve the nutrition of
populations in the countries of the Eastern Mediterranean region and to prevent NCDs. However, so
far, the use of FOP labelling is limited to only four countries (Iran, Saudi Arabia, Tunisia, United Arab
Emirates). Iran and Saudi Arabia have adopted traffic light labelling systems, while Tunisia and the
Emirate Abu Dhabi use a health symbol (called Weqaya in the latter). Morocco is currently also
considering the introduction of a logo or label describing the overall nutritional quality of foods.
To spur the introduction of FOP labelling in the EMR, the Regional Office of the WHO for the Eastern
Mediterranean (EMRO) held a technical consultation on developing a regional road-map in Beirut
from 11th to 13th September 2018. The road-map is intended to assist member states in the region in
the implementation of FOP labelling. Different existing systems were reviewed for their applicability
and based on the WHO Guiding Principles it was recommended that FOP systems should be
developed in a multisectoral government-led process with the early engagement of the food
industry, key opinion leaders and consumer organisations. The underlying stated aims, scope and
principles should be transparent and easily accessible and in accordance with national public health
and nutrition guidelines. Moreover, labelling should at least cover all pre-packaged foods with
mandatory back-of-pack nutrient declarations and sold through the retail sector with possible
extension to the out-of-home and catering sector. Labelling systems have to be based on a robust
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and transparent nutrient profile model, using contents in 100 g/ml as reference amounts and their
implementation should be accompanied by consumer education and awareness campaigns to
increase the understandability and use of the labels [WHO, 2019b].

Table 25 Principles for front-of-pack labelling [WHO, 2019b]

Overarching Principle 1: The front-of-pack labelling system should be aligned with national
public health and nutrition policies and food regulations as well as
principles
with relevant WHO guidance and Codex guidelines.
Principle 2: A single system should be developed to improve the impact of the
front-of-pack labelling system.
Principle 3: Mandatory nutrient declarations on food packages are a pre-
requisite for front-of-pack labelling systems.
Principle 4: A monitoring and review process should be developed as part of
the overall front-of-pack labelling system for continuing
improvements or adjustments as required.
Principle 5: The aims, scope and principles of the front-of-pack labelling system
should be transparent and easily accessible.
Collaborative Principle 6: Government should lead the multi-sectoral stakeholder
engagement process for the development of trusted systems,
principles
including nutrient profiling criteria.
Design Principle 7: The front-of-pack labelling system should be interpretive, based on
symbols, colours, words and/or quantifiable elements.
Principle 8: The design of front-of-pack labelling systems should be
understandable to all population sub-groups and be based on the
outcome of consumer testing, evidence of system performance
and stakeholder engagement.
Content Principle 9: Content should encompass nutritional criteria and food
components that aim to inform choice and enable interpretation
of food products against risks for diet-related NCDs and for
promoting healthy diets.
Principle 10: The front-of-pack labelling system should enable appropriate
comparisons between food categories, within a food category,
and between foods within a specific food type.
Implementation Principle 11: Uptake of the front-of-pack labelling system should be
encouraged across all eligible packaged foods, either through
regulatory or voluntary approaches.
Principle 12: Early engagement of industry groups and the development of
guidance documents (i.e. style guide) are necessary in facilitating
the implementation of the front-of-pack labelling system.
Principle 13: Engagement with key opinion leaders (including food and
nutrition experts and the media) and consumers are essential and
should be well managed.
Principle 14: Well-resourced public education campaigns and consumer
education with special consideration of techniques to target at-
risk groups are necessary for improving nutrition literary and
consumer understanding and use of the FOPL system.
Principle 15: Baseline data should be collected to support monitoring and
evaluation of the impact on consumers and reformulation of food
products.
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7.5. Coping with micronutrient deficiencies: Flour fortification, supplementation,

safety considerations
7.5.1. Background and principles of food fortification
There are different approaches to address micronutrient deficiencies at the population level:
supplementation on the one hand and food-based measures on the other. Supplementation is the
method of choice for acute severe micronutrient deficiencies, for specific at-risk population groups
like infants and pregnant women that are under regular medical care, as well as for emergency
situations. In turn, at the long-term, food-based interventions are more efficient and sustainable. Of
these latter, diet diversification is clearly the most desirable and sustainable approach as it is aimed
at the whole food environment and at consumption patterns and because a healthy varied diet also
supplies many components besides nutrients. Importantly, it also improves the supply of energy and
macronutrients and prevents overall malnutrition. However, efficient diet diversification requires the
availability of and access to adequate amounts of nutritious high quality foods and a sufficient
purchasing power. Moreover, achieving behavioural changes is challenging. It is generally more
successful in populations with a higher education level and requires accompanying nutritional
education. It also takes some time to show effects. These aspects all limit its applicability especially
for large populations in low-income countries [Lopez Villar, 2015].
In turn, food fortification as the other food-based approach, presents an efficient, convenient and
cost-effective means to improve the intake of one or several micronutrients at population level [Allen
et al., 2006]. According to the WHO/FAO Codex Alimentarius fortification or enrichment, defined as
“the addition of one or more essential nutrients to a food whether or not it is normally contained in
the food”, serves to prevent/reduce the risk of, or correct, a demonstrated deficiency of one or more
essential nutrients in the population; to reduce the risk of, or correct, inadequate nutritional status
or intakes of one or more essential nutrients in the population; to meet requirements and/or
recommended intakes of one or more essential nutrients; to maintain or improve health; and/or to
maintain or improve the nutritional quality of foods [FAO/WHO, 2015].
The practice of food fortification dates back to the 1920s when Switzerland, where the prevalence of
goitre was high, and the USA began adding iodine to table salt. The use of naturally iodine-rich salt
had already been suggested by the French chemist Boussingault in 1831 as a method to combat
iodine deficiency [Leung et al., 2012]. In the decades between the World Wars, fortification was
extended to vitamin D in milk, vitamins A and D in margarine, and iron and B vitamins in flour. The
purpose was to prevent micronutrient deficiencies but also, especially in the case of refined flour, to
replace nutrients lost during the milling process [Nilson & Piza, 1998; Allen et al., 2006].
Further distinctions can be made with regards to the target groups and the extent of the fortification
measure as well as the legal context. The universal fortification of widely consumed staple with
 121

micronutrients allows reaching wide parts of the general population including low-income groups.
This type of fortification is the best choice to address widespread micronutrient deficiencies in
populations whose diets are mainly constituted of staple foods like in most low-income countries. On
the other hand, fortification can be targeted to foods intended for specific population groups like
complementary foods for infants, foods distributed in emergencies or supplementary foods for
athletes. Legally, two approaches are possible, mandatory and voluntary fortification that differ
mostly in the level of certainty about sustained fortification of a given food or food category over
time, the latter being higher for a mandatory regulation [Allen et al., 2006].
Mass fortification is generally government-led and regulated with clearly defined standards and is
ideally mandatory. It is most successful when a large part of the flour or grain is produced in few
large-scale mills that dispose of the necessary technical and financial means. Fortification can also be
practised on a voluntary base by allowing food manufacturers to fortify their products. This market-
driven fortification can complement government-led mandatory fortification if motivated by
corporate social responsibility commitments but may also serve commercial purposes and is not
always addressing the nutritional needs of the target population. To prevent health risks and achieve
the intended benefits from fortification, an appropriate regulatory framework of all fortification
measures by the government is required for any type of food fortification, including among others
technical standards for the addition of micronutrients and for the monitoring of the fortified
products, and rules for labelling. [Allen et al., 2006].
Technical standards provide the manufacturers with the necessary guidance on the fortification
process. They should define the foods that are required or permitted to be fortified, the nutrients to
be added and the forms of these fortificants. The choice of the fortificants is determined by their
suitability for the vehicle food, their bioavailability and their potential effects on the food matrix.
Sensory and negative physical effects (e.g. oxidation, taste deterioration etc.) should be limited. An
allowable amount or a range have to be set for each nutrient added to achieve the desired intake
level while at the same time minimizing the risk of overdosing (see below under 7.5.4).
Any fortification programme should be based on recent and comprehensive data on the nutritional
situation in the target population, its dietary patterns and nutritional requirements. The choice of the
food vehicle must be made with care to assure that the target population consumes sufficient
amounts of the fortified food [Allen et al., 2006].

7.5.2. Current situation of food fortification

Mass fortification of widely consumed staples like wheat flour, maize flour and rice, plant oils, milk
and salt is nowadays implemented in many countries worldwide.
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In 2019, 118 countries had documented mandatory legislation on salt fortification with iodine, also
termed salt iodization, and 24 practised it on a voluntary basis (see figure 23). Some countries also
add other nutrients to salt, mostly fluoride or in the case of India and Ethiopia, iron [Global
Fortification Data Exchange]. Globally, the percentage of households consuming iodized salt has
reached 86% but shows a high variability [UNICEF, 2017b]. In countries with voluntary salt iodization,
the level of implementation varies widely and may be low. Household coverage of iodized salt is
variable even in high income countries. This is particularly the case in Europe where most countries
add iodine to table salt at least on a voluntary basis but where non-iodized salt is also available. Calls
for a harmonization of legislation of salt iodization across the European Union have so far gone
unheeded. Sales of iodized salt have even been found to decline in this region recently [EU Salt].
Moreover, many countries only mandate the iodization of table salt, while the use of iodized salt for
industrially processed foods is voluntary [Ohlhorst et al., 2012]. The availability and use of iodized
salt have also declined or been identified as inadequate in other countries like Vietnam [Codling et
al., 2015] and Saudi Arabia [Al-Dakheel et al., 2018].

Figure 23 Legislative status of salt iodization in 2019 [Global Fortification Data Exchange; Delshad &
Azizi, 2017]

As of 2019, 84 countries mandatorily fortify flour and/or grain products. The majority of them, 63
countries fortify only wheat flour, 14 fortify wheat and maize flour, four countries (Nicaragua,
Panama, the Philippines and the Solomon Islands) wheat flour and rice, and only two countries (the
US and Costa Rica) fortify all three grain products. Papua New Guinea only fortifies rice (figure 24)
[FFI].
 123

Figure 24 Countries with mandatory flour and/or grain fortification in 2019

(Source of data: [FFI network http://www.ffinetwork.org/global_progress/index.php], map
generated on mapchart.net)
In grey are shown countries not mandatorily fortifying any grain or flour.

Fortification of flour and rice has shown a steady increase in the last years. In the case of wheat flour
alone, the number of countries with mandatory fortification with at least iron and folic acid increased
from 33 in 2004 to 87 in 2017 and the percentage of industrially produced flour being fortified rose
from 18 to 31% [FFI, 2017]. However, fortification has been discontinued in Egypt and is
implemented on a voluntary basis in Iraq, its implementation being hampered by the country’s
current political instability and economic hardship [WHO EMRO, 2019].
Twelve countries fortify flour or rice on a voluntary basis (see table 26). Voluntary fortification is also
common for breakfast cereals especially in industrialized countries where it has been found to
contribute significantly to micronutrient intake in children [Hennessy et al., 2013].
Iron and the B vitamins folic acid, thiamine and riboflavin are the micronutrients most frequently
added to flour whereas only four countries (Jordan, the Palestinian Occupied Territories, Mongolia
and Saudi Arabia) currently add vitamin D (see figure 25). However, the USA fortify rice with vitamin
D [FFI].
At the regional level, the WHO region of the Americas has the highest coverage of mandatory flour
and/or grain fortification with all its countries fortifying at least wheat flour. The lowest coverage is
found in the European region where only seven of 54 countries have legislation for the fortification
of grain products (see table 25). Within the European Union, only the UK mandatorily fortifies
extracted wheat flour with iron, calcium, thiamine and niacin since 1953 [UK Bread and Flour
 124

Regulations 1998; SACN, 2012]. After earlier considerations of also adding folic acid to refined wheat
flour, the UK Government has resumed plans to implement this measure starting a public
consultation on 13th June 2019 [https://www.gov.uk/government/consultations/adding-folic-acid-to-
flour/proposal-to-add-folic-acid-to-flour-consultation-document].

Figure 25 Nutrients added mandatorily to wheat flour.

Shown is the number of countries adding the nutrient (source: data from FFI network; Tazhibayev et
al., 2008; Engle-Stone et al., 2017a; EMRO, 2019)

Fortification of wheat flour in the Eastern Mediterranean Region dates back to 1978 when Saudi
Arabia began to add iron, folic acid, thiamine, riboflavin and niacin. Other countries of the region
followed and in 2019, 15 out of 22 practised fortification of wheat flour with at least iron or folic acid,
11 of them mandatorily and 4 voluntarily, making it the region with the second-highest coverage
after the Americas (see table 27). In Pakistan, mandatory fortification is only implemented in certain
provinces but its nation-wide adoption is planned. Moreover, Afghanistan where fortification of
wheat flour has so far been voluntary is planning to implement it mandatorily as well [WHO EMRO,
2019].

Table 26 Countries with voluntary fortification of flour and grain products (data from Food
Fortification Initiative Network [FFI])

Wheat flour Maize flour Rice

Afghanistan, China, Eswatini, Ethiopia, Iraq,

Malaysia, Qatar, Rwanda, Sierra Leone, Zambia Bangladesh
United Arab Emirates, Zambia
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Table 27 Legal status of flour and grain fortification by WHO region (data from Food Fortification
Initiative Network [FFI]).
WHO region Number of Number of countries with legislation for the fortification of
countries wheat flour, maize flour and/or rice
Mandatory (%) Voluntary
Americas 35 35 (100) 0
Eastern 22 11a (50) 4
Mediterranean
Africa 46 23 (50) 4
South-East 11 3b (27) 1
Asia
Western 28 8 (29) 2
Pacific
Europe 54 7 (13) 0c
a
Pakistan has mandatory fortification on some provinces with plans to extend the programme
nationwide.
b
India has set steps to implement fortification of staple foods including wheat flour, rice, oil
and milk. The use of fortified rice is mandatory in school meal programmes.
c
In the European Union, fortification of foods with vitamins and minerals is generally permitted
based on the Regulation 1925/2006.

Another group of staple foods frequently fortified is cooking oils, margarine and fat spreads that are
being used as vehicles mostly for the fat-soluble vitamin A and more recently vitamin D as well as
vitamin E in some countries. Currently (2019), 34 countries have standards for oil fortification, in 24
of which it is mandatory and voluntary in ten (see table 28). Sixteen of these countries are low-
income countries, but only four are high-income. In most industrialized countries, margarine has
been fortified, either mandatorily or voluntarily, with vitamin A and D for many decades, originally to
make it equivalent to butter [IMACE, 2004].
Vitamin A and vitamin D are also being added to other foods. The mandatory fortification of sugar
with vitamin A was first introduced in 1974 in Guatemala, Costa Rica, Honduras and Panama and is
currently still practised also in other countries of Central America [Bonilla Soto, 2016] as well as in
Zambia since 1998 [Besa, 2001]. In the USA and Canada fluid or powdered milk are fortified with
vitamin A and vitamin D since the 1930s and this is mandatory in Canada [Allen et al., 2006].
 126

Table 28 Status of oil fortification by country in 2019 (source: [Global Fortification Data Exchange
(https://fortificationdata.org)]
Country Year of introduction Legislation Nutrients added
Afghanistan 2014 Voluntary Vit. A, vit. D
Australia 2017 Voluntary Vit. E
Bangladesh 2014 Mandatory Vit. A
Bolivia 2009 Mandatory Vit. A
Burkina Faso 2010 Mandatory Vit. A
Burundi 2018 Mandatory Vit. A
China 2012 Voluntary Vit. A, vit. E
Côte d'Ivoire 2007 Mandatory Vit. A
Djibouti 2013 Mandatory Vit. A, vit. D
Ethiopia 2018 Voluntary Vit. A, vit. D
Ghana n.d.* Mandatory n.d.*
India 2018 Voluntary Vit. A, vit. D
Indonesia 2012 Voluntary Vit. A
Kenya 2018 Mandatory Vit. A
Liberia 2014 Mandatory Vit. A
Malawi 2011 Mandatory Vit. A
Mauritania n.d.* Mandatory n.d.*
Mozambique 2012 Mandatory Vit. A, vit. D
Netherlands 2014 Voluntary Vit. A, vit. D
New Zealand 2017 Voluntary Vit. E
Nigeria 2000 Mandatory Vit. A
Oman 2010 Mandatory Vit. A, vit. D
Pakistan 2018 Mandatory Vit. A, vit. D
Philippines 2004 Mandatory Vit. A
Rwanda 2018 Voluntary Vit. A
Senegal 2013 Mandatory Vit. A
Sierra Leone 2010 Mandatory Vit. A, vit. D
South Sudan 2018 Mandatory Vit. A
Tanzania 2018 Mandatory Vit. A
Togo 2013 Mandatory Vit. A
Uganda 2018 Mandatory Vit. A
Vietnam 2011 Mandatory Vit. A
Yemen 2001 Mandatory Vit. A, vit. D
Zimbabwe 2016 Mandatory Vit. A, vit. D
* Fortification of oil is mandatory in this country but standards are not available to Global
Fortification Data Exchange.

Fortified milk is also available in many other countries even though fortification is in most cases not
universal. In particular, the addition of vitamin D to foods has received increased interest recently
with the growing awareness of widespread vitamin D insufficiency in many regions of the world and
milk is considered a good vehicle in regions where it is regularly consumed. Thus, milk fortification
with vitamin D has been introduced mandatorily in Sweden and voluntarily in Finland and Norway
[Itkonen et al., 2018].
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7.5.3. Effectiveness of food fortification

Evaluating the impact of food fortification is important to see whether the intended objectives, in
most cases the improvement of the supply and status of the added micronutrient(s) as well as
associated clinical outcomes, are achieved. Based on these findings, decisions can be made on
whether the programme should be continued and on necessary changes to its implementation.
Experience from countries with longstanding practice of food fortification supports the effectiveness
of food fortification as a means to improve micronutrient intake and status and prevent deficiency
diseases at population level. This was particularly shown for iron and folic acid. Following the
introduction of flour fortification with iron, the iron status, determined through the serum ferritin
levels, was found to improve in many countries. Anaemia prevalence declined. In a study conducted
in five Central Asian countries (Azerbaijan, Kazakhstan, Tajikistan, Uzbekistan, and Mongolia), the
frequency of anaemia in children aged 2-15 years decreased in four of the countries and in women of
child-bearing age (15-49 years) in three of the countries. Ferritin levels increased in children in
Kazakhstan and Tajikistan, and in women in Azerbaijan and Tajikistan [Tazhibayev et al., 2008]. Iron
status of preschool children (1-7 years) and women of child-bearing age (15-45 years) also improved
significantly after the introduction of wheat and maize flour, rice and milk fortification with iron, folic
acid and other B vitamins in Costa Rica. The prevalence of anaemia declined [Martorell et al., 2015].
However, fortification with iron has predominantly shown effects on ferritin status while the
effectiveness to reduce anaemia prevalence was lower. This was also the conclusion drawn from a
pilot intervention in two Iranian provinces: Two years after the introduction of flour fortification with
iron and folic acid, the mean level of ferritin in women aged 15-49 years increased significantly and
the prevalence of low ferritin levels declined significantly. However, the mean haemoglobin level did
not increase nor did the prevalence of anaemia decrease [Sadighi et al., 2009]. The fact that anaemia
is not only due to iron deficiency but can have a range of other causes is a possible reason for this
and other similar findings [Pachón et al., 2015]. An assessment of the consequences of ceasing the
fortification of wheat flour with iron, calcium, thiamine and niacin in the UK concluded that there
would be a high risk of negative effects on iron intake in girls aged 11-18 years and women aged 19-
64 years leading to higher prevalence of inadequacy in these groups. Based on data from the
National Diet and Nutrition Study 2008-2010, it was found that bread and other flour-containing
products supply about 20% of dietary iron to adults and about 25% to 11-18 year-old children [SACN,
2012].
In a systematic review of 27 studies from nine countries, folic acid fortification of flour was followed
by a significant decline in the incidence of neural tube defects (NTDs) in 15 of the included studies.
The greatest reductions, amounting to 50% and more, were found in Costa Rica, Canada, Argentina
and Chile and the smallest in the USA [Castillo-Lancelotti et al., 2013]. The impact of flour
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fortification with folic acid on NTDs was more recently reconfirmed in a Brazilian study using newer
data. In Australia, where mandatory flour fortification with folic acid was introduced in 2007, it was
also associated with a reduction in NTD incidence particularly in the Aborigines population in whom
it had been higher, thus abolishing the former disparity [D’Antoine & Bower, 2019]. Flour fortification
with folic acid in the Iranian province of Golestan was also associated with significantly higher daily
folate intake and serum folate in women aged 15-49 years. The prevalence of folate deficiency
decreased and the incidence of NTDs declined significantly [Abdollahi et al., 2011].
A number of studies have also shown successes with the fortification of different foods with vitamin
D. A meta-analysis of 16 studies from twelve countries showed a dose-dependent rise in serum
25(OH)D3 levels [Black et al., 2012]. Most of these were interventions to test the suitability of a given
vehicle, the fortificant and the applicability of the fortification. The effectiveness of the mandatory
fortification of milk and plant-based alternatives in Finland since 2003 is supported by the significant
post-intervention increase in mean serum 25(OH)D3 concentration at population level [Jääiskelainen
et al., 2017]. In Canada, higher consumption of fortified milk was associated with higher serum
25(OH)D3 concentrations across all age groups [Janz & Pearson, 2013]. Wheat flour or bread are
generally considered good vehicles due to their wide-spread consumption while the use of milk is
limited by the presence of lactose intolerance in a target population. In a study from Denmark, the
consumption of bread and skim milk fortified with vitamin D3 during six winter months led to a higher
vitamin D intake in the intervention group and prevented the seasonal fall in serum 25(OH)D3 levels
and the associated rise in parathormone compared to the control group consuming unfortified bread
and milk [Madsen et al., 2013]. Consumption of fortified bread also improved the vitamin D status in
a sample of Finnish women and this was unaffected by the bread’s content of dietary fibre [Natri et
al., 2006]. Model calculations from the UK and Germany suggested the addition of about 10 µg/100 g
flour or bread as sufficient to reach vitamin D adequacy while preventing excessive intake levels
[Allen et al., 2015; Brown et al., 2013].
Zinc, a major critical micronutrient worldwide, is currently mandatorily added to flour in 27 countries
and voluntarily in six [Global Fortification Database; Tazhibayev et al., 2008]. A meta-analysis of eight
intervention studies from one high-income and seven middle-income countries found that the
consumption of foods (mostly wheat flour-based) fortified with zinc had a small but significant
positive effect on serum zinc levels. However, this was only observed when zinc was added alone to
the food, not in combination with other minerals and trace elements that would competitively hinder
the absorption of zinc [Shah et al., 2016]. Cameroon and Fiji are two countries that mandate the
addition of zinc to wheat flour. Surveys on the effects of fortification showed positive effects on zinc
status in both countries with increases in mean serum or plasma Zn levels and decreases in the
prevalence of inadequate status [Schultz & Vatucawaqa, 2012; Engle-Stone et al., 2017b].
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7.5.4. Safety aspects

The dosage of nutrients is an important determinant of the effectiveness of food fortification. The
amount added to a food must be sufficiently high to ensure that the intake by the target population
is meeting the intended level so that the risk of inadequacy is as low to become acceptable, the focus
being on population groups most at risk of deficiencies. However, excessive intake levels must also
be avoided to prevent any potential health risks and make sure that the fortification programme
achieves the intended positive health outcomes.
The WHO in its Guidelines on food fortification with micronutrients recommends basing the setting
of the fortificant dosage on the estimated average requirement (EAR) of the target population [Allen
et al., 2006]. The EAR is defined as “the median usual intake value that is estimated to meet the
requirement of half the healthy individuals in a life stage and gender group” based on a specific
adequacy criterion that is derived from the scientific literature taking into account various health
parameters. This definition implies that this intake level does not meet the nutrient requirements of
the other half of the specified group. The EAR is used to derive the recommended daily intake level
of a given nutrient (Recommended Dietary Allowances (RDAs), Recommended Nutrient Intakes
(RNIs), Population Reference Intakes (PRIs) etc.) that are defined as the level of intake meeting the
requirements of most of the specific population i.e. of 97-98%. It corresponds to the EAR + 2 SDs
assuming a normal distribution of the population’s nutrient requirements [IOM, 2000].
The EAR can also be used to assess the adequacy of a population’s intake of a given nutrient provided
that the distributions of the intake and the requirements are symmetrical. In this case, the
proportion of individuals consuming less than the EAR is equal to the prevalence of inadequacy [IOM,
2000]. Apart from a few exceptions (iron, iodine, folic acid and vitamin D), this EAR cut-point method
is the approach recommended by the FAO for setting the target intake level and the amount of
nutrient added to the fortified food for nutrients. The acceptable prevalence of inadequate and
excessive intakes is generally considered to be 2–3%, so that 97-98% of the population have
adequate intakes. Knowing the range of usual intakes and the average consumption amount of the
vehicle food allows calculating the level of fortificant that must be added to move the nutrient intake
distribution so that the intended level of inadequacy is reached [Allen et al., 2006].
On the other hand, the risk of excessive intakes above the tolerable upper level of intake (UL) of the
specific micronutrient should also be minimized. Excessive intakes of certain micronutrient do not
necessarily result in toxicity but can have subtle negative effects on health and interfere with the
absorption, activity and metabolism of other micronutrients leading to an imbalance [Meltzer et al.,
2003]. Risk is particularly high for nutrients with a narrow safety range i.e. a small difference
between the RNI and the UL (see table 29). High consumers of the food to be fortified would be at
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risk to get too much of the added nutrient, especially when their intake from other sources is already
high before the fortification. Intake of the fortificant must therefore be estimated for all levels of
consumption of the vehicle food.
Some examples of negative effects of universal fortification with iron have been reported. A high
prevalence of iron overload in the Danish population due to a high occurrence of hereditary
hemochromatosis led to cessation of mandatory fortification of flour with 30 mg elementary iron per
kg flour practised in this country from 1954 to 1987. It was shown that the iron status did not decline
following this step even though iron deficiency is found in some at-risk groups like menstruating
women [Osler et al., 1999; Milman et al., 2003]. However, general fortification of staple foods is not
considered the appropriate solution in Denmark where voluntary fortification of foods with various
micronutrients is also subjected to tight control including the setting of minimum and maximum
contents and even the banning of imports of some fortified foods not complying with the law
[Fødevarestyrelsen, 2019]. In Iran, a pilot project to study the effects of flour fortification with iron
showed an increase in markers of oxidative stress in non-anaemic men after 16 weeks of the
intervention [Pouraram et al., 2012].
If the amount consumed of the vehicle foods shows a wide variability, the level of fortificant that
would be needed to reach the desirable intake in the lowest consumers would put the high
consumers at an inacceptable risk of excessive intake. In this case, it might be preferable to choose a
lower fortification dosage and select one or more additional food vehicles that are consumed by
persons at risk of inadequate intake of the nutrient to be added [Allen et al., 2006].

Table 29 Safety categories of micronutrients based on the recommended nutrient intake level (RNI)
and the tolerable upper intake kevel (UL) [Meltzer et al., 2003]
Safety range (ratio of UL to RNI) Examples
Category A Narrow (≤5) Vitamin A, folic acid, nicotinic acid, all minerals
Category B Medium (5-100) Vitamin D, vitamin B6, vitamin C, vitamin E
Category C Large (>100 or no adverse effects Vitamin K1, thiamine, riboflavin, pantothenic
known) acid, vitamin B12, biotin

For safety assessment, all potential sources of a given nutrient have to be considered, also including
supplements. This can be challenging when many different products are fortified, especially on a
voluntary basis, and consumed simultaneously. Therefore, setting maximum levels is especially
important when fortification is market-led. Additionally, some foods may be consumed in high
amounts by population groups for which the UL is lower than for other groups such as young children
in the case of breakfast cereals. This issue is also held up against universal fortification of flour with
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folic acid that would benefit women of childbearing age but might be detrimental to older adults
suffering from vitamin B12 deficiency by hindering the diagnosis of anaemia caused by cobalamin
deficiency and exacerbating neurological and cognitive disorders [Selhub & Rosenberg, 2016].
Therefore, any fortification programme has to be preceded by a thorough situation analysis and
safety assessment to ensure its effectiveness.

7.5.5. Monitoring and evaluation

While the careful preparation of a food fortification programme is crucial, it is not the only
determinant of the programme’s effectiveness. Evaluation of the programme and regular monitoring
of the implementation and compliance with the standards are important parts that should already be
included in the planning of the programme. Monitoring involves the ongoing collection and review of
data on programme implementation activities to control the quality of the fortified products and
their availability and accessibility to consumers, allowing the identification of problems and
noncompliance and providing the basis for corrective actions.
Evaluations of a food fortification programme serve to assess its effectiveness and impact on the
target population and to find out whether the objectives like higher intake of nutrients, better
nutritional status, improved health or functional outcomes are met. For obvious reasons, a
programme should only be evaluated after its full implementation and when it is operating as
planned. This premise requires appropriate monitoring.
Monitoring at production sites, retail stores and customs warehouses for imported foods makes sure
that food vehicles are fortified according to the quality and safety standards and regulations. This
regulatory monitoring is done by external regulatory authorities as well as by the producers
themselves (internal monitoring). In addition, monitoring is also conducted at household level to
assess the access of targeted individuals and households to fortified food of the expected quality
(service provision), the actual purchase and consumption of the fortified food by the target
population (service utilization), and whether consumed amounts and consumption frequency of the
fortified food are appropriate (coverage). Data obtained in this household monitoring also serves to
evaluate the impact of the programme and its effectiveness. Figure 26 shows a model of the
monitoring and evaluation process proposed by the WHO/FAO [Allen et al., 2006].
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Figure 26 Example of a system for the monitoring and evaluation of food fortification programmes
[Allen et al., 2006]

The frequency and intensity of monitoring depends on the compliance and technical performance of
the production unit as determined by previous monitoring. They have to be increased when
problems are discovered until these latter are solved [Allen et al., 2006].

7.5.6. Challenges and obstacles to food fortification and how to address them
Experience with food fortification from various countries reveals some common challenges that can
impede successful programme implementation [Luthringer et al., 2015; Osendarp et al., 2018]:
 Low awareness of the health impact of micronutrient deficiencies and low priority accorded
to addressing the problem;
 limited evidence of the programme’s impact and cost-effectiveness due to a lack of
evaluation and research;
 lack of regulatory clarity and of technical guidance;
 inadequate information on food consumption, nutrient status and the prevalence of
micronutrient deficiencies that are required to inform public policy-making and to monitor
the programme’s effectiveness;
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 insufficient coordination and cooperation between agencies and government bodies from
different fields as well as the private sector involved in the implementation and monitoring
of the programme;
 lack of the necessary financial and other resources for sustainable funding (e.g. for the
provision of the premix and the technical equipment and for maintaining monitoring);
 lack of human resources, technical equipment and know-how and low capacity to instruct
and train food producers and managers as well as food inspectors;
 predominance of decentralised small-scale production sites (cereal and oil mills etc.) that
hampers coverage expansion of fortification;
 high dependence on imported foods that have to be controlled and fortified as appropriate;
 opposition from interest groups;
 failure of regulatory agencies to ensure compliance.

Problems concerning the compliance with the standards have repeatedly been reported from various
countries where mandatory fortification is practised. Data from the GAIN Fortification Assessment
Coverage Toolkit (FACT) based on surveys conducted between 2013 and 2017 in 16 low- and middle-
income countries practising food fortification show gaps in the coverage of fortification programmes
especially in the case of wheat and maize flours [Keats, 2019]. In Palestine, only 45.1 % of the flour
samples collected for the Palestinian Micronutrient Study 2013 were fortified with iron as revealed
by a positive spot test. There was a large discrepancy between provinces with 88.9% of the samples
fortified in the West Bank but only 11.1% in the Gaza Strip. Moreover, in the latter, 75 % of the
samples tested positively contained inadequate amounts of iron with 70% being excessively fortified.
Vitamin A fortification was also unsatisfactory in the Gaza Strip with only 55% of the samples being
positively tested compared to 96 % in the West Bank [State of Palestine, 2014].
In Zambia, only 11.3% of sugar samples obtained in one district were adequately fortified with
vitamin A and 38.7% were not fortified at all [Greene et al., 2017].
In the case of iodized salt, the proportion of adequately fortified samples showed great variability
ranging from 6.2% in Niger to 97.0% in Uganda [Knowles et al. 2017]. Inadequate salt iodization was
also observed in Palestine where only about 6 % of the samples were adequately fortified and less
than 3 % in the Gaza Strip. In most cases, the content was lower than the mandated level while less
than 0.5% were excessively fortified [State of Palestine, 2014]. Low compliance is not limited to low-
income countries as revealed by a study from Saudi Arabia that found excessive levels of iodine in
about 71% of the salt samples and a mean content that was higher than the permitted maximum
(50.4 ppm vs 40 ppm) [Al-Dakheel et al., 2012].
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However, high costs of the premix were the dominant barrier to fortification named by producers
(75% of respondents) [Luthringer et al., 2015]. Costs of fortification (for the premix, the technical
equipment etc.) can place a high burden particularly on small-scale producers thereby limiting their
competitiveness, and if passed on to consumers make the fortified products inaccessible to low-
income groups that may the ones requiring them most. High costs may also tempt manufacturers to
deliberately underfortify their products, particularly when external monitoring is insufficiently
performed. This can only be prevented by providing incentives for compliance and strong and
consistent penalties for violations. Adequate regulatory documents and guidelines to steer the
fortification process and guide producers and controllers are indispensable but are often lacking or
insufficient as shown by a recent review on grain fortification legislation, standards, and monitoring
documents in 77 countries [Marks et al., 2018].
One key to success is a functioning cooperation between the public and private sectors as well as
engagement from consumers, civil society, academia, NGOs and donors to enable a holistic approach
to food fortification. A way to bring relevant stakeholders together is via the establishment of
coordination entities like the National Fortification Alliances (NFAs) that are operating in a number of
countries to facilitate the harmonisation of food fortification activities. NFAs have the role of neutral
supervisors that guide the establishment, improvement and maintenance of the food fortification
programme. In this way, the cooperation between the government, private sector, NGOs and the
civil society towards a common public health goal is facilitated. By providing the leadership and
managing the available budget, NFAs can help to overcome difficulties arising from diverging
interests of individual sectors, financial constraints and lack of concern for the matter.
Support to national fortification programmes also comes from international partners including non-
governmental technical agencies (the Food Fortification Initiative (FFI), the Global Alliance for
Improved Nutrition (GAIN), Helen Keller International (HKI), the Iodine Global Network (IGN), the
Micronutrient Forum, the Micronutrient Initiative (MI) and others) and UN Agencies (UNICEF, FAO,
WFP and WHO), academia, donors (governmental organizations, the World Bank, the European
Commission, Bill & Melinda Gates Foundation and others), and private sector players [Hoogendoorn
et al., 2016].

Food fortification, if appropriately regulated and implemented especially on a mandatory basis and
of widely consumed staple foods, provides a cost-effective approach to address widespread
micronutrient deficiencies in low-income and lower middle-income countries and can also contribute
to better micronutrient supply in higher income settings. However, it should always be considered a
complementary strategy for improving micronutrient status that has to be accompanied by policies
to modify dietary habits and improve diet quality.
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8. Nutrition in emergencies

8.1. Emergencies and their impact on food and nutrition security

According to the definition of the World Food Programme emergencies are categorized “as urgent
situations in which there is clear evidence that an event or series of events has occurred which
causes human suffering or imminently threatens human lives or livelihoods and which the
government concerned has not the means to remedy; and it is a demonstrably abnormal event or
series of events which produces dislocation in the life of a community on an exceptional scale” [WFP,
2005].
Emergencies arise from a number of causes including natural disasters like floods, extreme weather
events, earthquakes etc., conflicts and wars usually involving population displacement, famines
resulting from drought, crop failures, pests or diseases, as well as political and economic crises.
However, emergencies often cannot be ascribed to one single decisive incident but develop from a
series of events.
Emergencies pose a threat to food security by decreasing the availability of food and the access to it,
by disrupting health systems and by destroying water and sanitation systems. Additionally, during
political crises and conflicts, nutrition problems are often not adequately addressed. The
discrimination of certain ethnic groups also limits their access to food and health care [FAO, 2017].
Over the last years, the numbers of undernourished persons worldwide have been rising again after a
period of steady decline [FAO, 2018]. The last decade has also seen an increase in conflicts in many
regions of the world and an overall decline in the Global Peace Index despite a small improvement in
2019 [IEP. GPI, 2019]. At the same time, weather extremes and environmental deterioration resulting
from climate change has become more frequent. Together with the global economic slowdown, they
have led to reductions in food security and contributed to infectious disease outbreaks and
undernutrition even in more peaceful regions. Both, conflicts and natural disasters appear as key
drivers of the recent deterioration of food security especially when they coincide [FAO, 2017; FAO,
2018]. In 2018, almost two thirds (65%, 74 million) of the acutely undernourished people worldwide
lived in countries afflicted by conflicts and violence and these countries also have a higher prevalence
of malnutrition and food insecurity. 29 million people (26%) faced hunger due to climate and natural
disasters. In both cases, Africa was most affected [FSIN, 2019].

The Integrated Food Security Phase Classification (IPC) is a set of protocols for situation analysis in
food security assessment to classify the severity and causes of food insecurity and provide evidence-
based, actionable knowledge to decision makers (see tables 30 and 31). It also serves to enable
technical consensus among the various stakeholders involved in humanitarian response. In
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accordance with Action contre la Faim (ACF), the IPC defines famine as “the absolute inaccessibility
of food to an entire population or sub-group of a population, potentially causing death in the short
term” [IPC, 2008].

Table 30 Integrated food security phase classification (IPC) (modified from [IPC, 2008]).
Phase classification Key reference outcomes
1A Generally food secure CMR < 0.5/10,000/day
Wastinga < 3%
Stuntingb < 20%
Food access/availability: usually adequate (> 2,100 kcal/cap./d),
1B Generally food secure
stable
Dietary diversity: consistent quality and quantity
Water access/availability: usually adequate (> 15 l/cap./d), stable
2 Moderately / CMR < 0.5/10,000/day
borderline food U5MR < 1/10,000/day
insecure Wastinga > 3% but < 10%
Stuntingb > 20%
Food access/availability: borderline adequate (2,100 kcal/cap./d),
unstable
Dietary diversity: chronic dietary diversity deficit
Water access/availability: borderline adequate (15 l/cap./d),
unstable
3 Acute food and CMR 0.5-1/10,000/day
livelihood crisis U5MR 1-2/10,000/day
Wastinga 10-15%, higher than usual, increasing
Food access/availability: lack of entitlement; 2,100 kcal/cap./d via
asset stripping
Dietary diversity: acute dietary diversity deficit
Water access/availability: 7.5-15 l/cap./d via asset stripping
Disease: epidemic, increasing
4 Humanitarian CMR 1-2/10,000/day, >2x reference rate, increasing
emergency U5MR > 2/10,000/day
Wastinga > 15%, higher than usual, increasing
Food access/availability: severe entitlement gap; unable to meet
2,100 kcal/cap./d
Dietary diversity: Regularly ≤ 3 main food groups consumed
Water access/availability: < 7.5 l/cap./d for human usage only)
Disease: pandemic
5 Famine/Humanitarian CMR >2/10,000/day
catastrophe Wastinga > 30%
Food access/availability: extreme entitlement gap; much > 2,100
kcal/cap./d
Water access/availability: < 4 l/cap./d)
Disease: pandemic
a
Defined as weight-for-height <-2 z-scores
b
Defined as height-for-age <-2 z-scores
CMR: crude mortality rate; U5MR: under-5 y mortality rate
Table 31 IPC acute food insecurity classification at area and household level (modified from [IPC, 2012]
Phase 1 Phase 2 Phase 3 Phase 4 Phase 5
Minimal Stressed Crisis Emergency Famine
Description at area >4/5 households (HHs) ≥1/5 HHs face ≥1/5 HHs face food ≥1/5 HHs face large ≥1/5 HHs face extreme
level able to meet essential minimally adequate consumption gaps with food consumption gaps, lack of food and other
food and non-food food consumption and high/above usual acute very high acute basic needs where
needs without engaging inability to afford some malnutrition OR malnutrition and excess starvation, death, and
in atypical, essential non-food are marginally able to mortality destitution are
unsustainable expenditures without meet minimum food OR evident* even with any
strategies to access unusual coping needs only through extreme loss of humanitarian
food and income, strategies even with depletion of livelihood livelihood assets assistance.
including any reliance any humanitarian assets even with any causing food
on humanitarian assistance humanitarian consumption gaps in
assistance assistance the short term, even
with any humanitarian
assistance
Description at HH group able to meet Even with any Even with any Even with any Even with any
household level essential food and non- humanitarian humanitarian humanitarian humanitarian
food needs without assistance: assistance: assistance: assistance:
engaging in atypical, HH group has minimally HH group has food HH group has large HH group has an
unsustainable adequate food consumption gaps with food consumption gaps extreme lack of food
strategies to access consumption but is high or above usual resulting in very high and/or other basic
 138

food and income, unable to afford some acute malnutrition; acute malnutrition and needs despite full
including any reliance essential non-food OR excess mortality; employment of coping
on humanitarian expenditures without is marginally able to OR strategies. Starvation,
assistance. engaging in irreversible meet minimum food extreme loss of death, and destitution
coping strategies needs only with livelihood assets that are evident.
accelerated depletion leading to large food
of livelihood assets that consumption gaps in
will lead to food the short term.
consumption gaps.
Urgent action required to
Priority response Action required to build Action required to Protect livelihoods, Save lives and Prevent widespread
objectives resilience and reduce reduce disaster risk and reduce food livelihoods mortality and total
disaster risk protect livelihoods consumption gaps and collapse of livelihoods
reduce acute
malnutrition
* Evidence for all three criteria of food consumption, wasting, and CDR is required to classify Famine.
 8.2. Global commitment to nutrition in emergencies
Ensuring adequate nutrition in emergencies is a central objective of the recent initiatives to end
hunger and improve the global nutrition situation. In particular, complex emergencies arising from
internal or external conflicts require an international response extending beyond the mandate or
capacity of any single agency.
In the Rome Declaration of the ICN2 the impact of conflict and post-conflict situations, humanitarian
emergencies and crises on food security was recognized and it was reaffirmed that food should not
be used as an instrument for political or economic pressure. Refugees, displaced persons and war-
affected persons are recognized among the most nutritionally vulnerable groups, and there was a
commitment to increase investments for effective interventions and actions to improve people’s
diets and nutrition including in emergencies [ICN2, 2014a]. The ICN2 Framework for Action includes
recommendations to incorporate nutrition objectives in humanitarian assistance safety net
programmes, protect breastfeeding, and integrate disaster and emergency preparedness in
programmes and policies [ICN2, 2014b]. The UN Decade of Action on Nutrition 2016-2025 specifically
addresses the increasing number of emergencies, natural disasters, conflicts and protracted crises
affecting the nutritional status of vast populations [UN, 2017].

8.3. The UN’s role in emergencies

Providing humanitarian aid is one of the purposes of the United Nations according to article 1 of the
UN Charter. Emergency responses are coordinated by the Office for the Coordination of
Humanitarian Affairs (OCHA) of the UN Secretariat that originated from the Department for
Humanitarian Affairs (DHA) in 1998. The OCHA acts through the Inter-Agency Standing Committee
(IASC), made up of UN agencies involved in the providing of emergency relief. This allows a
coordinated, system-wide approach to humanitarian relief that is essential for a rapid and efficient
help to people in need. The IASC is headed by the Emergency Relief Coordinator (ERC) who is the
Under Secretary General for Humanitarian Affairs. The ERC oversees all humanitarian assistance
activities of the UN and appoints the Humanitarian Coordinators (HCs) in countries affected by a
disaster or conflict. At country level, the assessment of the situation, the identification of the needs
of the affected population, the setting of priorities, and the estimation of the local response capacity
fall into the responsibility of the HC and the Humanitarian Country Team (HCT) [OCHA, 2019].
A number of UN entities play important roles in humanitarian assistance including the United Nations
Development Programme (UNDP), the United Nations Refugee Agency (UNHCR), the United Nations
Children's Fund (UNICEF), the World Food Programme (WFP) and the World Health Organization
(WHO) among others. They also are Cluster Lead Agencies (see below).
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Figure 27 Chronology of the UN’s Humanitarian System (modified from [OCHA, 2019])

8.3.1. The Humanitarian Reform

The perception of considerable variability in the humanitarian response to various crises and its
frequent inability to meet the basic needs of affected populations appropriately stimulated two
major reforms of the UN’s humanitarian coordination system, starting with an independent
assessment of the global humanitarian system by the ERC. This Humanitarian Response Review (HRR)
that was conducted from February to June 2005 intended as an evaluation of the humanitarian
response capacities of the UN, NGOs, Red Cross/Red Crescent Movement and other key
humanitarian actors including the International Organization for Migration (IOM). Besides well-
known and long-standing gaps that the humanitarian system continuously fails to address, main
findings were an unpredictable response capacity, a poor coordination and a proliferation of
partnerships, an insufficient accountability as well as inconsistent donor policies and
recommendations were made on how to address them [UN ERC, Under-Secretary-General for
Humanitarian Affairs, OCHA, 2005].
These outcomes lead to a reform of the UN humanitarian system composed of three interrelated
measures aimed at improving humanitarian response:
To improve coordination, a Cluster Approach was adopted, defining groups of both, UN and non-UN,
humanitarian organizations assigned by the Inter-Agency Standing Committee (IASC) to specific
sectors of humanitarian action like water, food security or shelter, each having their clear
responsibilities and being accountable to the UN Humanitarian Coordinator. At the global level,
 141

cluster leads and co-leads have been designated for eleven sectors that experienced inadequate
leadership and cooperation between humanitarian actors in emergencies in the past. In turn, the
Cluster Approach is not applied to sectors where leadership and accountability among international
humanitarian actors are already well established like refugees led by UNHCR (figure 28). In this way,
coordination and partnership among humanitarian stakeholders can be organized to ensure an
effective, efficient, reliable and accountable humanitarian response that meets the needs of affected
people in an inclusive manner, respecting humanitarian principles. The Cluster Approach applies to
all humanitarian crises caused by natural disaster or conflict but not to refugee situations that are
coordinated by the UNHCR alone [IASC website; IASC, 2015].

Core functions of the Clusters [IASC, 2015]

 Support service delivery by providing a platform for agreement on approaches and
elimination of duplication
 Informing strategic decision-making of the HC/HCT for the humanitarian response
through coordination of needs assessment, gap analysis and prioritization
 Planning and strategy development including sectoral plans, adherence to standards
and funding needs
 Advocacy to address identified concerns on behalf of cluster participants and the
affected population
 Build national capacity in preparedness, contingency planning and response where
needed and where capacity exists within the cluster
 Monitoring and evaluation of the implementation of cluster strategy as well as on
the cluster results, recommending corrective action where necessary

The Cluster Approach acts at the global and the national level. Global Cluster Leads are designated to
strengthen system-wide preparedness and build technical capacity for the response to humanitarian
emergencies and to ensure predictable leadership and accountability in all main sectors or areas of
activity. At the country level, it allows for a more coherent and effective response by coordinating
groups of agencies, organizations and NGOs in a strategic manner across all key sectors or areas of
activity, each sector/cluster having a clearly designated lead in agreement with the Humanitarian
Coordinator and the Humanitarian Country Team [IASC, 2006; IASC, 2015].
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Figure 28. Global cluster lead agencies [IASC, 2015]

Country Level Cluster Leads have a number of responsibilities for which they are accountable to the
Humanitarian Coordinator (see table 32). Lead agencies must also ensure that humanitarian actors
build on local capacity and that cooperation with government and local authorities, state institutions,
civil society and other local stakeholders are maintained.
The aim of clusters at country level is to support and strengthen existing national capacity, not to
replace it or undermine national authority. They should contribute to sustainable coordination
mechanisms for the respective sector by building on and strengthening national and local
development initiatives. The coordination of a humanitarian response involving several agencies and
actors with potentially differing mandates and capacities requires a broad, documented consensus.
Roles and responsibilities of the different players must be clearly defined in a Memorandum of
Understanding (MoU) or Letter of Understanding (LoU).
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Table 32 Responsibilities of cluster leads at country level [IASC, 2006]

 Inclusion of key humanitarian partners

 Establishment and maintenance of appropriate humanitarian coordination mechanisms
 Coordination with national/local authorities, State institutions, local civil society and other
relevant actors
 Participatory and community-based approaches
 Attention to priority cross-cutting issues (e.g. age, diversity, environment, gender, HIV/AIDS
and human rights)
 Needs assessment and analysis
 Emergency preparedness
 Planning and strategy development
 Application of standards
 Monitoring and reporting
 Advocacy and resource mobilization
 Training and capacity building
 Provision of assistance or services as a last resort

Cluster activation depends on the emergency situation and the response capacities of the national
and international actors involved and therefore it has to be based on a thorough assessment and
analysis of the situation and the causes underlying the emergency. It is only intended for sectors or
thematic areas with insufficient existing coordination mechanisms [IASC, 2006; IASC, 2015].

The Global Nutrition Cluster

The global nutrition cluster is led by UNICEF and includes 34 United Nations (UN) agencies, non-
governmental organisations (NGOs), donor, and academic/research partner organisations. Although
UNICEF usually is the lead agency at the country level too with WHO, WFP, FAO, UNHCR and NGOs as
partner agencies, the composition may vary depending on the specific situation. Important criteria in
the choice of a lead agency include its local operational presence, its capacity to provide for staffing
needs and cover the associated costs, its capacity in fundraising and resource mobilization, its
working relationship with the national authority and its accountability [UNICEF, 2013b].

In light of the need for improved global funding for humanitarian activities, the Central Emergency
Response Fund (CERF) was established building on the earlier Central Emergency Revolving Fund
dating from 1991. Donations from various governments and the private sector are pooled and
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managed by the ERC on behalf of the Secretary General to enable timely and reliable humanitarian
assistance to those affected by crises. CERF grants amount to up to US$450 million per year and are
divided between two windows: one for Rapid Responses to emergencies and one for Underfunded
Emergencies (especially in the case of protracted crises). By mid-2019, the total contributions to the
CERF have reached US$ 6 billion since its creation [Development Initiatives, 2011; CERF website
https://cerf.un.org].
To respond to the need for improved leadership, the role of the HC was redefined and strengthened.
This involves the institutionalization of the improved HC system and setting standards for the
identification, appointment and training of HC candidates and also of the Resident Coordinators (RC)
acting as HC in many countries.

8.3.2. The Transformative Agenda

In light of persisting weaknesses in the multilateral humanitarian response and building on lessons
learned during large-scale emergencies, the IASC saw the need for a further reform, summarized as
the “Transformative Agenda” (TA). This set of actions on which the IASC Principles agreed in
December 2011 targets the three areas of 1) leadership, 2) coordination structures, assessment of
needs, planning and monitoring, and 3) accountability. The TA commits humanitarian agencies to a
reform process that aims at making humanitarian responses more effective, predictable, accountable
and responsible and at promoting partnership. Improving the quality of leadership and strategic
planning, and strengthening the coordination between IASC actors like the UN agencies,
international and national NGOs are further objectives of the TA [UNHCR Emergency Handbook].
A central part of the TA is the declaration of a ‘Level 3' (L3) emergency leading to an IASC
Humanitarian System-Wide Emergency Activation. L3 emergencies are major sudden-onset
humanitarian crises, caused by natural disaster or conflict, requiring a rapid, concerted system-wide
mobilization and response, as determined collectively by the IASC Principals under the leadership of
the ERC, to enable accelerated and scaled-up assistance and protection over a short and focused
duration. Although initially intended for sudden onset emergencies, L3 activations were in the
following often applied to large-scale protracted crises and sometimes even maintained over a
number of years. This prompted the IASC Principals to endorse new system-wide emergency
activation procedures renamed Humanitarian System-Wide Scale-Up Activation in November 2018.
Scale-Up activations are considered exceptional measures that are only applied for a time-bound
period of up to six months to respond to critical sudden-onset and/or rapidly deteriorating
humanitarian situations the gravity of which justifies the mobilization of system-wide capacities and
resources beyond standard levels. To determine the need for a Scale-Up Activation five criteria are
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assessed: scale, complexity, urgency, capacity, and risk of failure to deliver at scale to affected
populations [IASC website; UNHCR Emergency Handbook].
A set of protocols was developed to guide the implementation of the collective humanitarian
response to L3 emergencies (see table 33). These include the Humanitarian Programme Cycle, the
Inter-Agency Rapid Response Mechanism, the Reference module for cluster coordination at country
level, the Common Framework for Capacity Development for Emergency Preparedness and others.
The declaration of an L3 emergency entails the establishment of a Humanitarian Country Team (HCT)
and the deployment within 72 hours of a Senior/Emergency Humanitarian Coordinator for up to 3
months. The empowerment of the HC is a central element of the L3 response, enabling the HC to
make timely decisions without consensus within the HCT in the areas of overall priority setting,
resource allocation, cluster coordination and performance monitoring. To ensure emergency
response preparedness, a standby-list of senior, experienced and trained L3 capable staff for
immediate deployment is maintained to support the HCT in the implementation of a humanitarian
response [UNICEF, 2018c; IASC website].

Table 33 The IASC Protocols [UNICEF, 2018c; IASC website]

Concept Paper on "Empowered Leadership", 2014

Inter-Agency Rapid Response Mechanism (IARRM), 2013
Humanitarian System-wide Emergency Activation: Definitions and
Concept Papers
Procedures, 2012
Responding to Level 3 Emergencies: What "Empowered Leadership" Looks
Like in Practice, 2012

Accountability to Affected Populations: The Operational Framework, 2013

Frameworks
Common Framework for Preparedness, 2013

The Humanitarian Programme Cycle, Version 2.0, July 2015

Multi-Sector Initial Rapid Assessment (MIRA): Guidance, Revised July 2015
Reference Modules
Cluster Coordination at Country Level, Revised July 2015
Emergency Response Preparedness (ERP), Draft for Field Testing, July 2015

IASC Letter IASC Letter - Transformative Agenda, 2013

The negative impact of protracted humanitarian crises on nutrition security and their role in the
recurrence of famines in the affected countries was addressed in a Guidance Note for UN
Humanitarian Coordinators from August 2017 on Integrated multi-sectoral nutrition actions to
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achieve global and national nutrition-related SDG targets, particularly in fragile and conflict affected
states [UNSCN, GNC, SUN Movement, 2017]. It was noted that the focus on immediate lifesaving
interventions over a limited time during emergencies, a common lack of cooperation and
coordination between different actors and an insufficient involvement of national or local
stakeholders impede the tackling of multi-sectoral humanitarian issues like nutrition. To achieve
national nutritional targets, HCs are therefore advised to:
 Facilitate a multi-sectoral approach to address malnutrition in the humanitarian context
 Strengthen inter-cluster coordination
 Strengthen the accountability framework for nutrition
 Advocate for more long-term and integrated funding
 Leverage private sector for better nutrition outcomes

8.3.3. The World Humanitarian Summit

From 23rd to 24th May 2016, the first-ever World Humanitarian Summit was held in Istanbul, Turkey,
attended by about 9,000 participants from 173 UN Member States, including 55 Heads of
Government, 700 national and international NGOs, 130 representatives of the United Nations
agencies and other stakeholders. The Summit was intended as a global call to action by the then
United Nations Secretary-General Ban Ki-moon and pursued three main goals:
 to re-inspire and reinvigorate a commitment to humanity and to the universality of
humanitarian principles;
 to initiate a set of concrete actions and commitments aimed at enabling countries and
communities to better prepare for and respond to crises, and be resilient to shocks;
 to share best practices which can help save lives around the world, put affected people at
the center of humanitarian action, and alleviate suffering [Agenda for Humanity, 2016a].

Commitments to political leadership to prevent and end conflict, leaving no one behind, delivering
aid and ending need, addressing natural disasters and climate change, investing in humanity, and
achieving gender equality made at the summit also contribute to combat malnutrition and improve
food and nutrition security [Agenda for Humanity, 2016b].

8.4. The role of the WHO in emergencies

The WHO’s nutrition strategy Ambition and Action in Nutrition for the period of 2016 -2025 (the UN
Decade of Action on Nutrition) places special focus on nutrition in emergencies across all three core
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functions of the WHO in nutrition. Of the six priorities set in the strategy three have particular
relevance to nutrition in emergencies:
–Leadership: to leverage the implementation of effective nutrition policies and programmes in all
settings, including situations of emergencies and crises
–Guidance: to ensure that emergency considerations are made in WHO nutrition guidelines to
account for extraordinary situations
–Monitoring: by integrating nutrition indicators into existing health surveillance systems [WHO,
2017a].

Establishing closer linkages between the WHO’s work on nutrition and its humanitarian action in the
frame of the WHO’s Health Emergencies Programme (WHE) is a priority of the Organization.
The WHO’s Department of Nutrition for Health and Development (NHD), Department of Health
Action in Crises (HAC) and the six WHO regional nutrition advisors work in close collaboration with
the United Nations High Commissioner for Refugees (UNHCR), UNICEF, the World Food Programme
(WFP), various NGOs, academic institutions and other stakeholders. Besides its leading role in the
Health Cluster, the WHO is also an active member of the IASC Nutrition Cluster.

The main areas of the WHO's response in the context of emergencies are
 Technical support and advocacy on nutritional standards through its normative work and the
production and dissemination of scientifically validated and up-to-date guidelines, norms,
criteria and methodologies
 Capacity building through information dissemination and training to strengthen national,
subnational and international capacities to meet the nutritional needs of populations in
emergencies and manage malnutrition
 Surveillance, nutritional status assessment
 Monitoring and evaluation

Nutrition interventions may be categorized as belonging to the health sector as in the case of
therapeutic feeding for severe acute malnutrition (SAM). Health and nutrition services rely in part on
the same infrastructure for outreach, screening and referral and delivery. The prevention and
treatment of malnutrition are promoted by a functional health care system. Moreover, the gathering
of nutrition and health can be linked to allow evaluating the risk of malnutrition in relation to
morbidity status. Therefore, a central focus of the WHO’s work on nutrition in emergencies is on the
management of acute malnutrition in famine and pre-famine situations as well as on nutrition
surveillance. In 2013, the WHO released “Updates on the management of severe acute malnutrition
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in infants and children” serving as a guideline on the diagnosis and management of and basis for an
upcoming revision of the 1999 manual on the management of SAM for manual for physicians and
other senior health workers and the WHO Training Course on SAM [WHO, 2013b].

Overall, three areas of focus can be distinguished:

1) Life-saving programmes on nutrition and health through capacity building in health staff on
the management of severe acute malnutrition with medical complications and on
appropriate infant and young child feeding in the inpatient management of SAM to prevent
relapse, as well as by ensuring necessary supplies for the inpatient treatment of SAM.
2) The identification of persons needing nutrition interventions and appropriate referrals by
promoting the integration of nutrition screening at all levels of the health system
(community, PHC, tertiary), by ensuring that health facilities provide key nutrition
interventions (like micronutrient supplementations) as needed and that patients are referred
for nutrition interventions as appropriate.
3) A nutrition surveillance system that generates regular information together with health by
monitoring and evaluating the inpatient management of SAM in health facilities and the
availability of services and resources at different points of service delivery to identify gaps for
appropriate actions including nutrition. To monitor the outcomes of nutrition services
implemented at health facilities technical support is provided to strengthen the existing
routine health information system and integrate key program performance indicators [Weise
Prinzo et al., 2017].

Lessons learned in recent disease outbreaks and emergencies instigated a reform of the WHO’s work
in emergencies leading to the release of a second edition of the Emergency Response Framework
(ERF II) in 2017 and the generation of the WHO’s Health Emergencies Programme (WHE) and the
Incident Management System (IMS). The ERF II introduces a fundamental paradigm shift by
“complementing WHO’s traditional technical and normative role with new operational capacities and
capabilities for its work in outbreaks and humanitarian emergencies” [WHO, 2016c]. A strength of
the WHE is its form of “a single programme with one clear line of authority, one workforce, one
budget, one set of rules and processes, and one set of standard performance metrics”, having a
common structure across all WHO units, regional and country offices. It is divided into five technical
and operational areas (Infectious hazards management, Country health preparedness, Health
emergency information and risk assessments, Emergency operations, Emergency operations
management and administration and External relations) [WHO, 2017d]. The IMS serves as the
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standardised approach of the WHO to manage emergencies and public health events, ensuring that
best practice is followed. It covers six critical functions:
 Leadership
 Partner coordination
 Information and planning
 Health operations and Technical expertise
 Operations support and logistics
 Finance and administration

The ERF II defines a set of core commitments that the WHO will always deliver and be accountable
for in its response to emergencies:
1) Undertaking a timely, independent and rigorous risk assessment and situation analysis,
2) Deployment of sufficient expert staff and material resources early in the event to ensure an
effective assessment and operational response,
3) Establishment of a clear management structure for the response in-country, based on the
IMS,
4) Establishment of coordination with partners to facilitate collective response and effective in-
country operations,
5) Development of an evidence-based health sector response strategy, plan and appeal,
6) Ensuring that adapted disease surveillance, early warning and response systems are in place,
7) Provision of up-to-date information on the health situation and health sector performance,
8) Coordination of the health sector response to ensure appropriate coverage and quality of
essential health services,
9) Promotion and monitoring of the application of technical standards and best practices,
10) Provision of relevant technical expertise to affected Member States and all relevant
stakeholders [WHO, 2017d].

A number of principles guide the response to emergencies (see figure 29).

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Figure 29 Guiding principles of the WHO's response to emergencies [WHO, 2017d]

The ERF II also saw the introduction of a grading process to gauge the level of operational response
to a given emergency. However, the immediate response to acute incidents and emergencies,
uncovered by a risk assessment for public health events or situation analysis for sudden onset
emergencies, is the same regardless of grading. Country offices are instantly repurposed and
response activities and grading of the event initiated within no more than 24 hours. Grading is an
internal WHO process with the purpose of activating the IMS and Emergency SOPs, informing the
Organization of the level of WHO’s operational response and the need for mobilization of internal
and external resources, determining the need for additional human and material resources.
Grading is prompted by any public health event with a risk assessed as high or very high or with a risk
assessed as moderate or low, but requiring an operational response by WHO, by any emergency
situation with a health impact likely to require an operational response by WHO as indicated by the
situation analysis, as well as any request for emergency assistance from a Member State. The grading
process is guided by the scale of the event or emergency, its complexity, the urgency (determined
among others by mortality and disease rates and trends, acute malnutrition rates, risk of
international spread, changing of environmental conditions such as seasons speed of population
displacement, potential for further conflict, degree of water and food contamination, the capacity
and the reputational risk. For all grades, the provision of support to the WCO is coordinated by an
Emergency Coordinator in the Regional Office(s) or occasionally at the headquarters. Grade 2 and 3
emergencies also entail the appointment of an Emergency Officer at the WHO headquarters to assist
with the coordination of Organization-wide inputs. For grade 3 events or emergencies involving
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multiple regions, an IMS Team at headquarters will coordinate the response across the regions (see
table 34) [WHO, 2017d].

Table 34 WHO levels for graded emergencies (modified from [WHO, 2017d]

A public health event or emergency that is being monitored by WHO but

that does not require a WHO operational response.

A single country emergency requiring a limited response by WHO, but

that still exceeds the usual country-level cooperation between the WHO
Country Office (WCO) and the Member State. Most of the WHO
response can be managed with in-country assets. Limited organizational
and/or external support required.

A single country or multiple country emergency, requiring a moderate

response by WHO. The level of response required by WHO always
exceeds the capacity of the WCO. Moderate organizational and/or
external support required by the WCO.

A single country or multiple country emergency, requiring a

major/maximal WHO response. Any new IASC level 3 emergency.
Organizational and/or external support required by the WCO is major
and requires the mobilization of Organization-wide assets.

Despite the focus of the ERF II being primarily on acute events and emergencies, it includes a grading
process for protracted emergencies that persist for longer than six months as well. The
organizational or external support required by the WCO is coordinated by an Emergency Coordinator
in the Regional Office. In protracted level 2 and 3 crises, an Emergency Officer is concurrently
appointed at Headquarters level to coordinate any required support from other levels of the
Organization (see table 35).
In 2015, the WHO created the Contingency Fund for Emergencies (CFE) for an immediate release of
an initial amount of up to US$ 500 000 within 24 hours of a request from a Member State affected by
an emergency. The CFE is a pooled fund of contributions from various donors outside of WHO’s
Health Emergencies Programme core budget. As the contributions are not earmarked for specific
activities they can be flexibly allocated for a wide range of emergencies. This approach follows a “no
regrets” policy by making predictable levels of staff and funds available to the WCO even though it
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may later be found that the actual needs were lower. In this way, critical funding gaps in the early
phase of an emergency can be bridged until funds from other sources like the CERF that are bound to
different criteria and more slowly disbursed become available [WHO, 2017d; WHO, 2019c].

Table 35 Definition of WHO protracted grades (modified from [WHO, 2017d])

Protracted 1 A single country emergency associated with limited ongoing health consequences,
but still requiring a sustained WHO response and limited organizational or external
support to the WCO. Most of the WHO response can be managed with in-country
assets. required by the WCO. Support to the Country Office coordinated by an
Emergency Coordinator in the Regional Office.
Protracted 2 A single or multiple country emergency associated with moderate ongoing public
health consequences and requiring sustained WHO operational presence and
response as well as moderate organizational or external support
Protracted 3 A single or multiple country emergency associated with major ongoing health
consequences and requiring sustained WHO operational presence and response as
well as major organizational or external support

WHO also raises funds for emergencies through donor alerts following an estimation of needs for the
first 3 months within 72 hours of a grade 2 or 3 emergency, and keeps donors informed of the
situation and of WHO's activities and needs.

8.5. Interventions to address acute malnutrition

Regardless of the underlying causes, emergencies lead to a disruption of food production,
distribution and also interfere with safe food preparation when water supply and sanitation systems
are compromised. Besides infectious diseases, acute malnutrition is one of the main causes of death
in the initial phase of an emergency especially in vulnerable population groups like infants and young
children. Malnutrition increases the susceptibility to infection while infection promotes
undernutrition (see chapter 4.2). Restoring a safe food supply is therefore among the first priorities
of humanitarian measures [Bahwere, 2014].
Disrupted agriculture and market structures and the loss of financial assets and income limit the
availability and access to fresh foods in particular, like vegetables, fruits and other nutrient-rich
products. Populations under emergency situations are often completely dependent on food aid. This
makes them prone to the development of micronutrient deficiencies and can aggravate malnutrition
that pre-existed in a population already before the emergency. In infants and young children, low
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rates of breastfeeding are associated with a high risk of micronutrient malnutrition. The focus of
interventions to treat acute malnutrition is on infants and young children. However, adults may also
be affected especially during protracted crises. Even though their treatment is similar to that of
children in general terms, some aspects differ [ACF, 2006].
Acute malnutrition is distinguished into moderate (MAM) and severe forms (SAM). Both are
summarized as global acute malnutrition. Indicators and criteria for the identification of SAM are
described in chapter 4.2.
Severe acute malnutrition that is accompanied by medical complications warrants specialized
medical inpatient care in a hospital setting. This usually concerns 10 – 30 % of patients. SAM is often
associated with dehydration and profound physiological and metabolic perturbations including
electrolyte imbalances that cause high mortality rates and need treatment before the initiation of
intensive refeeding. Main causes of death in this group include hypoglycaemia, hypothermia, cardiac
failure caused by electrolyte imbalance as well as infections. Children with severe oedema or
showing no appetite should also be treated as inpatients. In turn, uncomplicated SAM can be
addressed through outpatient care as long as appropriate ready-to-use therapeutic-food is available.
This latter consists of high-energy, fortified, ready-to-eat foods with a nutrient density similar to that
of the therapeutic diet used for the treatment of SAM in hospital settings. A major difference lies in
the fact that ready-to-eat foods for outpatient treatment are not water based to reduce bacterial
growth and enable their safe use without refrigeration and under suboptimal hygienic conditions.
Their production is technologically simple, requiring minimal industrial infrastructure. They are
suitable for children from the age of 6 months, complying with the recommended international code
of hygienic practice for foods for infants and children of the Codex Alimentarius Standard CAC/RCP
21-1979, and have been effectively used in the treatment of SAM in children in communities or
hospitals after the stabilization phase [WHO, 2013b]. Outpatient care for SAM in emergencies allows
a significantly larger coverage, an increased number of successfully treated children and a lower
case-fatality rate. Following appropriate mobilization and sensitization of communities, the model of
community-based SAM management has been successfully extended to non-emergency settings
allowing the at-home treatment of the majority of diagnosed children [WHO/WFP/UNSCN/UNICEF,
2007].
The prevention and treatment of MAM in children relies on social and behaviour change
communication approaches including the promotion and support of breastfeeding and counselling
for families as well as the optimal use of locally available foods in infant and child feeding.
Additionally, specially formulated foods are used especially in the treatment of MAM. A targeted
supplementary feeding programme is warranted in emergencies when household food security is
compromised and the capacity to prepare safe food is limited. It directly provides nutritious ready-to-
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use food supplements and routine medical treatment and complements nutrition counselling and
support. Besides ready-to-use supplementary foods, fortified blended foods that need some
preparation as well as micronutrient powders to be added to food can be used in the management of
MAM. The appropriate product must be carefully selected depending on the situation and context.
Treatment of infections is also an important measure in the management of MAM [Global Nutrition
Cluster, 2017].
A timely well-coordinated response is crucial to alleviate malnutrition and prevent its worsening. It
faces a number of challenges:
 A rapid assessment of the nutrition and health situation and prompt analysis of the obtained
data are required to enable the development of a response strategy that matches the needs
of the affected population. Functioning surveillance systems have to be established or
existing ones be strengthened to enable the gathering of the necessary data and the
obtained information has to be managed appropriately.
 Key nutrition actions have to be delivered in a coordinated manner and in cooperation with
relevant activities from other clusters.
 Causal linkages of malnutrition have to be identified and understood.
 The coverage for reaching the malnourished is often inadequate.
 The response strategy has to include post-emergency rehabilitation and sustainable solutions
for long-term recovery.

8.6. Infant and young children feeding in emergencies

Infants and children are the population group most vulnerable to malnutrition. Interrupted
breastfeeding and inappropriate complementary feeding in particular are associated with a high risk
of malnutrition, illness and mortality. This is even more the case in emergencies. There are special
concerns about artificial feeding of infants under conditions of poor hygiene, crowding and limited
access to clean water and fuel. Therefore, the International Code of Marketing of Breast-milk
Substitutes use of breastmilk substitutes [WHO, 1981] has particular relevance in emergency
situations. The 47th World Health Assembly urged Member States “to exercise extreme caution when
planning, implementing or supporting emergency relief operations, by protecting, promoting and
supporting breast-feeding for infants, and ensuring that donated supplies of breast-milk substitutes
(BMS) or other products covered by the scope of the International Code be given only if all the
following conditions apply:
 infants have to be fed on BMS, as outlined in the guidelines concerning the main health and
socioeconomic circumstances in which infants have to be fed on breast-milk substitutes
(Document WHA39/1986/REC/1, Annex 6, part 2);
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 the supply is continued for as long as the infants concerned need it;
 the supply is not used as a sales inducement [WHO, 1994].

The Code does neither restrict the availability of BMS, feeding bottles or teats nor prohibit their use
during emergencies. It only regulates how they are marketed and the way in which they are procured
and distributed. The Code aims of protecting artificially fed babies by ensuring BMS will be used as
safely as possible on the basis of impartial, accurate information.
To ensure the nutritional needs of non-breastfed children in emergencies and to prevent risks arising
from inappropriate use, artificial feeding with BMS must be accompanied by a context-specific,
coordinated combination of care and skilled support. BMS, complementary foods and feeding
equipment like bottles and teats should not come from donations but appropriate products of high
quality have to be purchased in the required amounts. BMS but also dried and liquid milk should be
discreetly provided to the eligible beneficiaries only and never be part of a general distribution.

The Interagency Core Group on Infant and Young Child Feeding in Emergencies (IFE) has developed
an Operational Guidance on Infant and Young Child Feeding in Emergencies serving as the current
policy framework. First published in 2001 it has since undergone a number of revisions with the
latest version 3 dating from October 2017. The IFE Core Group is an interagency collaboration
devoted to the protection and promotion of safe and appropriate feeding of infants and young
children in emergencies by connecting practitioner experiences with the development of policies and
guidance as well as training materials. Members include UNICEF, WHO, WFP, UNHCR, the Emergency
Nutrition Network (ENN), Action contre la Faim and others.
The Operational Guidance targets emergency relief staff, programme managers and policy-makers in
the field of emergency response. It was endorsed by over 30 agencies and organisations and is
available in seven languages.
The objective is to offer concise, practical advice on how to ensure that infants and young children in
emergencies receive appropriate feeding. Target groups are infants and young children from birth up
to 23 months, but also pregnant and lactating women. The updated version takes into account the
latest technical guidance as well as recent experiences and developments with special focus on
collaboration between sectors and emergency preparedness. More attention is given to the needs of
non-breastfed infants and to complementary feeding and to special circumstances under which the
recommendations of the Operational Guidance cannot be fully met.
The Guidance emphasizes the role of the government as the leading authority in emergency
preparedness and response but also specifies the respective roles and responsibilities of UN agencies
in the support of national authorities. These include the endorsement or development of policies,
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the training of staff, the coordination of operations, monitoring and surveillance, and multisectoral
cooperation.
The Guidance also covers sectors beyond nutrition and defines essential collaborative actions to
complement direct nutrition interventions. Sectors with particular relevance are health with special
reference to maternal, newborn and child health; infectious disease management; and HIV among
others; water, sanitation and hygiene (WASH); disability; child protection; early childhood
development; adolescent services; cash transfer programmes; social protection; food security and
livelihoods (FSL); agriculture; shelter; camp coordination and camp management; and logistics.
The use of BMS in refugee situations has been addressed by the UNHCR in its Standard Operating
Procedures for the Handling of Breastmilk Substitutes (BMS) in Refugee Situations for children 0-23
months. Taking into account the high risk of malnutrition, illness and death in infants living in refugee
situations and who are not breastfed as recommended (i.e. exclusively during the first six months
and in addition to complementary feeding until the age of 2 years), the SOP concurs with the
recommendations of the Operational Guidance and the Code on Marketing of BMS [UNHCR, 2015].
Special attention is needed for children of HIV-positive mothers in emergencies. The use of anti-
retroviral therapy (ART) greatly reduces the risk of viral transmission through breastmilk so that
mothers living with HIV are recommended to exclusively breastfeed their infants during the first six
months and to continue for at least six further months. This recommendation is founded on the clear
health benefits of breastfeeding and on its protective effect against infections including those by HIV.
These benefits may even outweigh the risks of transmission arising from interrupted supply of ART as
it may occur in emergencies. This prompted the WHO to develop an Operational Guidance on HIV
and Infant Feeding In Emergencies that was presented in 2018 to support pregnant and lactating
women living with HIV in feeding their HIV-exposed infants and young children, to promote and
protect breastfeeding while at the same time enabling appropriate and safe artificial feeding [WHO,
2018g].
Besides the nutrition of infants and children, that of pregnant and lactating women in emergencies
requires special attention as well. Their higher needs of energy, macronutrients and micronutrients
make them particularly vulnerable for nutritional deficiencies that not only threaten their own health
but also that of their unborn child. The importance of ensuring that the nutritional needs of pregnant
and lactating women are met especially during crises and disasters is underscored in the 65th WHA’s
report on Nutrition of women in the preconception period, during pregnancy and the breastfeeding
period. It urges countries to “include specific provisions for women in preparedness plans for
emergencies” [WHO, 2012c].
WHO’s Essential Nutrition Actions also focus on the nutritional requirements of pregnant women
during emergencies and on approaches to meet them. While micronutrient-fortified foods such as
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corn-soya blend, biscuits, vegetable oil with added vitamin A and iodized salt that also supply protein
are usually contained in the distributed food rations during emergencies they may not be sufficient
to achieve adequacy in pregnant and lactating women. Therefore, supplementation as indicated in
table 31 is recommended for this population group regardless of the consumption of fortified foods.
In addition, the establishment of nutrition education and counselling services is advised that would
also serve as easily-accessible safe areas offering not only food and water but also privacy, security,
shelter and basic supportive breastfeeding care to pregnant and lactating women [WHO, 2013c].

Table 36 Composition of multiple micronutrient supplements for pregnant women, designed to

provide daily recommended intake of each nutrient (one RNI) [WHO, 2013c]

Micronutrient Content

Vitamin A µg 800.0
Vitamin D µg 5.0
Vitamin E mg 15.0
Vitamin C mg 55.0
Thiamine (vitamin B1) mg 1.4
Riboflavin (vitamin B2) mg 1.4
Niacin (vitamin B3) mg 18.0
Vitamin B6 mg 1.9
Vitamin B12 µg 2.6
Folic acid µg 600.0
Iron mg 27.0
Zinc mg 10.0
Copper mg 1.15
Selenium µg 30.0
Iodine µg 250.0
 158

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