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The reduction of salt intake in the WHO

European Region within the framework of

the Action Plan on the NCD

Dr João Breda PhD MBA MPHDr João Breda PhD MBA MPHProgramme Manager Nutrition, Physical Activity and Obesity

Division Noncommunicable Diseases and Health Promotion

WHO Regional Office for Europe

Outcomes of the

2011 UN General Assembly

High-level Meeting on NCDs

World Health Assembly resolution WHA64.11

REQUESTS THE DIRECTOR-GENERAL TO:

(4) to report to the Sixty-fifth World Health Assembly,

through the Executive Board, on the outcomes of the

first Global Ministerial Conference on Healthy Lifestyles

and NCD Control and the high-level meeting, and to

develop, together with relevant United Nations

agencies and entities, an implementation and follow-agencies and entities, an implementation and follow-

up plan for the outcomes, including its financial

implications, for submission to the Sixty-sixth World

Health Assembly, through the Executive Board.

(24 May 2011)

2000

2003

2004

2008

Global Strategy for the Prevention and

Control of Noncommunicable Diseases

Global Strategy on Diet,

Physical Activity and Health

Action Plan 2008-2013 on the Global Strategy for the

Prevention and Control of NCDs

Global Strategy to

Reduce the Harmful Use

of Alcohol

WHO’s global road map on NCDs

2010

2009

2011

of Alcohol

WHO Global Status

Report on NCDs

Political Declaration on NCDs

2013

2020WHO Action Plan for the Prevention and Control of NCDs for 2013-2020

Vision:

A world in which all countries and partners sustain their political

and financial commitments to reduce the avoidable global burden

and impact of NCDs, so that populations reach the highest

attainable standards of health and productivity at every age and

NCDs are no longer a barrier to socio-economic development

Overarching principles:

Main elements of the Draft Action Plan

Human rights NCDs are a

challenge to

social and

economic

development

Universal access

and equity

Life-course

approach

Evidence-based

action

Empowerment

of people and

comunities

Goal:

To reduce the burden of preventable morbidity and disability and

avoidable mortality due to NCDs

Formal Meeting of Member States to conclude the Formal Meeting of Member States to conclude the

wwork on the comprehensive global monitoring framework ork on the comprehensive global monitoring framework

including indicators and a set of voluntary targets for the including indicators and a set of voluntary targets for the

prevention and control of NCDsprevention and control of NCDs

On 7th November the meeting agreed

on a global monitoring framework and

a set of voluntary global targets for

the prevention and control of

noncommunicable diseasesnoncommunicable diseases

This will be integrated into the work

under way to develop a draft WHO

Action Plan (2013-2020)

Comprehensive Global Monitoring Framework

Mortality & Morbidity

Unconditional probability of dying between ages 30 and 70 years from

cardiovascular diseases, cancer, diabetes or chronic respiratory

Salt

Fruits and Vegetables

Saturated Fat

Physical Inactivity (2)

Harmful use of Alcohol (3)

Risk FactorsNational Systems

Response

Essential NCD Medicines

Drug therapy and counseling

Cervical cancer Screening

Hepatitis B Vaccine

Cancer incidence by type of cancer per 100 000

population

chronic respiratory diseases

Saturated Fat

Overweight and Obesity (2)

Blood glucose/diabetes

Blood Pressure

Total Cholesterol

Tobacco use (2)

Access to palliative care

Policies to limit SFA and virtual elimination of

PHVO

HPV Vaccine

Marketing to children

Physical

inactivity

10% reduction

Harmful use of

alcohol

10% reduction

Drug therapy

and counseling

50%

Premature

mortality from

NCDs

25% reductionEssential NCD

medicines and

technologies

80%

Set of 9 voluntary global NCD targets for 2025

Raised blood

pressure

25% reduction

Salt/

sodium intake

30% reduction

Tobacco use

30% reduction

Diabetes/

obesity

0% change

Mortality and morbidity

Risk factors for NCDs

National systems response

Health 2020: a

European policy

framework

supporting action

across government across government

and society for

health and well-

being

Planning and oversight

National plan

Health in all policies

Fiscal policies

Marketing

Healthy settings

Workplaces and schools

Secondary prevention

Cardio-metabolic risk assessment and management

Health 2020

Health information system with social

disaggregation

Salt

Trans-fat

Active mobilityEarly detection of cancer

Public Health Action Framework

http://bit.ly/WHOHealth2020

Reduction of Circulatory Mortality

European

average

European

average

European

average

http://dl.dropbox.com/u/77053/motionchart/data.html

UK of GB and N

10.0

12.0

14.0

16.0

18.0

Salt intake for men or total (g per capita/day)*

Austria

Belgium

Bulgaria

Cyprus

Czech Republic

Denmark

Estonia

Finland

France

Germany

Hungary

Ireland

Italy

Latvia

Lithuania

Netherlands

Poland

Portugal

Romania

Slovakia

Slovenia

Spain

Sweden

UK of GB and N-Ireland

0.0

2.0

4.0

6.0

8.0

Eu 27 countries

UK of GB and N

50

60

70

80

Overweight in adults 2008 ( % pre-obesity and obesity)

Austria

Belgium

Bulgaria

Cyprus

Czech Republic

Denmark

Estonia

Finland

France

Germany

Greece

Hungary

Ireland

Italy

Latvia

Lithuania

Luxembourg

Malta

Netherlands

Poland

Portugal

Romania

Slovakia

Slovenia

Spain

Sweden

UK of GB and N-Ireland

0

10

20

30

40

Eu 27 countries

UK of FB and N

8

10

12

14

Saturated fat intake 2007 (% of calories in total diet)

Austria

Belgium

Bulgaria

Denmark

Estonia

Finland

France

Germany

Greece

Hungary

Ireland

Italy

Latvia

Lithuania

Luxembourg

Malta

Netherlands

Poland

Portugal

Romania

Slovenia

Spain

Sweden

UK of FB and N-Ireland

0

2

4

6

Eu 27 countries

25%

30%

35%

40%

45%

50%

Percentage distribution

Projected obesity distribution to 2030 for adult males

2010

0%

5%

10%

15%

20%

Percentage distribution

2010

2030

Prevalence gains avoided per 100,000 of

the EU population in 2030 by scenarios

600

800

1000

1200

1% decrease

0

200

400

Cancer CHD+stroke Diabetes Hypertension

5% decrease

Scenario 1 – 3 Mo avoided

Scenario 2 – 9 Mo avoided

Proportion (%) of children exclusively

breastfed at 3 and 6 months, 2005-2010

40

50

60

70

80

90

100

3 Months

6months

0

10

20

30 6months

Sources: National Surveys

Prevalence of overweight, incl. obesity –boys %Based on the 2007 WHO growth reference for children and adolescents 5-19 years

34.332.5

28.2

31.8

40.5

49

30

40

50

60

7 year-olds except for Malta (6) & ITA + NOR (8)

23.421.4

24 24.8 23.5 23

0

10

20

30


National plan


Fiscal policies

Marketing

Healthy settings




Health 2020


disaggregation

Salt

Trans-fat



WHO/EUROPE: mandate for action

• Vienna

Conference

Nut & NCDs;

July 2013

• New NAP;

July 2013

Best buys package

population-based approaches

• Smoke-free environments

• Warning about the dangers of tobacco use

• Bans on tobacco advertising

• Raising taxes on tobacco

• Raising taxes on alcohol

• Restricting access to retail alcohol• Restricting access to retail alcohol

• Bans on alcohol advertising

• Reducing salt intake and salt content of food

• Replacing trans-fat in food with polyunsaturated fat

• Promoting public awareness about diet and physical activity


National plan


Fiscal policies

Marketing

Healthy settings




Health 2020


disaggregation

Salt

Trans-fat



No Action

Partly Implemented

Fully Implemented

Overview Policy Actions

Implementation 27 EU Member States

Food Based Dietary Guidelines

Guidelines Physical Activity

Subsidized School Fruit Scheme

School Vending Machines

Promote Active Travel

Initiatives to reduce Salt Initiatives to reduce Salt

Increase healthier processed foods

Measures to affect food prices

Legislation labelling energy

Signposting Food Products

Regulation Marketing

Baby Friendly Hospital

Promotion Breastfeeding

Capacity to measure National Health

Reporting

All EUR-A EUR B+C

NCD mortality 100% 100% 100%

NCD morbidity 98% 96% 100%NCD morbidity 98% 96% 100%

NCD risk factors 73% 78% 68%

Capacity to Disaggregate: Medium to Low

Analysis of 144 WHO Country Cooperation Strategies Number

Promoting risk reduction, prevention, treatment and monitoring of

noncommunicable diseases, mental health, disability and injuries.

136

Strengthening the structure, organization and financing of health systems,

with a particular focus on achieving universal coverage, strengthening human

resources for health and increasing access to medical technologies including

medicines.

134

Supporting the achievement of the health-related Millennium Development 119

Individual country needs: Demand for technical assistance to address NCDs is huge

Supporting the achievement of the health-related Millennium Development

Goals (primarily Goals 4, 5 and 6) bringing together HIV/AIDS, tuberculosis,

malaria, and maternal and child health, with a focus on integrated service

delivery.

119

Surveillance of, and response to, disease outbreaks and acute public health

emergencies, and the effective management of humanitarian disasters.

119


National plan


Salt

Marketing

Healthy settings




Health 2020


disaggregation

Fiscal Policies

Trans-fat



Mapping salt reduction

initiatives in the WHO

European RegionEuropean Region

Current policy and environmental scanCountry Existing plan Environmental scan

Existing task force/working

group

National salt

initiative

Part of bigger

initiativeFood reformulation 24-hour urine Spot urine

Primary sources of

dietary saltDietary intake survey

Austria xxx xxx xx xxx

Belgium xxx xxx xxx xxx xxx xxx

Bulgaria xxx xxx xxx xxx xxx

Cyprus xxx xx xxx

Czech Republic

xxx xxx

Denmark xxx xxx xxx xxx xxx

Estonia xxx xxx xxx

Finland xxx xxx xxx xxx xxx xxx

France xxx xxx xxx xxx xxx

Germany xxx xxx xxx

Greece xxx xx

Hungary xxx xxx xxx xxx xxx xxx

Iceland xxx

Ireland xxx xxx xxx xxx xxx xxx xxx

Italy xxx xxx xxx xxx

Latvia xxx

Lithuania xxxLithuania xxx

Luxembourg xxx

Malta xx xxx xxx

Netherlands xxx xxx xxx xxx xxx xxx

Norway xxx xxx xxx xxx xxx

Poland xxx xxx

Portugal xxx xxx

Romania xxx

Slovakia xxx xxx xxx xxx

Slovenia xxx xxx xxx xxx xxx

Spain xxx xxx xxx xxx

Sweden xxx xxx xxx

Switzerland xxx xxx xxx xxx xxx xxx

Turkey xxx xxx

United Kingdom xxx xxx xxx xxx xxx xxx xxx

Country National target set/goals

Dietary target Overall population consumption Specific food category

Andorra 7.5g/day

Austria 9g/day m and 8g/day w 15% by 2015 in bread

Belgium reduce 10% by 2012 8.25g/day m and 5.75g/day w max 2% salt on dry matter

Bulgaria <5 g/day 12.5–14.5g/day m and 11.4–16.6g/day w

Croatia 30% by 2012 in bread

Cyprus <5 g/day 5g/day m and w

Czech Republic <5 g/day 16.6g/day m and 10.5g/day w

Denmark 5g/day w and 6–8g/day m 9.8g/day m and 7.3g/day w 16% by 2012

Estonia 5g/day w and 6g/day m 10g/day

Finland 6g/day w and 7g/day m <2 years 0.5 g/day 9.3g/day m and 6.8g/day w 20–25 % in bread

France <8 g/day 9g/day 20% by 2012 in bread

Georgia

Germany 3.5–6g/day 9g/day m and 6.5g/day w

Greece <5 g/day

Hungary <5 g/day 17.5g/day m and 12.1g/day w 16% by 2017 in bread

Iceland 6–7g/day 9.5g/day m and 6.5g/day w

Ireland <6 g/day 10.3g/day m and 7.4g/day w 16% by 2013 in bread

Israel <5–6g day 7g/day 35% by 2020

Italy <6 g/day 11g/day m and 8g/day w 10% by 2012 in bread

Latvia <5 g/day 7.1g/day

Lithuania <5 g/day 10.75/day m and 7g/day w 10% by 2013 in bread

Luxembourg 5g/day

Malta <5 g/dayMalta <5 g/day

Montenegro <5 g/day

Netherlands <6 g/day > 8.5g/day 25–30% by 2015

Norway <5 g/day (6g/day w and 7g/day m) 9.2g/day m and 7.9g/day w

Poland 5–6 g/day 7g/day (HBS) 16% in 2012 in bread

Portugal <5 g/day 12.3 g/day

Roman <6 g/day 11.25g/day

Serbia

Slovakia <5 g/day 9.6–9.8g/day m and 7–7.2g/day w

Slovenia <6 g/day 12.4g/day (14.3g/day m and 11g/day w) 16% in 2012 in bread

Spain <5 g/day 9.8g/day 20% in 2014 in bread

Sweden 5–6 g/day 10–12g/day

Switzerland <8 g/day by 2012 and then 5g 9g/day

Turkey 5 g/day 18.01g/day

United Kingdom <6 g/day 8.7g/day

United Kingdom (Scotland) <6 g/day 8.8g/day

Uzbekistan

Benchmarks

Country Consumer awareness campaigns Industry

involve-

ment

Label-

ling

Brochure/

printTV/radio

Website/

software

Education/

schools/health care

facilities

Conference Reports

Andorra xxx xxx xxx

Austria xxx xxx

Belgium xxx xxx xxx xx xxx

Bulgaria xxx xxx xxx xxx

Croatia xx

Cyprus xxx xxx xxx xx xxx

Czech Republic xxx xxx xx

Denmark xxx xxx xxx xxx xx xxx

Estonia xxx xx xxx

Consumer awareness. Industry involvement and labelling

Finland xxx xxx xxx xxx

France xxx xxx xxx xxx xxx

Georgia xxx xxx xxx xxx

Germany

Greece xxx xx xxx

Hungary xxx xxx xxx xxx xxx xx

Iceland xxx xxx xxx xx

Ireland xxx xxx xxx xxx

Israel xx xxx

Italy xxx xxx xx xxx xx

Latvia xxx xxx xxx xx xx xx

Matrix for fiscal policy

Evidence Current

Practice

Social

Impact

Tobacco • Effect on

consumption

• Elasticity

• Pass through

• Response to

financial crisis

• What products

are targeted?

• Regressivity

• Effects on

different SEG

• What is the

Alcohol

Foods

• Pass through

effects

• Effects on

revenue

• Mechanisms:

minimum

price, excise…

are targeted?

• Cross-border

sales

• Smuggling

• Illegal

production

• Earmarking

• Monitoring

• Strategy

• What is the

health impact?

• Competitiveness


National plan


Fiscal policies

Marketing

Healthy settings




Health 2020


disaggregation

Salt

Trans-fat



Governance

EPHO 6

PH Workforce

EPHO 7

The ten Essential Public Health Operations (EPHOs)

- for strengthening Public Health service delivery

INTELLIGENCE

EPHO 1 + 2

Surveillance

MonitoringEPHO 4

CORE EPHOs

Health Promotion

VISION: Sustainable Health & Well-Being

SERVICE DELIVERY

ENABLER

EPHOs

Funding

EPHO 8

Communication

EPHO 9

Research

EPHO 10

Monitoring

Informing

health

assessments

and plansEPHO 3 EPHO 5

Disease

PreventionHealth Protection

Objective 1:

To strengthen

advocacy and

international

cooperation

and to raise the

priority

accorded to

prevention and

Objective 2:

To strengthen

capacity,

leadership,

governance,

multisectoral

action and

partnerships to

accelerate

Objective 3:

To reduce

exposure to

modifiable risk

factors through

creation of

health

promoting

environments

Objective 4:

To strengthen

and reorient

health

systems to

address NCD

prevention

and control

through

Objective 5:

To promote

and support

national

capacity for

quality

research and

development

for prevention

Objective 6:

To monitor

NCD trends and

determinants

and evaluate

progress of

prevention and

control of NCDs

WHO Global NCD Action Plan 2013-2020 – Proposed objectives

prevention and

control of NCDs

at global,

regional and

national levels

and in the

development

agenda

accelerate

country

response for

prevention and

control of NCDs

environments through

people-

centred

primary care

and

universal

coverage

for prevention

and control of

NCDs

The Action Plan will comprise a set of actions which, when performed

collectively by Member States, UN agencies, international partners and

WHO, will reduce the burden of preventable morbidity and disability and

avoidable mortality due to NCDs.

WHO Global NCD Action Plan 2013-

2020

(including the global monitoring

framework and voluntary global

targets)

How: NCD implementation toolkit and modules

Develop an NCD implementation toolkit

Examples of existing modules:

• MPOWER (tobacco)

• Physical activity for health

• PEN (NCD interventions for primary care)

• WHO STEPs (surveillance)

Examples of pending modules:

• Setting national targets and measuring results

• Salt reduction

• Self-care of NCDs

• Health-in-all-Policies

• Obesity prevention

2013

Develop an NCD implementation toolkit

(with various modules)

Phase 1 (in-depth):

Fine-tune the toolkit in 12-24 countries

Phase 2 (breadth):

Roll out

• Situation analysis

• Capacity assessment

• Work plan

• Review and feedback

• Roll-out approach

• Roster of international NCD experts

and "market place"

2013

2014

2015

UN Task Force on NCDs:

Fostering collaboration

• Operational level:

joint programmes at country level

• Institutional level :

joint global programmes

• Technical level:

transfer knowledge

Proposed WHO Business model: Forging collaborative arrangements

Social movement:

• Whole-of-society

• Converging advocacy

UN Task

Force on

NCDs

Global NCD

Coordination

Network

Global

NCD

social WHO

Political

Declaration

on NCDs

Global Coordination Network:

Facilitating collaboration and cooperation

to address five functional gaps:

• Advocacy and awareness

• Health financing

• Capacity building

• Product access

• Product development and innovation

WHO:

• Moving from global agenda setting to

national action

• Focusing efforts as part of WHO reform:

� What: WHO Global NCD Action Plan

2013-2020

� How: Catalyzing transformational

change at country level: Implementation

toolkit

NCDs Network social

movementon NCDs

WHO Action Plan for the

prevention and control of

NCDs for 2013-2020

Comprehensive review and

assessment of the progress

achieved in the prevention and

control of NCDs

Global monitoring framework,

indicators and and targets for

NCDs

WHO Global Status Report

on NCDs (2013)

SG's report on the progress

achieved in realizing the

commitments made in the

Political Declaration

Timelines

3rd informal

consultation

on the revised action

WHR 2014: NCDs and PHC

Draft WHO Global NCD Action

Plan 2013-2020

Revised draft WHO Global NCD

Action Plan 2013-2020

Global monitoring framework,

indicators and and targets for

NCDs

Sep 2013

2014

UNGA2014

28 Nov 2012Dec 2013

on the revised action

plan

11-12 Mar 2013(to be followed by informal dialogues with NGOs and the private sector)

21-29 Jan 2013

EB132February 2013

20-28 Jan 2013

WHA66

WHO's input into SG's

report on the progress

achieved in realizing the

commitments made in the

Political Declaration

Programme area NCDs (4 diseases and 4 risk factors)

Proposed Programme Budget 2014-2015 – Category 2 (NCDs)

Outcomes

Outcome: Increase the number of people with access to interventions to

prevent and manage the four major NCDs and their risk factors

Outputs:

1. Support provided to countries to engage in multisectoral policy dialogue, establish policies and

plans and implement the ‘best buy’ interventions to prevent and manage the major NCDs,

Outputs

plans and implement the ‘best buy’ interventions to prevent and manage the major NCDs,

including measures to reduce exposure to their risk factors

2. Support provided to strengthen national capacity for operational research for early detection,

diagnosis and use of cost‐‐‐‐effective treatment interventions for noncommunicable diseases and

for the promotion of health‐‐‐‐in‐‐‐‐all‐‐‐‐policies and whole‐‐‐‐of‐‐‐‐government approaches and

multisectoral action

3. Global targets set and monitoring framework established to report on progress in realizing the

commitments made in the Political Declaration of the High‐‐‐‐level Meeting of the General

Assembly and the action plan for the global strategy for the prevention and control of

noncommunicable diseases 2013‒‒‒‒2020, including the progress towards achieving the voluntary

global targets

Thank [email protected]

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