Policy Tag: Nutrition

Adopted by the 70th WMA General Assembly, Tbilisi, Georgia, October 2019

 

PREAMBLE

Non-communicable diseases (NCDs) are the leading causes of death worldwide. Every year 40 million people die from NCDs [1]. The most common causes of these diseases are poorly balanced diet and physical inactivity. A high level of free sugar consumption has been associated with NCDs because of its association with obesity and poor dietary quality.

According to the World Health Organization (WHO), free sugar is sugar that is added to foods and beverages by the manufacturer, cook or consumer that results in excess energy intake which in turn may lead to parallel changes in body weight.

WHO defines free sugar as ‘all sugars that are added during food manufacturing and preparation as well as sugars that are naturally present in honey, syrups, fruit juices, and fruit concentrates.’

Sugar has become widely available and its global consumption has grown from about 130 to 178 million tonnes over the last decade.

Excess free sugar intake, particularly in the form of sugar-sweetened beverages, threatens the nutrient quality of the diet by contributing to the overall energy density but without adding specific nutrients. This can lead to unhealthy weight gain and increases the risk of dental disease, obesity and NCDs. Sugar-sweetened beverages are defined as all types of beverages containing free sugars (include monosaccharides and disaccharide) including soft drinks, fruit/vegetables juices and drinks, liquid and powder concentrates, flavored water, energy and sports drinks, ready-to-drink tea, ready-to-drink coffee and flavored milk drinks.

The World Health Organization recommends reducing sugar intake to a level that comprises 5% of total energy intake (that is around 6 teaspoons per day) and not to exceed 10% of total energy intake [2].

The price elasticity of sugar-sweetened beverages according to a meta-analysis published in USA, is -1.21. This means that for each 10% increase in the price of sugar-sweetened beverages, there is a -12.1% decrease in consumption. Successful examples of price elasticity were seen in Mexico as the consumption of sugar-sweetened beverages decreased after imposing the sugar tax.

Data and experience from across the world demonstrate that a tax on sugar works best as part of a comprehensive set of interventions to address obesity and related chronic diseases. Such interventions include food advertising regulations, food labelling, educational campaigns, and subsidy on healthy foods.

 

RECOMMENDATIONS

The World Medical Association (WMA) and its constituent members should:

  • call upon the national governments to reduce the affordability of free sugar and sugar-sweetened beverages through sugar taxation. The tax revenue collected should be used for health promotion and public health preventive programs aimed at reducing obesity and NCDs in their countries;
  • encourage food manufacturers to clearly label sugar, if present, in their products and urge governments to mandate such labeling;
  • urge governments to strictly regulate the advertising of sugar containing food and beverages targeted especially at children;
  • urge national governments to restrict availability of sugar-sweetened beverages and products that are highly concentrated with free sugar from educational and healthcare institutions and replace with healthier alternatives.

Constituent members of the WMA and their physician members should work with national stakeholders to:

  • advocate for healthy sustainable food with limited free sugar intake that is less than 5% of total energy intake;
  • encourage nutrition education and skills programs toward preparing healthy meals from foods without added sugar;
  • initiate and/or support campaigns focused on healthy diets to reduce sugars intake;
  • advocate for an inter-sectoral, multidisciplinary and comprehensive approach to reducing free sugar intake.

 

References

[1] http://www.who.int/fr/news-room/fact-sheets/detail/noncommunicable-diseases

[2] WHO Guideline: Sugars Intake for Adults and Children 2015

Adopted by the 59th WMA General Assembly, Seoul, Korea, October 2008
and revised by the 70th WMA General Assembly, Tbilisi, Georgia, October 2019

 

PREAMBLE

Dietary table salt is an ionic compound comprising of sodium chloride, which is 40% sodium (Na+) and 60% chloride (Cl-). There is overwhelming evidence that excessive sodium intake is a risk factor for the development, or worsening of hypertension, which is one of the main cardiovascular risk factors. Hypertension may also be an independent risk factor for cardiovascular diseases as well as all-cause mortality. The effect of dietary sodium on blood pressure is influenced by various demographic factors such as age and ethnicity.

Salt intake is also a risk factor for gastric cancer [1].

The World Health Organization (WHO) recommends that average daily sodium consumption in adults (≥16 years of age) should be less than 2000 mg (5 g salt). For children (2–15 years of age), the adult intake limit of 2 g/day sodium should be adjusted downward based on the energy requirements of children relative to those of adults [2].

The majority of the world’s population consumes too much sodium – 3.95 (3.89–4.01) g/day, equivalent to table salt level of 10.06 (9.88–10.21) g/day. These consumption levels are far above the recommended limit [3].

The main source of sodium is dietary consumption, 90% of it in the form of salt [4], as added salt during cooking or eating, or in processed foods such as canned soups, condiments, commercial meals, baking soda, processed meats (such as ham, bacon, bologna), cheese, snacks, and instant noodles, among others. In higher-income countries sodium added during food processing can be as high as 75%-80% of total salt intake [5].

The Global Action Plan for the Prevention and Control of Non-Communicable Disease (NCDs) 2013-2020 is made up of 9 global targets, including a 30 % relative reduction in mean population intake of sodium. The WHO has created the S.H.A.K.E technical package to assist Member States with the development, implementation and monitoring of salt reduction strategies.

The WHO recognises that while salt reduction is recommended globally, there is concern that iodine deficiency disorders (IDD) may re-emerge as iodized salt is the main vehicle for dietary iodine intake through fortification. Therefore the WHO, in recognition of the importance of both sodium reduction and iodine fortification, urges that efforts of the two programs be coordinated [6].

Substantial overall benefits can result from even small reductions in the population’s blood pressure. Population-wide efforts to reduce dietary sodium intake are a cost-effective way to reduce overall hypertension levels and subsequent cardiovascular disease. Evidence shows that keeping sodium consumption within the reference level could prevent an estimated premature 2.5 million deaths each year globally [7].

 

RECOMMENDATIONS

1. WMA and its Constituent Members should:

a. Urge governments to recognise that salt consumption is a serious public health problem and prioritise prevention as an equitable, cost effective and lifesaving population-wide approach to address high sodium intake and the associated high burden of cardiovascular diseases.

b. Work in cooperation with national and international health organisations to educate consumers from childhood about the effects of excessive sodium intake on hypertension and cardiovascular disease, the benefits of long-term reductions in sodium intake, and about the dietary sources of salt/sodium and how these can be reduced.

c. Urge the governments and other stakeholders work together to achieve the targets set in the Global Action Plan for the Prevention and Control of NCDs 2013-2020.

d. Recognise the critical role of the food processing and food services industry in reducing dietary sodium, and support regulatory efforts involving mandatory targets in food processing, sodium content of foodstuffs, and clear labelling. Food reformulation efforts must target food products that are most commonly consumed in the population.

2. Constituent members of WMA should:

a. Encourage their governments strictly to enforce laws regulating the sodium content in processed foods.

b. Embrace a multi stakeholder approach in working towards reducing the consumption of excessive sodium by the population, including active promotion of physician awareness regarding the effects of excessive dietary sodium.

c. Recognise that sodium reduction and salt iodization programmes need to be compatible and support sodium reduction strategies that do not compromise dietary iodine content, or increase or worsen iodine deficiency disorders, especially in low income settings.

d. Contribute to making the public aware of the potential consequences of low iodine levels as a result of restricted iodized salt intake.

e. Encourage their members to contribute to scientific research on sodium reduction strategies.

f. Encourage the initiation of food labeling, media campaigns and population-wide policies such as mandatory reformulation to achieve larger reductions in population-wide salt consumption than individually focused interventions.

3. Individual physicians should:

Counsel patients about the major sources of sodium in their diets and how to reduce sodium intake, including reducing the amount of salt used in cooking at home, use of salt substitutes, and addressing any relevant local practices and beliefs that contribute to high sodium intake.

 

References:

[1] World Cancer Research Fund / American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR, 2007.

[2] Guideline: Sodium intake for adults and children. Geneva, World Health Organization (WHO), 2012.

[3] Mozaffarian, Dariush, Fahimi, Saman, Singh, Gitanjali M., Micha, Renata, Khatibzadeh, Shahab, Engell, Rebecca E., Lim, Stephen, Danaei, Goodarz, Ezzati, Majid and Powles, John (2014) Global sodium consumption and death from cardiovascular causes. New England Journal of Medicine, 371 7: 624-634. doi:10.1056/NEJMoa1304127.

[4] J. He, N.R.C. Campbell, G.A. MacGregor. Reducing salt intake to prevent hypertension and cardiovascular disease. Rev. Panam. Salud Publica, 32 (4) (2012), pp. 293-300.

[5] World Health Organization Regional Office for Europe Mapping salt reduction initiatives in the WHO European Region (Web. 10 May 2014.) http://www.euro.who.int/__data/assets/pdf_file/0009/186462/Mapping-salt-reduction-initiatives-in-the-WHO-European-Region.pdf (2013).

[6] Salt reduction and iodine fortification strategies in public health. 2014. http://www.who.int/nutrition/publications/publichealth_saltreduc_iodine_fortification/en/.

[7] McLaren L, Sumar N, Barberio AM, Trieu K, Lorenzetti DL, Tarasuk V, Webster J, Campbell NRC.Population-level interventions in government jurisdictions for dietary sodium reduction. Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD010166. doi: 10.1002/14651858.CD010166.pub2.

Adopted by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 67th WMA General Assembly, Taipei, Taiwan, October 2016 

PREAMBLE

Obesity is one of the single most important health issues facing the world in the twenty-first century, affecting all countries and socio-economic groups and representing a serious drain on health care resources.

Obesity in children is of increasing concern and is emerging as a growing epidemic in itself.

Obesity has complex origins linked to economic and social changes in society including the obeso-genic environment within which much of the population lives.

Therefore the WMA urges physicians to use their roles as leaders to advocate for recognition by national health authorities that reduction in obesity should be a priority, with culturally and age appropriate policies involving physicians and other key stakeholders.

THE WMA RECOMMENDS THAT PHYSICIANS:

  • Lead the development of societal changes that emphasize environments which support healthy food choices and regular exercise or physical activity for all people, with a specific focus on children;
  • Individually and through medical associations, express concern that excessive television viewing and video game playing are impediments to physical activity among children and adolescents in many countries;
  • Encourage individuals to make healthy choices and guide parents in helping their children to do so;
  • Recognise the role of personal decision making and the adverse influences exerted by current environments;
  • Recognise that collection and evaluation of data can contribute to evidence based management, and should be part of routine medical screening and evaluation throughout life;
  • Encourage the development of life skills that contribute to a healthy lifestyle in all persons and to better public knowledge of healthy diets, exercise and the dangers of smoking and excess alcohol consumption;
  • Advocate for appropriately trained professionals to be placed in educational facilities, highlighting the importance of education on healthy lifestyles from an early age;
  • Contribute to the development of better assessment tools and databases to enable better targeted and evaluated interventions;
  • Ensure that obesity, its causes and management remain part of continuing professional development programmes for health care workers, including physicians;
  • Use pharmacotherapy and bariatric surgery consistent with evidence-based guidelines and an assessment of the risks and benefits associated with such therapies.

Adopted by the 67th WMA General Assembly, Taipei, Taiwan, October 2016 

PREAMBLE

Childhood obesity is a serious medical condition and a major public health concern affecting many children.  Childhood obesity is emerging as a growing epidemic and is a challenge in both developed and developing countries.  Due to its increasing prevalence and its immediate and long-term impact on health, including predisposition to diabetes and cardiovascular abnormalities, childhood obesity should be viewed as a serious concern for public health. The increase in childhood obesity may be attributed to many factors:

  • Recent studies show that marketing targeted at children has a wide influence on the shopping trends and food preferences of households all over the world. Special offers, short-term price reductions and other price promotions and advertising on social as well as traditional media all play a role in increasing product demand.
  • Many advertisements are in conflict with nutritional recommendations of medical and scientific bodies. TV advertisements for food and drink products with little or no nutritional value are often scheduled for broadcast hours with a large concentration of child viewers and are intended to promote the desire to consume these products regardless of hunger. Advertisements increase children’s emotional response to food and exploit their trust. These methods and techniques are also used in non-traditional media, such as social networks, video games and websites aimed at children.
  • Unhealthy dietary patterns, together with a sedentary lifestyle and lack of exercise, contribute to childhood obesity.  The sedentary lifestyle is the most predominant one in the developed world today. Many children typically spend more time than ever in front of screens, rarely engaging in physical activities.
  • International corporations and conglomerates that manufacture foods and beverages are not always subject to regional regulations that govern food labeling. Concern for profits may come at the expense of corporate responsibility for environmental and public health issues.
  • Products containing large amounts of added sugar, fat, and salt can be addictive, especially when combined with flavor enhancers. In some countries, not all ingredients are required to be listed on food labels and manufacturers often refuse to release data on methods employed to maximize consumption of their products.  Governments should require that all ingredients in food and beverages be clearly labeled, including those proprietary ingredients intended to increase consumption of the product.
  • Socioeconomic disparities also correlate with increasing rates of childhood obesity. The link between living in poverty and early childhood obesity continues to negatively affect health in adult life.[1] Exposure to environmental contaminants, sporadic medical checkups, insufficient access to nutritious foods and limited physical activity lead to obesity and other chronic illnesses that are all more prevalent among children living in poverty.

RECOMMENDATIONS

  1. A comprehensive program is needed to prevent and address obesity in all segments of the population, with a specific focus on children.  The approach must include initiatives on price and availability of nutritious foods, access to education, advertising and marketing, information, labeling and other areas specific to regions and countries.  An approach similar to that on tobacco in the WHO Framework Convention on Tobacco Control is advocated.
  2. International studies stress the importance of adopting an integrated approach to education and health promotion.  Investment in education is key to minimizing poverty, improving health and providing economic benefits.
  3. Quality education offered in formal settings to children aged 2 to 3 years, combined with enrichment activities for parents, and sufficient supply of nutritious food and beverages may help to reduce the rate of adolescent obesity and reduce its health implications throughout the life course. Developing early healthy eating practices and experiencing flavors of healthy food when very young appear to be positive factors in prevention of childhood obesity.
  4. Governments should invest in education related to menu design, food shopping including budget setting, storage and preparation so that people are better equipped to plan their food intake.
  5. Governments should seek to regulate the availability of food and beverages of poor nutritional value, by a range of methods including price.  Attention should be paid to the availability close to schools of establishments selling products of poor nutritional quality.  Governments should seek to persuade manufacturers to reformulate products to reduce their obesogenic effects.  Where possible government and local authorities should seek to manage the density of such establishments in the area.
  6. Governments should consider imposing a tax on non-nutritious foods and sugary drinks and use the additional revenue to fund research and epidemiological studies aimed at preventing childhood obesity and reducing the resulting disease risk.
  7. Ministries of health and education should regulate food and beverages that are sold and served at educational and healthcare facilities.
  8. Given the scientifically proven link between the extent of media consumption and adverse effects on body weight in children, the WMA recommends that the advertising of non-nutritious products be restricted during television programming and other forms of media that appeal to children.  Regulators should be aware that children access television programs designed for adults and ensure that legislation and regulation also limits marketing associated with such programs.
  9. Governments should work with independent health experts to produce sound guidance on food and nutrition, with no involvement of the food and drink industry.
  10. Governments and local authorities should subsidize and encourage activities that promote good health among their residents, including providing safe spaces for walking, bike riding and other forms of physical activity. 
  11. Parents have a crucial role in fostering physical activity in their children. Schools should incorporate daily physical activity into their daily routine.  Participation in sport activities should be possible for everyone regardless of their economic situation.
  12. National Medical Associations should support or develop guidelines and recommendations to ensure that they reflect current knowledge of prevention and treatment of childhood obesity.
  13. National Medical Associations should work to raise public awareness on the issue of childhood obesity and highlight the need to tackle the rising prevalence of obesity and its health and economic burden.
  14. Clinics and Health Maintenance Organizations should employ appropriately trained professionals to offer classes and consultation in selecting appropriate amounts of nutritious foods and beverages and attaining optimal levels of physical activity for children.  They should also ensure that their premises are exemplars in the provision of healthy food options.
  15. Educational facilities should employ appropriately trained professionals who educate for healthy lifestyles from an early age and allow all children, whatever their social environment, to practice regular physical activities.
  16. Physicians should guide parents and children in how to live healthy lives and emphasize the importance of doing so, and must identify as soon as possible obesity in their patients, particularly children. They should direct patients suffering from obesity to the appropriate services at the earliest possible stage, and conduct regular follow-ups.
  17. Physicians and health professionals should be educated in nutrition assessment, obesity prevention and treatment. This could be accomplished by strengthening CME activities focused on nutritional medicine.

[1] WHO Commission on Social Determinants of Health (Closing the Gap in a Generation) 2008.