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Virtual session, 13–15 September 2021 2 August 2021
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Provisional agenda item 14 ORIGINAL: ENGLISH
Progress report on the European Food and Nutrition Action Plan 2015–2020
This report describes progress in implementing the European Food and Nutrition Action Plan 2015–2020 (document EUR/RC64/14), as well as the efforts made by the WHO Regional Office for Europe to support this implementation. It outlines developments, achievements and reporting requirements in line with the commitments made through the adoption of resolution EUR/RC64/R7 at the 64th session of the WHO Regional Committee for Europe in 2014.
This report is submitted for consideration by the Regional Committee at its 71st session in accordance with resolution EUR/RC64/R7.
Background
1. This report provides an update on progress made since the 64th session of the WHO Regional Committee for Europe on the adopted resolution EUR/RC64/R7 on the European Food and Nutrition Action Plan 2015–2020. The European Food and Nutrition Action Plan 2015–2020 (document EUR/RC64/14) contributed to the vision and mission of Health 2020, the European policy framework for health and well-being endorsed by the Regional
Committee in 2012.
2. By adopting the European Food and Nutrition Action Plan 2015–2020, Member States have taken an important and decisive step towards promoting healthy diets and addressing the high rates of obesity and diet-related noncommunicable diseases (NCDs) across the WHO European Region.
3. There is evidence that the burden of unhealthy diet, unhealthy weight and other forms of malnutrition remains very large in the European Region. In a significant number of Member States, energy-dense diets, high consumption of fat, trans-fats, free sugars and salt, low
consumption of fruit and vegetables, and high overweight rates are impeding progress towards achieving the Sustainable Development Goals, global NCD targets and global nutrition targets.
4. The Action Plan is aligned with the global policy frameworks for nutrition and for the prevention and control of NCDs, which were available at the time of development, notably the Comprehensive implementation plan on maternal, infant and young child nutrition. The Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020 and the voluntary global targets emerging from these global processes have also been incorporated in the Action Plan.
5. The strategic actions are in line with the new European Programme of Work, 2020–2025 – “United Action for Better Health in Europe” (EPW), which sets out a vision of how the WHO Regional Office for Europe (WHO/Europe) can support countries in the European Region to better meet their citizens’ health expectations. The Action Plan aligns the work of
WHO/Europe with the Triple Billion targets of the Thirteenth General Programme of Work, 2019–2023 (GPW 13), while supporting countries in their commitments to implement the 2030 Agenda for Sustainable Development.
6. Following the decision to extend regional strategies and action plans expiring in 2020 by one year and review them in line with the EPW, the proposed actions aim to continue the work started, and further align them with the Triple Billion targets.
Progress and implementation at regional level
7. The goal of the Action Plan is to avoid premature deaths and significantly reduce the burden of preventable diet-related NCDs, obesity and all other forms of malnutrition still prevalent in the Region. There is consistent evidence indicating that people who contract COVID-19 are more likely to be admitted to hospital, admitted to an intensive care unit and die from COVID-19 if they are overweight or living with obesity compared to people with a healthy body weight status. Therefore, the necessity to act to address high rates of obesity and diet-related noncommunicable diseases has never been greater. This report describes progress
made by Member States from 2017 to 2020, with support from WHO/Europe, in each of the five main priority areas described in the Action Plan.
Priority area 1: Create healthy food and drink environments
8. Patterns of food consumption in the European Region have changed rapidly in recent decades, and consumption of processed foods high in saturated fat, free sugars and salt (HFSS foods) is high. WHO/Europe has issued guidance in this area, encouraging governments to enforce standards.
9. Recognizing the detrimental impact of high-salt intake on the health of the population, around 40% of countries have fully achieved policies to reduce population salt intake, while a further 40% have taken steps towards partially achieving this target indicator. Despite
ongoing efforts, surveillance data indicate that salt intake still far exceeds the limits recommended by WHO to protect health. WHO/Europe has published Accelerating salt reduction in Europe: a country support package to reduce population salt intake in the WHO European Region (2020), which countries throughout the Region can use either to accelerate their existing efforts to reduce salt intake or to take decisive action to embark on salt
reduction journeys that have yet to begin.
10. National policies to reduce saturated fatty acids and eliminate trans-fats from industry were fully adopted in 75% of WHO European Member States in 2019, an increase of 13%
since 2017, with a further seven countries with partial or national commitments. With the Eurasian Economic Union (EEU), the European Union and Turkey, as well as other countries in the Region, taking measures to eliminate trans-fats, the European Region is moving closer to becoming the first WHO region in the world to become trans-fat free. Technical work in this area is supported by Resolve to Save Lives, a cardiovascular health initiative of
Bloomberg Philanthropies.
11. Policies to reduce the marketing of foods and sugary beverages have been fully implemented in 66% of WHO European Member States since 2017. The WHO European Office for the Prevention and Control of Noncommunicable Diseases (NCD Office), Moscow, Russian Federation, launched a tool in 2019 – the CLICK monitoring framework – to monitor the digital advertising of HFSS foods to children; it is a flexible tool that can be adapted to national contexts. Five countries – Finland, Norway, Portugal, the Russian Federation and Slovenia – have since started the process of objectively collecting data on the digital advertising of HFSS foods and beverages. In addition, countries including Portugal and the United Kingdom of Great Britain and Northern Ireland are strengthening their legislative frameworks to restrict digital marketing.
12. Twenty-three countries (WHO NCD Country Capacity Survey 2019) in the WHO European Region have now implemented front-of-pack labelling (FOPL); WHO/Europe developed a manual to provide guidance to countries wishing to implement an effective FOPL scheme, building on experiences from 15 countries in the Region including France and the United Kingdom with the most comprehensive interpretive labels. Most recently, WHO/Europe has been supporting Kyrgyzstan and Uzbekistan to develop effective FOPL policies.
Priority area 2: Promote the gains of a healthy diet throughout the life course, especially for the most vulnerable groups
13. Exclusive breastfeeding rates continue to be low in the Region. WHO/Europe continues to work with Member States on the promotion of breastfeeding, including through the Baby- friendly Hospital Initiative, which was successfully implemented in 36 countries, and most recently by providing support to Cyprus, Hungary, the Russian Federation and Sweden, as well as supporting the implementation of the Guidance on ending the inappropriate promotion of foods for infants and young children: implementation manual at the European level.
14. Little progress has been made towards the target of fully implementing the International Code of Marketing of Breast-milk Substitutes, with 6% of countries in the European Region achieving it, although 94% have partially achieved it. Although adopted by WHO since 1981,1 additional political commitment will be required to fully implement the Code.
15. WHO/Europe has assisted in the development of a nutrient profiling model (NPM) to guide decisions on which commercially available baby foods targeted to infants and young children aged 6–36 months are inappropriate for promotion. The NPM refers to existing European Commission directives and Codex standards, and reflects the approach used in the WHO/Europe NPM for children over 36 months. This NPM was developed using product information from three countries (Denmark, Spain, and the United Kingdom) and pilot-tested in a further seven countries (Estonia, Hungary, Italy, Malta, Norway, Portugal and Slovenia).
16. WHO/Europe also provides up-to-date guidance for ensuring healthy nutrition and physical activity of primary-school-aged children. New guidance was published in the Russian language and can be used by parents and other adults working with children across the Russian-speaking countries in the European Region.
17. In response to the COVID-19 pandemic, WHO/Europe developed a position paper alongside the European Paediatric Association to provide guidance on COVID-19 and breastfeeding which was distributed to and adopted by Member States.2
Priority area 3: Reinforce health systems to promote healthy diets 18. The Action Plan urges Member States to ensure that nutrition and healthy eating are priorities for people-centred health care systems and to include brief interventions and
nutrition counselling in primary health care settings. Most countries in the Region (over 90%) have reported providing education and counselling on nutrition and healthy diets for patients, with the most common setting being primary care (approximately 50%). Building on the outputs of an expert meeting to address this gap, WHO/Europe is developing a manual on brief interventions on NCD risk factors in primary health care settings. Capacity-building workshops for primary health care workers (training of trainers) were organized in countries including Malta, the Republic of Moldova and the Russian Federation.
19. Data to assess the response of health care delivery systems to the childhood obesity epidemic were collected in 19 countries in the European Region. Overall, the findings indicate
1 See https://www.who.int/nutrition/publications/code_english.pdf.
2 See https://www.euro.who.int/en/health-topics/Life-stages/maternal-and-newborn-
health/publications/2020/covid-19-and-breastfeeding-position-paper,-8-april-2020-produced-by-whoeurope.
that countries are taking some action to tackle the problem, but that there is a delay in the health system response and there are several constraints.
20. WHO/Europe convened a virtual expert meeting in October 2020 to discuss how countries can share data and best practices regarding obesity and NCD risk factors in the context of COVID-19. In addition to the publication of a meeting report and a peer-reviewed journal article, the meeting will inform recommendations to encourage countries to engage in data sharing and obesity prevention.
Priority area 4: Support surveillance, monitoring, evaluation and research
21. The European Food and Nutrition Action Plan 2015–2020 explicitly encourages
Member States to “strengthen and expand nationally representative diet and nutrition surveys”
and to ensure the availability of anthropometric data (particularly for children). High quality data collection on nutrition including salt intake, obesity, and fruit and vegetable consumption is routinely coordinated by the WHO/Europe NCD surveillance programme via the WHO STEPwise approach to surveillance (STEPS), and country capacity surveys capture progress on the nutrition policy interventions reported throughout this document. Data on obesity collected through surveys such as the WHO European Childhood Obesity Surveillance Initiative (COSI), a unique initiative with repeated measurements looking at trends, a common protocol and highly comparable data, are needed to drive policy. COSI is now established in around 45 Member States of the European Region, and the number of countries is increasing with each round of data collection.
22. FEEDcities, an innovative study established to describe urban food environments and drive policy actions, is extending to countries in central Asia, the Caucasus and south-eastern Europe. These cities (and countries) have street markets and other vending sites that are a unique and important part of their food culture. Data for this project have been collected from eight countries including, most recently, from the Russian Federation, and is now being collected from Azerbaijan, Georgia and Kazakhstan.
23. WHO/Europe continues to contribute to the evidence base, facilitating research to understand the main barriers to and facilitators of evidence-based and cost-effective interventions for nutrition. Eleven countries in the Region have directly contributed to boosting the understanding of the main barriers to and facilitators of implementing a
sugar-sweetened beverage (SSB) tax, providing recommendations and lessons learned to other countries in the Region and globally. Eleven countries in the Region have now implemented the SSB tax: Belgium, Finland, France, Hungary, Ireland, Latvia, Monaco, Norway, Poland, Portugal and the United Kingdom.
Priority area 5: Strengthen governance, alliances and networks for a health-in-all-policies approach
24. Member States continue to prioritize nutrition and obesity in national and subnational strategies. WHO/Europe has been compiling an overview of countries’ progress in adopting nutrition and obesity strategies, using various sources and with validation by Member States to determine which areas are covered by their policies.
25. The development of the now established networks in the Region including COSI, the European Salt Action Network, and the WHO European Action Network on Reducing Marketing Pressure on Children, and collaborations with the EEU on trans-fats elimination, provide opportunities for information exchange on implementation strategies, as well as on related activities and achievements from which countries can learn and develop their own strategies.
26. The model law developed by WHO/Europe to restrict marketing of unhealthy food products to children was adopted by the Council for Health Cooperation of the Commonwealth of Independent States in 2020.
27. WHO collaborating centres from many Member States including Germany, the Netherlands, Portugal, the Russian Federation and the United Kingdom have provided concrete support for the implementation of the Action Plan.
Conclusions and future plans
28. This report highlights the notable achievements of Member States and WHO/Europe’s activities to implement the Action Plan. The activities described here were possible due to the commitment of Member States and several donors including the Government of the Russian Federation in the context of the WHO European Office for the Prevention and Control of NCDs, and Resolve to Save Lives.
29. Within the context of the EPW, new actions have been proposed to extend the Action Plan to link nutrition promotion to NCD disease management, including novel approaches to training primary health care professionals and the promotion of assessments and brief
interventions for diet and other NCD risk factors in primary health care settings.
30. Decisive actions to reduce salt and saturated fatty acids intake, achieve trans-fats elimination and tackle obesity are needed, and continue to be priority actions for the Region.
31. Furthermore, many countries have requested support for developing policies to support healthy and sustainable diets. WHO/Europe now has to meet these needs and respond with evidence-based guidance on issues such as food-based dietary guidelines and labelling, food reformulation, digital food environments and public procurement. There is a strong link between the food system and the environment, and WHO/Europe’s future work will assess the impact of current dietary patterns on health. WHO/Europe is developing a tool for Member States to conduct this analysis at a national level, in order to inform national strategies to promote healthy and sustainable diets. These activities will complement the ambitions of the European Commission’s European Green Deal and Farm to Fork Strategy – highlighted as immediate and priority action areas.
32. The CLICK monitoring framework developed by WHO/Europe has been recognized as the leading tool to monitor digital marketing of unhealthy food products to children.
WHO/Europe can scale up this technology and build capacity in countries to use it widely for monitoring.
33. Engaging with different stakeholders can accelerate the progress towards achieving nutrition-related targets. WHO/Europe could work with Member States to explore potential
mechanisms to establish a dialogue with non-State actors including the food industry, within the Framework of Engagement with Non-State Actors. These activities should have a clear purpose, such as improving the nutrient profile of foods within a set timeline.
34. The new EPW and its flagship initiatives are a powerful channel through which the nutrition agenda can be promoted; they also enable thinking beyond traditional approaches and motivate the public to perceive health as an investment. The digital food environment is rapidly changing, especially due to COVID-19 restrictions. Novel approaches, including those using big data and artificial intelligence, provide opportunities to collect nutrition information of foods delivered via online delivery platforms and could contribute to the Empowerment through Digital Health flagship initiative. Communication campaigns can be enhanced with the support of behavioural and cultural insights. Providing tools for Member States to manage nutrition-related misinformation on social media is a novel challenge which requires a
consolidated approach. Introduction of novel approaches such as systems approaches and implementation research could facilitate the rapid uptake of sustainable nutrition policies with context-relevant adaptation.
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