I am responding to this open consultation as Chair of the UK Need for Nutrition Education/Innovation Programme (NNEdPro: www.nnedpro.org.uk). The NNEdPro Group represents a strategic partnership between doctors, dietitians, nutritionists, and other healthcare professionals. It is composed of several partner organisations including the British Dietetic Association, Society for Nutrition Education and Behaviour, the Cambridge University Hospitals/School of Clinical Medicine, the University of Ulster and the UK Medical Research Council Human Nutrition Research unit in Cambridge, UK.
I commend the spirit of this draft framework for action and welcome the Second International Conference on Nutrition in November this year. Particularly following the United Nations High Level Meeting on Non Communicable Diseases (NCDs) in June and July this year, the November meeting is both timely and necessary to move from recommendations into implementation. I would be interested in attending the meeting in November and representing a section of the UK academic sector particularly in relation to translation into healthcare practice which is a key domain of interest.
However, upon internal discussion with colleagues I do have some key comments for consideration, below…
Comments on the draft ‘Framework for Action’
Overall, the draft document contains a number of balanced recommendations that will be useful to give flight to the Rome declaration. However, in addition to highlighting key evidence supporting the recommendations made (chapters 1-2), some ‘grey’ areas (chapter 3) are also highlighted below:
Ø Chapters 1-2
The following references made in chapters 1 and 2 are of key positive value:
o “nutritionally appropriate diets” (par. 1.1), without singling out any specific type of food as “unhealthy” – it is increasingly recognized that despite the nature of evidence in nutrition which often relies on single nutrient research, individuals consume foods in the form of diets and dietary patterns which can also be observed at regional/population level providing a composite indicator linked with health which can be monitored at population level.
o “knowledge and evidence-based strategies, policies and programmes” (par. 2.1) – as nutrition is a multipartite discipline the knowledge bases can be incongruous as well as the ways in which quality of evidence is assessed in the wake of incorporation into generalised policies or more focused programmes; placing emphasis on the need for a ‘knowledge economy’ in nutrition and a strong evidence base are of key importance in keeping policies and programmes fit for purpose.
o “involve regular consultations among all implementing partners, including consumer groups, other civil society organizations, producers, processors, distributors and retailers of food” (par. 2.2) – this recognises the importance of the food chain and how the importance of ensuring a harmonized approached across various partners in this chain.
o “professional nutritionists, research scientists, educators” (par. 2.2) – there is great potential for these groups of professionals to work in partnership, alongside healthcare professionals who may not be nutritional experts but have the opportunity to provide advice/advocacy in a nutrition and health related context.
Ø Chapter 3
The following statement is encouraging as it recommends a ‘whole systems’ approach: “interventions in isolation may have limited impacts within such a complex system, interventions that consider food systems as a whole are more likely to succeed” (par. 3.1). However, the following points made in chapter 3 require further review and possible fine-tuning:
o “Food systems” (3.1, paragraph 10): the reference to WHO recommendations on diets contained in this paragraph, refers to draft recommendations not yet approved or enshrined in policy by Member States, such as the one included in the 5th bullet point (“WHO recommends that intake of free sugars is less than 10% of total energy intake or, preferably, less than 5%”). These Guidelines are still in a draft version, recently put to public consultation and currently under revision. The WHO website (http://www.who.int/nutrition/sugars_public_consultation/en) states the following: “Once the peer-review and public consultation are complete, the guideline will be finalised and reviewed by the WHO Guidelines Review Committee for final clearance prior to its official release”. The real practical concerns with this particular recommendation are gaps in Level-1 evidence alongside concerns around achievability but also appropriateness for this to apply to different geographic and socioeconomic contexts as a blanket policy. This paragraph should be modified, maintaining only the references to WHO documents already approved by Member States.
o “Food Environments” (3.1.1 page 12, 2nd bullet point in the section on “incentivize healthy dietary choices”): “Create fiscal incentives and disincentives to encourage healthy diets by reducing the cost of more healthy diet options relative to less healthy ones” - this sentence opens the door to unjustified forms of “food taxes” which, without adequate research based evidence towards effectiveness of such a policy on appropriate health outcomes. This may disproportionately discriminate certain types of foods which, when consumed in moderation as part of a balanced diet/lifestyle, would not be considered as “unhealthy”. Food taxes can be a risky venture as their social and cultural value/acceptability has not been fully assessed. Additionally, the Danish experience of implementation without adequate piloting led to the following statement by their government: “the fat tax hit jobs and increased cross border trade, with rising numbers of Danes heading into Germany to buy butter”. This sentence would therefore merit significant modification.
o “Nutrition education for behavior change” (3.3.4, page 21, 7th paragraph): “Nutrient profiling has been used as a tool to qualify the nutritional value of individual foods and help consumers make healthy choices, as well as governments design schemes to control food marketing and label food products”. Particularly given that current focus has shifted to diet and lifestyle patterns rather than single foods investment in nutrient profiling may be a blunt instrument, further offset by difficulty in reaching agreement e.g. since 2007 the European Commission has been trying to define nutrient profiles to regulate health claims, without being able to reach any agreement among Member States. This section also does not refer to behaviour change and nutrition education geared towards healthcare professionals. The aforementioned sentence should, therefore, be reviewed.
o “International Trade and Investment”, (page 24, third paragraph- it follows par. 3.3.6 and before par. 4): “The availability of and access to unhealthy foods should be effectively regulated and discouraged. International standards in regulations for nutrition content to promote compliance with nutrition requirements should be established, implemented and enforced.” This may lead to negative consequences particularly on traditional quality European products including component foods of the Mediterranean Diet which would all be classified as “unhealthy” due to fat, sugar and/or salt content. This sentence requires rethinking.
In addition, throughout the draft document there is a lost opportunity through heavy focus on policy but without accompanying strategies for implementation into practice or impact evaluation relating to uptake of policy or indeed translation into practice. In order to emphasize the practice angle further in relation to public health nutrition and the control/prevention of non-communicable diseases it is also necessary through this document to highlight the need to build capacity in the nutrition and healthcare workforce as well as improve engagement on the part of healthcare practitioners to foster ‘nutritionally informed’ health advice and advocacy, underpinned by robust evidence based policies, wherever possible.
I would be happy to provide further clarification/information and further supporting references if required and hope that there will be an opportunity to attend/feed into the meeting in November.
Kind regards
~Shumone~
Dr Sumantra Ray
Senior Medical Advisor | Senior Clinician Scientist
UK National Diet and Nutrition Survey (NDNS) Lead Clinician
Prof. Sumantra Ray
On behalf of the NNEdPro Global Centre for Nutrition and Health in Cambridge, we are delighted to submit our response to this cardinal and timely initiative. We particularly hold the fort in regard to Nutrition Education of healthcare and public health professionals as a self-sustaining strategy to promulgating adequate preventative as well as therapeutic aspects of Nutrition across at-risk populations, globally. We would be happy to have further dialogue and form partnerships with both the secretariat as well as other relevant stakeholders.
Professor S Ray, NNEdPro Chair and Executive Director & Dr G Jones, Head of Core Support for the NNEdPro Group
The Need for Nutrition Education/Innovation Programme (NNEdPro) and its Global Centre for Nutrition and Health in Cambridge, welcomes the opportunity to comment on the first draft of the ‘FAO/WHO Work Programme of the UN Decade of Action on Nutrition, 2016-2025’.
Q1. Does the work programme present a compelling vision for enabling strategic interaction and mutual support across existing initiatives, platforms, forums and programmes, given the stipulation of Res 70/259 that the Decade should be organized with existing institutions and available resources?
As a global organisation concerned with malnutrition at all levels we fully support a collective vision that is inclusive of all, irrespective of life stage, geographic location or economic standing. The vision should underpin the work programme and its inclusion of activities addressing the complex and multi-factorial issues of over and under nutrition, food security, availability, sustainability, safety and access to knowledge and training.
The draft work programme identifies the use of existing institutions and resources but must also ensure that it is open to utilising the skills and assets of emerging stakeholders as well as institutions with established FAO/WHO relationships.
To achieve the commitments made at ICN2, in the 2025 Global Nutrition and diet-related NCD targets and in the 2030 Agenda for Sustainable Development it is essential activities are inclusive, accountable and transparent with data collection and evaluation undertaken in agreement with open data principles.
Q2.What are your general comments to help strengthen the presented elements of the first draft work programme of the UN Decade of Action on Nutrition?
The Nutrition Decade aim to ‘be for all’ is commendable, as malnutrition is a global issue impacting on health and the environment, as well as the economy at both national and global level. However research has shown there are currently significant gaps in the required nutrition knowledge and skills to deliver change, particularly in countries with the greatest need. This is an area that needs to be developed, as without a trained and competent workforce nutrition interventions will be limited in their impact and effectiveness. Whilst it is the focus of Action Area 3, the need for nutrition education, knowledge and training actually underpins all the Action Areas. We believe that the work programme would be strengthened by providing further clarity that nutrition education, training and skill development is the foundation for all action, so as to underpin the importance to member states investing in this fundamental requirement. In addition we believe the draft work programme would be strengthened by the explicit mention of the role of implementation science. The funding, application and capacity for implementation science could, for example, be highlighted in Table 1. Furthermore, it is important for such Nutrition Education to be targeted towards a critical mass of healthcare and public health professionals and not just simply the population at large. The benefit of targeting such a group would be that statutory regulated professionals have a responsibility to consistently discharge safe, effective and evidence-informed advice, taking into account individualised requirements and circumstances. Internalising adequate Nutrition knowledge and skills within the healthcare and public health workforce is therefore a self-sustaining strategy.
Q3.Do you feel you can contribute to the success of the Nutrition Decade or align yourself with the proposed range of action areas?
NNEdPro is a global organisation with expertise in researching, developing and delivering nutrition education and skill development. Our multi-country network is ideally placed to support the Nutrition Decade in supporting the development of measurable markers for the nutrition knowledge and skill level of those delivering change and activities at a global, national and local level. Through our partnership with GODAN (Global Open Data for Agriculture and Nutrition) we can also support the implementation requirements for open data collection and reporting.
Q4.How could this draft work programme be improved to promote collective action to achieve the transformational change called for by the 2030 Agenda for Sustainable Development and the ICN2 outcomes? What is missing?
To promote collective action the draft work programme would be improved by the inclusion of more specificity in respect to timelines, activities, responsibilities and measurable outcomes. This could be achieved by providing more detail in Table 2 following dialogue with member states and stakeholders.
Clearer measures of capacity, activities and outcomes would be beneficial for transparently assessing impact and success. NNEdPro would request in particular the inclusion of measures for nutrition education provision (particularly to the healthcare and public health workforce) and for the measurement of the level of nutrition knowledge and skill of those delivering interventions and initiatives ‘on the ground’. This would enable Member States to clearly determine and measure investment in this area and enable global comparisons and accountability.
Q5. Do you have specific comments on the section on accountability and shared learning?
NNEdPro supports transparent reporting and the principles of open data. The use of a publicly-accessible repository would enable nutrition researchers to explore this rich dataset for further research and investigations to further this area of knowledge. We would also seek to utilise our Annual International Summit in Medical Nutrition Education and Research for knowledge exchange from the UN Decade of Actions in Nutrition, with a dynamic international cross-section of healthcare professionals in particular.