1 Hidden ingredients: salt, sugar, fat, total caloriesDr João Breda, MPH PhD MBA Programme Manager Nutrition, Physical Activity & Obesity WHO Regional Office for Europe

2 NCD targets – a challenge for Europe2025

3 WHO European Region MS achieving global targets around nutrition & physical inactivity by updated Staggering progress towards the achievement of WHO Global targets Progress towards the achievement of some selected global targets is uneven. For some indicators a vast majority of countries is off-tack particularly when it comes to breastfeeding, obesity, anemia and physical activity.

4 WHO Guidelines and mandate

5 WHO sodium guidelines (2013)WHO recommends a reduction to <2 g/day sodium (5 g/day salt) in adults (strong recommendation) In children, WHO also recommends a reduction in sodium intake to control blood pressure (strong recommendation). The recommended maximum level of intake of 2 g/day sodium in adults should be adjusted downward based on the energy requirements of children relative to those of adults

6 2015 sugar guidelines WHO recommends reduced intake of free sugars throughout the life-course (strong recommendation) In both adults and children, WHO recommends that intake of free sugars not exceed 10% of total energy (strong recommendation) WHO suggests further reduction to below 5% of total energy (conditional recommendation)

7 Association between free sugars intake and measures of body fatness in childrenWHO guideline: no more than 10% TEV but 5% better AHA – 2016 – children, no more than 25 g sugar p/day Source : Te Morenga et al., 2012

8 Limit saturated fats and avoid iTFAsSaturated fatty acids and trans fatty correlated with CVD Saturated fatty acids are found in foods from animal sources Industrially-produced trans-fatty acids (iTFAs) can be found in baked and fried foods, prepared snacks and partially hydrogenated cooking oils and spreads. Results of recent WHO systematic reviews show that replacing saturated fatty acids and trans fatty acids with other macronutrients, particularly PUFA, has a favourable effect on CVD risk.

9 IARC monographs (Aug 2016) Overweight / ObesityConfirmed: colorectal, oesophagus, kidney, breast in postmenopausal women, endometrium new: gastric cardia, liver, gallbladder, pancreas, ovary, thyroid, meningioma, and multiple myeloma Overweight /Obesity RR associated to the additional 8 cancers Gastric Cardia RR = 1.8 ( ) Liver RR = 1.8 ( ) Gallbladder RR = 1.3 ( ) Pancreas RR= 1.5 ( ) Ovary RR = 1.1 ( ) Thyroid RR = 1.1 ( ) Meningioma rr = 1.5 ( ) Multiple myeloma RR = 1.5 ( )

10 WHO Mandate on Nutrition, Diet & Obesity in EuropeTo tackle obesity, diet and physical inactivity related problems member states have committed to join efforts to collectively address it. The Food and Nutrition Action Plan and the Physical Activity Strategy for the WHO European Region , both combined give WHO and Member States an ideal framework to develop their initiatives. We are now in full blown implementation mode. Action is being taken and support is being provided to member states in the context of the 10 priority areas included in the policy frameworks. EU Action Plan on Childhood Obesity:

11 State of play in europe and beyond

12 Lancet, April 2016: NCD RF collaboration

13 Projected prevalence of obesity (≥30 kg/m2) to 2025 14 with best quality dataThe WHO European Region made significant progress towards the elimination of all forms of under-nutrition although in some countries more needs to be done. Progress towards the achievement of some selected global targets is uneven. For some indicators a vast majority of countries is off-tack particularly when it comes to breastfeeding, obesity and physical activity. Unpublished data. Please do not quote

14 Childhood obesity – a challenge for the RegionDiet and physical activity account for a big share of the burden of disease in the WHO European Region. Our Region is strongly hit by the challenges posed by childhood obesity. In an original initiative from the Regional Office comparable data is being produced in a timely and sophisticated fashion. COSI provides us with rich information about childhood obesity across Europe and shows that we probably have between 20% an just below 50% of all school age children that are overweight in a large number of countries.

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16 15 g Overview of data on salt consumption in the EURO region tells us that Turkey is a champion with 18 although some indications it might have been reduce significantly in recent times All countries are above the WHO recommended average. Considerable number of countries have no data on salt consumption at all. Reminds us that efforts need to be invested in surveillance. Much of the data are not very reliable. The problem is underestimated. No data

17 Salt reduction can work 9 countries in WHO European Region have reported reduction in salt intakeFinland – 36% Lithuania – 19% Turkey – 17% UK – 15% Ireland – 14% Slovenia – 9% Denmark – 7% Iceland – 6% France – 5% Salt reduction is one of the most effective actions at population level to reduce NCDs. In the WHO European Region several member states have successfully implemented salt reduction policies. However more can and needs to be done! WHO urges MS to scale up their action on salt reduction in order to increase their likelihood to achieve the 2025 target of 30% reduction in comparison to 2010 baseline

18 Projected changes of prevalence in stroke if MS achieve salt targetStroke Country Current Reduction % Finland 127,400 5,600 4.4 France 943,000 48,000 5.1 Ireland 72,900 3,800 5.2 Italy 1,396,600 75,300 5.4 Netherlands 303,600 12,700 4.2 Poland 788,000 50,200 6.4 Spain 783,700 40,100 Sweden 184,000 12,200 6.6 UK 1,339,200 37,200 2.8 Only for stroke one could expect a reduction of 3% to 7% if the WHO target would be achieved.

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20 Sugar content of SSBs…. 30-32g 30g 38g 23g 40g 39gRefers to the sugar content of a 330ml can of a popular international soft drink brand. Source: Action on Sugar, 2015 & WHO/Europe

21 In one Baltic country (retailers website analysis)87 soft drinks analyzed 84% more than 6 g sugar per 100 ml 85% more than 25 g sugar per smaller container in the market

22 Availability of Commercially Produced Baby Food Products in the Market PlaceA Project which as recently started with the data collection. The project will identify and evaluate the nutritional composition of commercially produced baby food products and compare them to the WHO as well as national food-based dietary guidelines for infants and young children (specifically investigating the lack of essential nutrients, or excess nutrients, e.g. salt, sugar fat, trans fat) and their promotion methods Methods: data will be collected in low and in high income areas in capitals of selected countries. For this a mobile application has been developed in order to obtain information about: Location information Type of retail place and branch Food product information (age group, nutritional composition (100g / serving size)) Visual information of the product (photos) Price and promotion information From field visit we have noticed the very broad range of for example the use of sugar. many different violations for the Code

23 Very significant amounts of sugar….Baby food in Portugal – 2015 (large collection included) With milk 35,5g/100g Very significant amounts of sugar…. Importa realçar o considerável teor de açúcar bem como a frequência da adição de chocolate e mel. By courtesy of Prof. Carla Rego, Porto University, Portugal Without milk 27,7g/100g

24 Trans-fatty acids, TF and SFWHO recommends a maximum of 10% of total calories consumed per day are fat, … however, 48 countries in the WHO European Region exceed this recommendation.

25 Denmark: banning trans fat and saving lives1st world legislate against trans-fat: since 2005 Max. level 2 g trans fatty acids per 100 g of fat No strong objection from industry Ban followed by a decrease in CVD mortality rates Estimated reduction 14,2 deaths per Other countries followed: Austria, Georgia, Hungary, Iceland, Switzerland Evidence on the effects of industrially produced trans fats has been increasing over the past three decades. The most recent WHO recommendations state that intake of trans fats should be as low as possible The recommendation to minimize trans-fat intake is based predominantly on evidence that trans-fat consumption significantly increases the risk of coronary heart disease WHO advocates for a pan-European trans fat ban that can save many thousands of cardiovascular events, cancer and avoid premature mortality.

26 In one Baltic MS:partly hydrogenated vegetable fat/oil (survey based)43% of the producers used PHVF in their products Handlers that produce: pastries, confectionery products made of flour, confectionery containing sugar, half-fabricates, ice cream, mayonnaise and other sauces Out of the 47 producers that used PHVF, 43 were based in the capital (92%) Edasi räägime ainult osaliselt hüdrogeenitud taimsest rasvast Analüüsides tulemusi ettevõtete järgi: Jagasime ettevõtted töötajate arvu järgi 4 gruppi. Kõige rohkem ettevõtteid on kuni 10 töötajaga grupis, kes kasutavad OHTR. Loogiliselt on siis ka nn väga suuri ettevõtted kõige vähem. 109st ettevõttest kasutas 47 s.o 43%– 47st ettevõttest oli 43 ettevõtet täielikult eesti kapitalil põhinevad. Ehk meie eeldus, et see nii võib olla leidis kinnitust

27 High trans fat still a problem in EuropeAssociated with socio-economic disadvantage Extreme values Influence other markets POR - TFAs are present in food products, situation is only of major concern in two particular cases: pastry and cookies Source: Croatian Food Agency

28 Trans fat content (g/ serving)Highest TFA content observed on the most commonly available industrial products Food product % TFA Serving (g) Trans fat content (g/ serving) Industrial Products Pastries Sample I 15.6 53.8 8.4 Sample II 9.6 33.1 3.2 Sample III 7.5 29.0 2.2 Sample IV 20.3 0.7 Mean 9.0 3.6 Cookies 14.9 29.4 4.4 7.0 13.0 0.9 30.0 0.2 0.5 9.8 0.1 5.8 1.4 Waffles 12.3 54.4 6.7 7.1 69.8 5.0 6.5 33.6 8.6 4.6 From a total of 35 collected samples of industrial products, 49% showed a content of trans fat above 1%, reaching a maximum level of 15,60% (pastries). The industrial products that showed a higher content of trans fat: pastries, cookies and waffles (values between 12,3% - waffles and 15,6% - pastries) Different samples, from different vendors were collected for each food category and higher and lower content content of trans fat were observed among them – important for reformulation.

29 Where to from here? Monitoring and surveillance needs to be largely improved…. Reduce children’s exposure to food marketing (digital) Considering economic tools and improve information to consumers Food product reformulation can only be successful if mainstreamed Measure of and environment nature are crucial notably healthier food environments in schools Policies target macro environment-population wide- increase effectiveness 29