Qatar National Nutrition and Physical Activity Action Plan 2017 - 2022

Qatar National Nutrition and Physical Activity Action Plan I- Introduction: The Action Plan brings together nutrition & physical activity – related actions from global, regional and national guidance documents to address diet and physical inactivity related diseases. The plan aims to achieve the Global targets related to the nutrition and Non-Communicable Diseases (NCD) in the State of Qatar. This plan describes the magnitude of the double burden of malnutrition in the State of Qatar and highlights the need to address micronutrients deficiencies and halt the rise in overweight, obesity and diet-related NCDs. To address nutrition and physical activity challenges in the State of Qatar, the following sectors, including agriculture, trade and industry, environment, communication, education, labor, Health and Sports sectors must work together and towards policy coherence across sectors. The NCD Regional Framework for Action (RFA) continues to provide strategic direction for interventions and their indicators to assess country progress in the four areas. Implementation of the RFA will also contribute to advancing the 9 global NCD targets by 2025, which includes a 25% relative reduction in premature mortality from NCDs by 2025 (and now also a 33% reduction by 2030 for the SDGs). The Sustainable Development Goals and the Decade on Action for Nutrition are bringing a renewed momentum for Nutrition globally, regionally and nationally with a clear leadership role for MoPH in the State of Qatar, in coordination with other sectors. Nutrition & Physical Activity are contributors to two of the seventeen Sustainable Development Goals defined in 2015. A direct contributor to Goal 2 (“End hunger, achieve food security and improved nutrition, and promote sustainable agriculture”) and a decisive enabler to Goal 3 (“Ensure healthy lives and promote well being for all at all ages”). The Nutrition & Physical Activity Action Plan 2017-2022 is in line with the global and Regional targets for improving maternal, infant and young child nutrition set in 2014 as well as in a number of commitments and guiding strategies developed over the years in multiple nutrition domains. The National Nutrition & Physical Activity Action Plan is based on a clear results chain articulating how MoPH and key partners core activities contribute to the reduction of malnutrition, and NCDs, all requisites for the achievement of other SDGs. The Action Plan is guided by the WHO strategies and targets, most notably: o The Global Strategy on Diet, Physical activity and Health (DPAS) in 2004 o The “Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition” (WHA65/6, 2012) and the subsequent resolutions on indicators and; o The WHO & UNICEF Global Strategy for Infant and Young Child Feeding (WHA 54.2, 2002) o The WHO “Global Action Plan for the Prevention and Control of Non Communicable diseases” (WHA66.10, 2013) o The Global Strategy for Women’s, Children’s and Adolescents Health 2016-2030, (2010, updated in 2015) o Report of Commission, Ending Childhood Obesity (WHO, 2016) o The NCD Regional Framework for Action (RFA); 2012. o The Regional Nutrition Strategy and Action Plan, 2010 II- Situation Analysis: Chronic Non-communicable Diseases (NCDs) are the leading causes of death, causing more deaths than all other causes combined. Of 56 million global deaths in 2012, 38 million, or 68%, were due to non-communicable diseases. The leading causes of NCD deaths in 2012 were cardiovascular diseases (17.5 million deaths, or 46% of all NCD deaths), cancers (8.2 million, or 22% of all NCD deaths), and respiratory diseases, including asthma and chronic obstructive pulmonary disease (4.0 million). Diabetes caused another 1.5 million deaths (WHO 2016 http://www.who.int/gho/ncd/mortality morbidity/en/). http://www.who.int/gho/ncd/mortality morbidity/en/ In the WHO Eastern Mediterranean Region (EMR), non-communicable diseases (NCDs) are the biggest killers, with NCDs accounting for 57% of all deaths – more than 2.2 million people –across the Region in 2012. In WHO EMR’s more advanced country groups 1 and 2, up to 75% of deaths are due to NCDs. Of these deaths around half occur prematurely (before the age of 70) in the EMR. The Region also suffers from some of the highest burdens of NCD-related risk factors, such as physical inactivity, tobacco use, and unhealthy diet (e.g. high salt, sugar and fat intake). About 65% of death and disability is preventable, through evidence-based interventions that address the four main groups of diseases (CVDs, chronic lung diseases, diabetes and cancers) and their related risk factors. In Qatar, NCDs constitute more than half of the deaths registered per annum and with many more suffering of one or more of these diseases (resource: http://www.who.int/nmh/countries/qat en.pdf?ua=1). The WHO STEPwise survey was conducted in 2012 in the state of Qatar under the lead of the Ministry of Public Health and in the participation of a total of 2,496 Qatari population (with an overall response rate of 88%. The results of this Stepwise survey have shown that the mean BMI for the Qatari population aged between 18 and 64 was 29.2 kg/m2 (28.8 kg/m2 for men and 29.5 kg/m2 for women) and 70.1% of the studied population were classified as overweight with BMI equal or above 25 kg/m2 . As such around 70.1% of the population are mainly at risk of developing coronary heart disease, ischemic stroke and type 2 diabetes mellitus (WHO 2002). Additionally, the trend of women being more likely to be obese in Qatar follows the same trend in the Eastern Mediterranean region. The application of WHO Growth References in Qatar in 2014/2015 has also raised significant concerns regarding the overweight, obesity and malnutrition among children (students in all independent schools between 5 and 19 years old). 7.3% of the students were obese, 11.7% were overweight, 5.4% were underweight and 2.5% are stunted. The total malnutrition (overweight, obesity, underweight, and stunted growth) amongst students of the three levels: primary, preparatory and secondary was 26.86%. In response to this growing challenge of obesity and its associated diseases in Qatar and building on the success of the National Nutrition and Physical Activity Project 3.2 implemented from 2011 to 2016, the Ministry of Public Health in the country has developed a National Nutrition and Physical Activity Action Plan for 2017-2022 in alignment with the Public Health Strategy 2017-2022. http://www.who.int/nmh/countries/qat en.pdf?ua=1 III- Goal, objectives and expected outcomes of the action plan: 1. Goal The main Goal of the Action Plan is to reduce morbidity and mortality attributable to chronic non-communicable diseases through healthy nutrition and increased physical activity of the people through life cycle in the State of Qatar. The action plan developed to implement the National Health Strategy 2017 - 2022 which aims to provide: o Better Health o Better Care o Better Value For the people of State of Qatar 2. Strategic objectives (outcomes): The strategic objectives of the Sate of Qatar’s action plan (2017-2022) are to: A- Improve Maternal, infant and young child nutrition, through achieving the following targets:: 1. Achieve a 50% reduction of anaemia in women of reproductive age; 2. Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50%; B- Reduce premature mortality from NCDs through healthy diet and physical activity through achieving the following targets: 1. 10% relative reduction in prevalence of insufficient physical activity 2. A 30% relative reduction in mean population intake of salt/sodium 3. Halt the rise in diabetes and obesity 3. Results (outputs) The expected results of each of the strategic objectives are as follows: 1. Supported a healthy start by promoting and protecting the nutritional well-being of women and children and ensure good nutrition throughout the life cycle for all age groups. Priority areas: a) Promoted optimal fetal nutrition, which includes: ensuring appropriate maternal nutrition from pre-conception; providing counselling on diet to pregnant women; and providing micronutrient supplementation, as required, to pregnant women. b) Protected, promoted and supported breastfeeding and timely, adequate and safe complementary feeding of infants and young children by implementing the Global Strategy on Infant and Young Child Feeding. c) Promoted and protected the nutritional well-being of all age groups including adolescent, elderly, women, as well as groups with special needs such as disabled people. Strategic interventions: 1. Fully adopt, enforce and monitor the International Code of Marketing of Breastmilk Substitutes (the Code) and subsequent relevant World Health Assembly resolutions into effective national measures:  Finalizing and Enactment of National Code of Marketing of Breastmilk Substitutes,  Implement measures to eliminate conflicts of interest, including in health professional and civil society groups, and  Conduct regular monitoring exercises on marketing practices. 2. Institutionalize the baby Friendly Hospital Initiative (BFHI), including assessment and reaccreditation into national accreditation, licensing, financial standards or other acceptable health-care system structures. 3. Develop and align maternity protection as a minimum with the International Labour Organization Maternity Protection Convention, 2000 (No. 183). 4. Measures implemented to regulated food fortification by iron, folic acid and vitamin D. 5. Support optimal and appropriate complementary feeding practices of locally available and acceptable foods. 6. Implement measures to prohibit inappropriate promotion of complementary feeding. 7. Use social marketing approaches to promote breastfeeding as an intervention to prevent childhood under nutrition, reduce the risk of childhood obesity and NCDs. 8. Incorporate breastfeeding practices in high school curriculum 9. Nutrition counseling services established for all age groups including adolescent, elderly, women, as well as groups with special needs such as disabled people, elderly and others. Indicators: a. The Code fully adopted and endorsed by the State of Qatar into effective national measure. b. Code monitoring mechanisms in place and functioning. c. Percentage of hospitals assessed and meeting BFHI standards. d. Maternity protection measures enacted and aligned with ILO Convention 183. e. Developed a legislation on mandatory fortification of staple foods (wheat flour, oil, cereals) by iron, folic acids, vitamin D. f. No. of training / workshops organized for health workers on best practices of complementary feeding. g. No. of PHC centers conducted counselling sessions for mothers on best practices of complementary feeding and the prohibition of inappropriate complimentary feeding practice. h. A regulation is in place to prevent the advertisement of inappropriate feeding practices i. No. of breast feeding campaigns conducted. j. Prevalence of exclusive breastfeeding for 6 months and continuity for 2 years with the complementary feeding. k. Breastfeeding practices developed and incorporated in high school curriculum l. No. of Nutrition counseling sessions conducted for all groups including adolescent, elderly, women, as well as groups with special needs such as disabled people, elderly and others 2- Strengthen and enforce legal frameworks that protect, promote and support healthy food: Priority areas and strategic interventions: 1- Regulating marketing:  Restrictions on marketing, advertising and sponsorship across all media (including digital) platforms for all fat/sugar rich foods and drinks to children.  Restrictions on marketing, advertising and sponsorship across all media (including digital) platforms for all fat/sugar-rich foods and drinks to adults. 2- Fiscal policies:  Progressive elimination of any subsidies by national governments for certain food items. i.e., sugar, fat.  Tax(es) to raise the price of sweetened soft drinks and beverages.  Tax(es) on fat(s). 3- Price promotion: actions to limit price promotions on foods high in fat, sugar or salt (HFSS) in supermarkets, catering or street markets; and offer free places for physical activities to the public. 4- Public procurement: action on publicly-funded food—standards for foods in public institutions and improving public procurement. 5- Reformulations: Progressive reformulation of sugar-rich drinks to lower sugar intakes. Progressive reformulation of foods high in fat, sugar or salt (HFSS). 6- Mass media: conduct mass media campaigns to increase political/public acceptance of these initiatives. The following sub activities recommended: 7- Labelling: introduction of new standards for nutrition labelling (front-of-pack labelling, colour-coded schemes, menu labelling, warning labels). Including examination of (1) evidence on whether Front-of-Pack (FOP) nutrition labels garner attention more readily than more complete, mandated nutrition information (the Nutrition Facts Panel), and (2) To determine whether label design characteristics, specifically, colour-coding and/or coding with facial icons, increase attention to the FOP label; and to provide health education for consumers. 8- Trade regulations: developing trade-related policy approaches to create a less obesogenic food environment. Indicators: a) No. of legislation adopted and implemented to restrict the marketing of foods and non-alcoholic beverages to children b) No. of legislation adopted and implemented to reduce TFA intake to less than 1% of the total calories intake (GCC legislations on TFA approved) c) No. of legislation adopted and implemented to reduce SFA intake to less than 10% of the total calories intake d) No. of legislation adopted and implemented to reduce salt intake from bread, pickles, cheeses, fast food, snacks, and other processed foods. e) Governments subsides removed on unhealthy diet f) Tax on sugar-sweetened beverages adopted and implemented g) No. of regulatory measures developed and adopted on nutrition labelling, including front-of-pack labelling on pre-packaged food and beverages. h) No. of communication campaign conducted on healthy diets i) % of daily consumption of fruits and vegetables by children. 3- Increased consumption of healthy foods and physical activity levels in schools: Priority areas and Strategies interventions: a) School policy on healthy diet and physical activity established and implemented b) Availability of food in the school environment regulated c) Fruits and vegetables made available to school children d) Nutrition education incorporated in the school curriculum and implementation enforced a. Enforced as an independent subject within the curriculum e) Physical activity promotion and quality physical education incorporated in the school curriculum a. Opening school facilities for the community (4 schools as a pilot since 2016) b. Extracurricular activities c. Grading system for PE classes in independent schools (preparatory and secondary last grade excluded) i. Baseline participation rates 2106/2017 (ministry of education and higher education) ii. Questionnaire Level of Physical Activity (GSHS 2011 MOPH merged with Ministry of Education 2017 approach) f) Roll out wellness programs across 5 wellness centers at PHCC - preventative healthcare (adults) g) Improving infrastructure to promote Physical Activity Indicators: a) No. of schools adopted a school policy on healthy diet and physical activity. b) No. of schools developed and implemented a regulatory measures for marketing of unhealthy foods to children. c) No. of schools set a class on nutrition education (weekly) d) No. of schools set a class on physical activity (weekly). e) No of schools implemented “healthy school canteen guidelines” (Target 50%) f) Number of students actively participating in PE (Target 90%) 4- Improved implementation and coordination of nutrition and NCD prevention policies Priority areas and strategic interventions: a) Mapping of key stakeholders involved in nutrition and physical activity and define their role and responsibility. b) Enhance coordination mechanism and create coherence policies among different sectors i.e. health, trade, agricultures ; industry, education,..etc.. c) Enhance participation of the civil societies and non-government organization Indicators 1) A clear roles and responsibilities among stakeholders defined and published.. 2) No. of coordination meetings held annually. 3) No of NGOs participated in the implementation of the action plan. 5- Monitoring, evaluating and conducting research into nutrition and NCD preventions Strategic priorities 1. Setting up a national monitoring mechanism to monitor progress and maintain accountability for results at the national level 2. Promoting operational research to monitor the implementation of the work plan interventions and their impact; 3. Engage academia and scientific institutions to include healthy diet related issues for consideration in academic research. 4. Setting data base on average salt, fat and sugar intake at population levels. Strategic interventions 5. Developed national nutrition monitoring and surveillance systems to monitor the key indicators and assess the impacts of the work plan. 6. Assessed nutritional status, food availability and consumption and the physical activity patterns of population through small scale studies. 7. Expand the stepwise survey on NCD risk factors to include food consumption pattern. 8. Build national capacity in the area of NCD surveillance through provision of training of national staff on NCD surveillance based on the Global Monitoring Framework for NCDs. Indicators: 1. Established functional nutrition surveillance and monitoring system, for a set of indicators. 2. No of studies and research conducted related to the prevalence of NCD risk factors, with more focus on diet and physical activity. 3. Stepwise survey conducted with additional indicators related to healthy diet and physical activity. 4. No. of studies and research conducted on micronutrient deficiencies (Vitamin D, Iron,…etc). 6. Activity schedule outcomes Responsibl e Indicator (outputs) Current Target 16 17 18 19 20 Product 1 Supported a healthy start by promoting and protecting the nutritional well-being of women and children and ensure good nutrition throughout the life cycle for all age groups. MOH 1- The Code fully adopted and endorsed by MOH into effective national measure. 2- National Code developed and approved. 3- National code implemented in the State of Qatar. 4- Code monitoring mechanisms in place and functioning. 5- Percentage of hospitals assessed within the past two years and meeting BFHI standards. 6- Maternity protection measures enacted and aligned with ILO Convention 183. 7- Developed a legislation on fortification of staple foods (wheat flour, oil, cereals) by iron, folic acids, vitamin D. 8- No. of training / workshops organized for health workers on best practices of complementary feeding. 9- No. of breast feeding campaigns conducted. 10- No. of Nutrition counseling sessions conducted for all groups including adolescent, elderly, women, as well as groups with special needs such as disabled people, elderly and others Product 2 Strengthen and enforce legal frameworks that protect, promote and support healthy food: 1- No. of legislation adopted and implemented to restrict the marketing of foods and non-alcoholic beverages to children 2- No. of legislation adopted and implemented to reduce TFA intake to less than 1% of the total calories intake (GCC legislations on TFA approved) 3- No. of legislation adopted and implemented to reduce SFA intake to less than 10% of the total calories intake 4- No. of legislation adopted and implemented to reduce salt intake in bread, pickles, cheeses, fast food, snacks, and other processed foods. 5- Governments subsides removed on unhealthy diet 6- Tax on sugar-sweetened beverages adopted and implemented 7- No. of regulatory measures developed and adopted on nutrition labelling, including front-of-pack labelling on pre-packaged food and beverages. 8- No. of communication campaign conducted on healthy diets 9- % of daily consumption of fruits and vegetables by children. Product 3 Increased consumption of healthy foods and physical activity levels in schools 1- No. of schools adopted a school policy on healthy diet and physical activity. 2- No. of schools developed and implemented a regulatory measures for marketing of unhealthy foods to children. 3- No. of schools set a class on nutrition education (weekly) 4- No. of schools set a class on physical activity (weekly). 5- No of schools implemented “healthy school canteen guidelines” (Target 50%) 6- Number of students actively participating in PE (Target 90%) Product 4 Improved implementation and coordination of nutrition and NCD prevention policies 1- A clear roles and responsibilities among stakeholders defined and published. 2- No. of coordination meetings held annually. 3- No of NGOs participated in the implementation of the action plan. Product 5 Monitoring, evaluating and conducting research into nutrition and NCD preventions 1- Established functional nutrition surveillance and monitoring system, for a set of indicators. 2- No of studies and research conducted related to the prevalence of NCD risk factors, with more focus on diet and physical activity. 3- Stepwise survey conducted with additional indicators related to healthy diet and physical activity. Table 1: Summary of stakeholder analysis GOVERNMENT GROUP Stakeholder and basic characteristics Institutional interests (mission) How are they affected by the problem? Capacity in terms of human, financial and technical resources (low, medium, high) Political influence (low, medium, high) Motivation to produce change Possible actions (of government) to address stakeholder’s interest Ministry of Public Health Prepare policies, strategies and plans, deliver health services and health education, monitoring of imported foods Deal with high burden of disease Low-medium Medium Strong primary health care Good planning, legislative and strategic planning capacity Good multisectoral monitoring system Guidance and leadership of other sectors Ministry of Education & Higher Education Education for all Quality of education, sick leave rate Low-medium Medium Strong physical education system Healthy Canteen Guideline Develop Department to support healthy options Physical activity sessions, healthy environment, healthy meals, green gardens, curriculum Ministry of Municipality & Environment Ensure high quality of food, Public garden, physical activity areas, Food standards, labelling and control Food production More public pressure and complaints from public Provide more gardens Implement GCC standards and metrology Inspection of restaurants Provide standards and labelling of products Provide licensing to restaurants and coffee shops Stakeholder and basic characteristics Institutional interests (mission) How are they affected by the problem? Capacity in terms of human, financial and technical resources (low, medium, high) Political influence (low, medium, high) Motivation to produce change Possible actions (of government) to address stakeholder’s interest Ministry of Economy and Trade Consumer Protection Department To protect consumers from commercial fraud Raise awareness among consumers Need for more resources Reputational risk Health outcomes related to obesity could raise the cost of treatment Human – low Financial – low Technical – medium Medium Supported by authority body, the PACP Increase consumer awareness Limited power to prevent commercial fraud Government develop authority so that it has strong power to protect consumers from commercial fraud. Develop and implement consumer protection laws Ministry of youth & Sport Deliver sport for all Deal with high burden of physical inactivity Medium Open new facilities TOT in PA Implement sports programmes and improve facilities Ministry of Labour and Social Affairs Social stability and security for community Increased social burden Medium Policy development Implement law for mothers (working hours) Improve work environment CIVIL SOCIETY GROUP Stakeholders and basic characteristics Institutional Interest (Mission) How are they affected by the problem? Capacity in terms of human, financial, and technical resources Political Influence Motivation to produce change Possible actions of Government Qatar Diabetes Association Prevent DM Guarantee care for DM patients Increase awareness through media campaigns Increased activities and work related to DM Increased need for resources Human – medium Financial – low Technical – high Medium Highly motivated Strong knowledge and technical skills Highly qualified to contribute to prevention of DM Motivated to reduce obesity and achieve the goals of their mission Share national targets and goals Facilitate implementation of their programs, activities and initiatives Involvement in workshops and training PRIVATE SECTOR GROUP Stakeholders and basic characteristics Institutional Interest (Mission) How are they affected by the problem? Capacity in terms of human, financial, and technical resources Political Influence Motivation to produce change Possible actions of Government 1. Food industry Sustain or increase profit Public image Profit losses Financial – high High Low Increase awareness of obesity and impact on morbidity and mortality. Formulate and implement legislation for reduction of salt, sugar, fat in food. Legislation for food labeling and nutrition information. Tax breaks for healthy food options e.g. fruits and vegetables. Increase tax on unhealthy food options e.g. fast food, sugary drinks . 2. Media, communication and entertainment industry Sustain or increase profit Profit losses Financial - high Low with government, high with community Low Education campaigns/advertising/documentaries to increase awareness about the problem and impact of obesity on morbidity and mortality in mass media Legislation to ban advertising of unhealthy foods (movies/collectibles/movie memorablia toys e.g. kungfu panda) Legislation for selling unhealthy food at entertainment venues –movie theatres , fairs etc. Qatar Green Association ASPIRE HASSAD