Submitted to the World Health Organisation. Date: 8 th March Contact:

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1 Wrld Cancer Research Fund Internatinal input t the third rund f infrmal cnsultatins n the revised draft WHO glbal actin plan fr the preventin and cntrl f NCDs cvering the perid 2013 t 2020 Submitted t the Wrld Health Organisatin Date: 8 th March 2013 Cntact: Crinna Hawkes (Head f Plicy and Public Affairs) c.hawkes@wcrf.rg J Jewell (Plicy and Public Affairs Manager) j.jewell@wcrf.rg WCRF Internatinal, 22 Bedfrd Square, Lndn, WC1B 3HH, UK +44 (0)

2 Abut WCRF Internatinal WCRF Internatinal and its fur cancer charities a,b are dedicated t the preventin f cancer thrugh fd 2, nutritin, physical activity, and preventin and cntrl f bdy fatness. Our missin is t empwer peple t make chices tday t prevent cancer tmrrw by: 1. Bringing tgether the scientific research n the relatinship between fd c, nutritin, physical activity, bdy fatness and cancer int recmmendatins fr peple and ppulatins t reduce their cancer risk. This invlves a cntinually updated rigrus review prcess which builds n the WCRF Internatinal s Secnd Expert Reprt, Fd, Nutritin, Physical Activity, and the Preventin f Cancer: a Glbal Perspective (2007), and an expert panel f leading academics. d 2. Awarding funding t cutting-edge research n fd, nutritin, physical activity, bdy fatness and cancer. Since 1982, the WCRF netwrk has funded ver 85 millin wrth f research, including research by the WHO Agency, IARC the Internatinal Agency fr Research n Cancer. 3. Cmmunicating the evidence and recmmendatins t scientists, health prfessinals, plicymakers and individuals arund the wrld. 4. Thrugh the fur charities a, prviding science-based infrmatin abut healthy eating and physical activity. This infrmatin is targeted at the supprters f the charities, health prfessinals, children and their families. The WCRF Internatinal Academy als educates yung scientists and decisin-makers abut the relatinship between diet, physical activity and cancer. 5. Cnducting activities t advance plicy at all levels f sciety. This includes cmmunicating its set f evidence-based plicy recmmendatins fr the preventin f cancer. e 6. Raising funds thrugh the netwrk f fur cancer charities as a means f financing the abve activities. Unique in its fcus n preventin, WCRF Internatinal wrks in cllabratin with the Unin fr Internatinal Cancer Cntrl (UICC) and ther NGOs, as well as the scientific cmmunity, in advancing the gal f preventing and cntrlling nn-cmmunicable diseases (NCDs). a. American Institute f Cancer Research (AICR); Wrld Cancer Research Fund UK (WCRF UK); Wereld Kanker Onderzek Fnds (WCRF NL); Wrld Cancer Research Fund Hng Kng (WCRF HK). b. WCRF Internatinal and the fur charities are cllectively referred t as the WCRF glbal netwrk. WCRF Internatinal leads and directs the science and plicy activities f the netwrk. c. Includes alchl d. The Cntinuus Update Prject is an nging review f cancer preventin research that builds n the WCRF/AICR reprt Fd, Nutritin, Physical Activity, and the Preventin f Cancer: a Glbal Perspective (2007), a cmprehensive analysis f the literature n fd, nutritin, physical activity and cancer. Available at: e. WCRF/AICR. Plicy and Actin fr Cancer Preventin (2009). Available at: 2

3 COMMENTS WCRF Internatinal bradly welcmes the revised draft glbal actin plan (GAP) fr the preventin and cntrl f NCDs cvering the perid 2013 t 2020, including the majrity f the revisins made in the tw iteratins since the Zer Draft, the structuring int six clear bjectives and the scpe and verarching principles. In particular, WCRF Internatinal welcmes the inclusin f specific plicy actins t reduce expsure t the mdifiable risk factrs relevant t cancer and ther leading NCDs: unhealthy diets, physical inactivity, the use f alchl, and tbacc use. These prvide the package f measures frm which Member States can chse in rder t mve twards the targets set ut in the Glbal Mnitring Framewrk. Prmting a healthy diet (paragraph 36) We cntinue t be encuraged by the emergence f a cre set f plicy measures fr Member States t cnsider. It represents the mst useful guidance prvided t date by WHO n the actins Member States can chse frm t prmte healthy diets, which will be essential if Member States are t meet the besity target set ut in the Glbal Mnitring Framewrk. Mst f these actins are already cntained in existing plitical cmmitments. In rder t better reflect existing plitical cmmitments, as well as mre develpments in the evidence base, we recmmend sme further amendments t Paragraph 36, as cntained in the ur specific recmmendatins fr amendments (see Table 1). Our recmmended amendments recgnise the tensin between specificity and flexibility when prviding glbal guidance in this area t specific and the recmmended actin becmes t prescriptive and insufficiently flexible given differences in natinal cntext; t flexible and it becmes vague and immeasurable and even harder fr Member States t priritise. The current list f plicy actins prvides a basis frm which WHO can cntinue t develp a cre plicy package f actins t prmte healthy diets what t d and hw it can be dne. This shuld prvide an verarching framewrk fr plicy, frm which Member States can priritise, select and develp mre specific plicy actins relevant t their cntexts. WCRF Internatinal wuld be happy t cntribute expertise t this prcess. It is a prcess that will als require mre and better evaluatin, as emphasised in ur cmment belw. 3

4 Table 1: Prpsed amendments t Paragraph 36 Edit in initial paragraph...n emerging favurable cst-effectiveness data. Plicies shuld be develped free frm cnflict f interest. Such plicies and prgramme wuld aim t... Justificatin: the develpment f plicies t reduce expsure t risk factrs (including thse that will shape the market) shuld be safeguarded frm cnflicts f interest A) Edit: Prmte, prtect and supprt breastfeeding, including exclusive breastfeeding fr the first six mnths f life, cntinued breastfeeding until tw years ld and beynd and adequate and timely cmplementary feeding, and, in this regard, strengthen the implementatin f the internatinal cde f marketing f breast milk substitutes and subsequent relevant Wrld Health Assembly reslutins. Justificatin: in rder t reflect the wrding f the UN Plitical Declaratin B) Edit: Develp plicy measures directed at fd prducers and prcessrs: - t reduce the level f sdium in fd by setting targets fr all fd categries which are timespecific and mnitred, and accmpanied by public awareness campaigns, and, where apprpriate the use f mineral salt is used as a salt replacement. t eliminate industrially prduced trans-fatty acids frm fd and t replace them with plyunsaturated fatty acids15 t decrease the level f saturated fatty acids in fd and t replace them with plyunsaturated fatty acids16 t reduce the cntent f free sugars in fd and nn-alchlic beverages. - Add: where apprpriate, t reduce the calrie cntent f high-calrie packaged fds and drinks, including thrugh reductins in prtin size (nt including fds targeting peple at risk f underweight). Justificatin: t reflect in-cuntry experience and best practice, and t recgnise that reducing calrie intake is imprtant fr besity C) Edit: Develp plicy measures directed at fd retailers and fd service utlets t imprve the availability, affrdability and acceptability f healthier fd prducts (fruit and vegetables, prducts with reduced sdium cntent, saturated fatty acids, trans-fatty acids, free sugars, calries). Justificatin: there is an evidence base n the relatinship between availability and diet, as well as n chice architecture, thrugh which retailers which can influence fd chices. D) Delete as it verlaps with 36 (G). E) Edit: Cnsider ecnmic tls, including taxes, subsidies targeted at vulnerable ppulatins, and the use f pricing as a prmtinal tl, t imprve the affrdability f healthier fd prducts and t discurage the cnsumptin f less healthy ptins; with the aim f prmting healthier diets amng vulnerable ppulatins. Justificatin: t reflect wrding cntained in the Glbal Strategy n Diet, Physical Activity and Health and the full range f ptential plicy measures F) Edit: Cnduct public campaigns thrugh mass media, scial media and at the cmmunity level, and scial marketing initiatives t infrm and mtivate cnsumers abut healthy dietary patterns and t facilitate healthy behaviurs, including thrugh the cmmunicatin f fd-based dietary guidelines. Justificatin: t reflect the WHO best buys, wrding in the Glbal Strategy n Diet, Physical Activity and Health (als see new J belw) 4

5 G) Edit: Create health and nutritin prmting envirnments in schls, wrk sites, clinics and hspitals, including thrugh nutritin educatin, the prvisin f healthy fds (e.g. fruit and vegetable initiatives), prcurement frm lcal fd grwers, and limiting the availability f prducts high in salt, sugar and fats. Justificatin: t reflect wrding cntained in the Glbal Strategy n Diet, Physical Activity and Health H) Edit: Implement the Cdex Alimentarius internatinal fd standards fr the labelling f prepackaged fds as well as the Cdex Guidelines n Nutritin Labelling, and cnsider labels which are easy t interpret and understand by cnsumers in rder t prvide accurate and balanced infrmatin fr cnsumers.20 Justificatin: in rder t validate the ftnte, since frnt-f-pack labels are nt included in Cdex Alimentarius guidance (therwise, the ftnte makes n sense) I) Edit: Implement WHO s set f recmmendatins n the marketing f fds and nn-alchlic beverages t children, including mechanisms fr mnitring and evaluatin. Justificatin: t reflect Recmmendatin 11 in the WHO Set f Recmmendatins, which states that The plicy framewrks shuld als include a system t evaluate the impact and effectiveness f the plicy n the verall aim, using clearly defined indicatrs. (Recmmendatin 10 states that All plicy framewrks shuld include a mnitring system t ensure cmpliance with the bjectives set ut in the natinal plicy, using clearly defined indicatrs ). Add a new J): Draw up natinal dietary guidelines, including fd-based dietary guidelines, taking accunt f evidence frm natinal and internatinal surces. Such guidelines shuld guide all plicy measures t prmte healthy diets. Justificatin: t reflect existing wrding in the Glbal Strategy n Diet, Physical Activity and Health, and t acknwledge the rle f FAO in this area Add a new K): Prvide nutritin educatin in the frm f a cmbinatin f educatinal strategies and envirnmental supprts designed t facilitate healthy diets, in educatinal facilities, wrkplaces, and ther cmmunity settings, and including health literacy. Justificatin: t reflect existing wrding in the Glbal Strategy n Diet, Physical Activity and Health, and t acknwledge the rle f FAO in this area Other mdifiable risk factrs WCRF Internatinal als calls n Member States t take actin t prmte physical activity and reduce the use f alchl and tbacc as risk factrs fr many types f cancer. In line with ur recmmendatins fr prmting healthy diets, this actin shuld be infrmed by the best available evidence and existing plitical cmmitments in these areas. T that end, we supprt the suggestins made in the NCD Alliance respnse t the revised GAP fr sme amendments t imprve Paragraphs 37, 38 and 39. 5

6 Integratin f Glbal Mnitring Framewrk with plicy actins WCRF Internatinal welcmes the new Paragraph 34 which emphasises that the actins taken reduce expsure t mdifiable risk factrs will cntribute t achieving 6 f the 9 vluntary glbal targets. We als welcme the inclusin f a prpsed set f prcess indicatrs in Appendix 6. Hwever, we see rm fr imprvement in integrating the Glbal Mnitring Framewrk (GMF) int the GAP and with prcess indicatrs s that it is clear that the WHO Secretariat, Member States and internatinal partners need t implement the actins in the GAP t achieve the vluntary targets. They als need t use the indicatrs in the GMF and sme f the prcess indicatrs t reprt n and reflect prgress in implementing the GAP. In the current draft, the targets, bjectives, actins, indicatrs, and prcess indicatrs remain detached. We thus call fr an initial paragraph fr each bjective stating that the Objective N can attain target/s X thrugh the subsequently listed actins, which shuld be measured by indicatr/s Y (frm the GMF), and prcess indicatr/s Z in rder t mnitr prgress in implementing the GAP. This will help clarify fr Member States the links between the bjective, targets, actins, indicatrs and prcess indicatrs. In additin, while we warmly welcme the inclusin f a prcess indicatr n number f cuntries with an peratinal plicy, strategy r actin plan t reduce the fur majr behaviural risk factrs (number 3, Appendix 6) the current wrding is unclear. We thus recmmend rewrding t Number f cuntries with an peratinal plicy, strategy r actin plan fr (i) harmful use f alchl (ii) physical inactivity (iii) tbacc use, and (iv) unhealthy diet, either as stand alne dcuments r integrated with heart disease, cancer, diabetes, and r/besity plicies, strategies r plans. Evaluatin f plicy measures and interventins WCRF Internatinal believes the evaluatin f plicy measures and interventins is essential t identify what wrks. We thus supprt the call in Paragraph 39c fr the WHO Secretariat t prvide tlkits n hw t evaluate interventins. Hwever, Member States and internatinal partners shuld likewise play a rle. We thus recmmend that: Paragraph 40b (fr internatinal partners) is rewrded Cntribute t expediting the reductin f mdifiable risk factrs fr reducing tbacc use, prmting healthy diet and physical activity, and reducing the harmful use f alchl by supprting and participating in shaping implementing the research agenda, including thrugh the evaluatin f plicies and interventins, the develpment and implementatin f technical guidance, and mbilizing financial supprt, as apprpriate. Paragraph 50b (fr Member States) is rewrded Plicies and plans: Develp, implement and mnitr jintly with academic and research institutins a shared natinal research plicy and plan n preventin and cntrl f nncmmunicable diseases that priritizes research in 6

7 public health needs, implementatin and innvatin, and the evaluatin f plicy measures and interventins. Internatinal partners and safeguarding against cnflicts f interest In rder t implement the plan, actin is clearly needed by internatinal partners. Hwever the definitin f the term internatinal partners is nt clear. Fr example, in certain sectins the term appears t include the private sectr (e.g. the fllwing actins are prpsed fr internatinal partners [including, as apprpriate, the private sectr]); in thers the private sectr is excluded (e.g. prcesses that wuld enable the Secretariat, Member States and internatinal partners t engage with the private sectr... ). Nr is it clear hw the specific actins listed fr the internatinal partners shuld be allcated t these partners. We wuld thus like t see a definitin f internatinal partners in the GAP. WCRF Internatinal recgnises the imprtance f the nging internatinal debate abut the ptential fr cnflicts f interest with the private sectr in plicy develpment. The inclusin f the prpsed actin fr the WHO Secretariat t strengthen gvernance, including management f ptential cnflicts f interest in engaging the private sectr in cllabrative partnerships fr implementatin f the actin plan. (Paragraph 22c) is t be welcmed. It is very timely fr WHO t address this issue, given the cmmercial cmplexities arund the drivers f NCDs and related cnditins. Hwever, we are cncerned that the wrding has been narrwed in the revised draft t fcus nly n cllabrative partnerships. In additin t re-strengthening this paragraph, we recmmend the fllwing amendments: Owing t the cntinuing lack f clarity at the internatinal level in relatin t the rle f the fd and drink industries, an additinal sentence shuld be added t Paragraph 36 as fllws: n emerging favurable csteffectiveness data. Plicies shuld be develped free frm cnflict f interest. Such plicies and prgramme wuld aim t..: T clarify the rle fr WHO in prducing nrms and standards in this area, we recmmend the fllwing amendments t Paragraph 39d Nrms and standards: Supprt the Cnference f the Parties f the WHO Framewrk Cnventin n Tbacc Cntrl in develping guidelines and prtcls; develp nrmative guidance and technical tls and mdel legislatin and plicies t supprt the implementatin f WHO s glbal strategies fr addressing mdifiable risk factrs, including, in cllabratin with ther apprpriate UN agencies, principles t help identify and safeguard against cnflicts f interest and t ensure transparency and integrity in public plicy decisin-making ; further develp a cmmn set f indicatrs and data cllectin tls fr tracking mdifiable risk factrs in ppulatins, including the wrk n the feasibility f cmpsite indicatrs fr mnitring the harmful use f alchl at different levels. 7

8 Opprtunities fr glbal actin Finally, WCRF Internatinal welcmes the actins specified fr the WHO Secretariat t crdinate and supprt actins by Member States and internatinal partners, as articulated in the aim f the GAP in Objective 1. Fr example, we welcme the actin fr WHO t prmte and facilitate internatinal and inter-cuntry cllabratin fr exchange f best practices in the areas f health in all plicies, whle-f-gvernment appraches, legislatin, regulatin, health system strengthening and training f health persnnel (Paragraph 22d). Hwever, we wuld like t express ur cncern abut the lack f adequate inclusin f glbal actin n NCDs in the current draft. That is, actin abve and beynd crdinatin and supprt at the natinal level at the glbal level. Glbal actin t mitigate risk factr transmissin acrss brders wuld be ne such example. In additin, while we think there is value in establishing a glbal crdinating mechanism, the prpsed mdel is inadequately defined in terms f structure and peratin. WCRF Internatinal believes there is significant scpe fr mre actin at the glbal level by WHO and internatinal partners n NCDs thrugh a better-defined crdinating mechanism. Our recmmendatin is that a Glbal Crdinating Mechanism is needed which: Clearly differentiates between, and defines rles fr, different stakehlders and sectrs Is clear in terms f wh will crdinate and lead the activities f internatinal stakehlders, including n the plicies, strategies and actins f institutins beynd the WHO. Includes the fllwing cre functins fr glbal actin: cnvening t prmte dialgue; crdinatin f plicy and actin t prmte cherence; identifying incentives t stimulate actin acrss sectrs; advcating actin; and develping mechanisms fr mnitring t ensure prgress and accuntability. Establishes a gvernance mdel t fulfil these functins, including an inter- agency plicy crdinating mechanism; a civil sciety mechanism t develp a transfrmative scial mvement; and, ptentially, a platfrm fr psitive actin by business. Ensures that glbal actin is supprted by a mechanism t prtect against cnflicts f interest including a framewrk fr the gvernance f public-private interactin and the preventin f cnflicts f interest. A cmmn public health bjective is essential. 8