FIFTH CONFERENCE ON NUTRITION NUTRITION AND NCDS: A PALESTINIAN AGENDA 15-16 SEPTEMBER 2012 Summary Report A. Background The continuing political crisis in Palestine, the severe restrictions on the movement of people and goods, and high food insecurity rates continue to affect the livelihoods of Palestinians, with adverse consequences for their health status. In 2009, an estimated 38% of the population was found to be food insecure in Palestine, with lack of income and livelihood opportunities leading households to adopt less diverse diets with high content of sugar and deficient in micronutrients. The country is increasingly characterized by the double burden of malnutrition: the persistence of under-nutrition especially among younger children, combined with a rapid rise in overweight, obesity and diet related chronic diseases among adults. Various studies across the world also indicate that those who suffer from malnourishment at the beginning of life have a higher risk of chronic diseases as adults. In Palestine, a cross-sectional survey, carried out in 2009, to assess the nutritional status of school children and adolescents in the West Bank reveal that children start school with moderate stunting and underweight, but by the 9th grade, overweight and risk of overweight start to be observed, especially among girls. NCDs are the leading causes of death worldwide, killing more people each year than all other causes combined. 1 It is estimated that by the year 2015 noncommunicable diseases associated with obesity will surpass malnutrition as the leading causes of death in lowincome communities. 2 Almost half of the total chronic NCD deaths are attributable to cardiovascular diseases; obesity and diabetes are also showing worrying trends because they have started to appear earlier in life. It is expected globally that NCDs will increase by 17% in the next 10 years. NCDs are among the top five leading causes of death in Palestine. 3 High rates of adult population in Palestine are estimated to be affected by cardiovascular disease, diabetes, and respiratory diseases. With rapid changes in diets and lifestyles that have occurred with urbanization, economic development and globalization, have accelerated over the past 1 WHO. Global status report on non-communicable disease 2010 2 Tanumihardjo SA, Anderson C, Kaufer-Horwitz M, Bode L, Emenaker NJ, Haqq AM, et al. Poverty, Obesity, and Malnutrition: An International Perspective Recognizing 3 MoH. Health Report, Palestine. Mid Year 2011. PHIC.
decade, the incidences of NCDs are likely to rise in Palestine. The increase in diet-related chronic non-communicable diseases will place a heavy burden on an already severely strained health sector. There is an urgent need for action to strengthen control and prevention measures to counter the rapid rise of NCDs, which threatens harm to individuals, families, and the society at large. Epidemiological studies show that nutrition is a very important factor in preventing and controlling morbidity and premature mortality resulting from NCDs. Lifestyle changes, in particular an appropriate diet which provides an adequate intake of micronutrients, would significantly contribute to the fight against NCDs. Cost-effective and sustainable nutrition interventions, based on scientific evidence and new global developments in this field, are needed to effectively combat NCDs. As such, the Fifth Palestinian Nutrition Conference, Nutrition and NCDs: A Palestinian Agenda was convened in Ramallah, Palestine September 15-16, 2012 under the patronage of the Ministry of Health, UNRWA, and UNICEF. The purpose of the conference was to inform, influence, and catalyze action by key stakeholders including policymakers, nongovernmental organizations, and researchers to achieve nutrition security and to promote healthy lifestyle in order to combat NCDs. The five main objectives were: 1. To raise awareness on the importance of nutrition for combating NCDs; 2. To expose Palestinian institutions and professionals to the latest development in evidence based nutrition& NCDs programs and research findings; 3. To review Palestinian nutrition and NCDs existing programs in terms of impact, challenges and lessons learned; 4. To enhance the coordination and cooperation of various actors; and to assess how to scale up nutrition programs and jointly tackle under-nutrition, obesity, and dietrelated chronic diseases; 5. To enhance policy formulation and implementation related to nutrition and NCDs. The conference brought together approximately 400 professionals from governmental and non-governmental organizations, from academic and private institutes and key international organizations. Participating organizations included: Ministry of Health, Ministry of National Economy, Birzeit University, Columbia University, Uppsala University, AlQuds University, Arab American University, An Najah University, Bethlehem University, Ibn Sina College, Augusta Victoria Hospital, Pediatric Hospital, Makased Hospital, Mustakbal Hospital, Caritas Hospital, Spafford Children's Center, Ard Al Atfal, PMRS (Palestinian Medical Relief Society), Health Workers Committee, United nations Relief Works Association (UNRWA), United Nations Children s Fund (UNICEF), UNFPA, World Food Program (WFP), and World Health Organization (WHO), in addition to the sponsoring organizations.
B. Summary of Conference Proceedings Visiting professors from Columbia University, Uppsala University, and University College London Institute of Global Health presented their global research on cardiovascular disease, diabetes mellitus, and provided opportunity for knowledge exchange on the double burden on under and under nutrition in Armenia and among the Western Saharan refugee population. Palestinian researchers and academics presented evidence-based research on NCDs and their determinants, including prevalence of overweight and obesity among Arab adolescents, infant feeding practices in Palestine, metabolic syndrome among Palestinian refugees, and diabetes mellitus complications. Lifestyle approaches to NCD Prevention were also discussed, including alcohol use among Palestinian Youth, and consumption patterns of energy drinks among university students in Palestine, and the health and economic impacts of salt reduction schemes. UNRWA presented its global school-based student health survey from 2010 which showed the remarkable inadequate levels of physical activity and good nutrition among students. Lively presentations and discussion around interdisciplinary approaches to nutrition policy and prevention of NCDs highlighted the importance and impact of agriculture policy, food security, and donor interventions and free trade policies on the nutrition and NCD status of Palestinians. Participants also took a look at the Palestinian health system s response to NCDs, from the experience of the Ministry of Health and UNRWA. UNICEF, Birzeit University, Juzoor for Health and Social Development, Palestinian Food and Nutrition Association, and UNRWA presented their lessons learned and innovations in nutrition promotion and NCD prevention. C. Recommendations for the Way Forward Several key themes and recommendations were raised throughout the conference. The following provides a summary of the priority areas for action: Nutrition and NCDs must be prioritized on the national agenda. Nutrition specific interventions should be prioritized on the national agenda. Likewise, nutrition policies should integrate NCD prevention strategies. The studies presented in this conference further confirmed NCDs as the major causes of mortality and morbidity in the opt, and the association between nutrition all risk factors with NCDs. This means that NCDs and their risk factors should be prioritized according to their impact on the health of the population. Examples of active implementation of health public policies include: tobacco control, advertising bans on tobacco, promotion of health foods, coordination with industry to enforce salt and sugar content reductions in processed foods both imported and locally produced. Addressing the Social Determinants of NCDs. It was widely agreed that addressing the social determinants of health is critical to effectively combatting NCDs, and is the responsibility of
all sectors. As a starting point, eliminating taxes on locally grown vegetables and fruits was raised as a policy decision that would promote healthy eating as well as promote Palestinian agriculture. At the same time, eliminating promotional marketing and advertising of unhealthy foods (e.g. fast food), energy drinks, and tobacco products, especially those that target children and youth, would minimize promotion of unhealthy living. In addition, physical education has been jeopardized in several schools, where physical education classes are often cancelled to make up for missed academic courses. Physical education must be considered as a core and mandatory part of the education curriculum. IN addition, schools must be better equipped with safe and accessible facilities for physical activity and sports. Urban planning must also be improved within Palestine. There are currently very few areas designed to promote safe and accessible physical activity. Efforts should be made by urban planners and municipalities to design and improve space for physical activity, such as walking and cycling paths. The occupation, protracted conflict, economic instability, violence, and loss has had an impact on the mental health and well-being of the Palestinian population, which has been documented in several research studies in Palestine. The correlation between mental health within this context, unhealthy nutrition and lifestyle, and NCDs should be examined both in terms of research and in policy making and interventions. Programs geared towards addressing mental health promotion, resilience, and positive well-being should be visited by policy-makers, civil society, and institutions. Health sector reform. There was a consensus that health sector reform is needed in Palestine to address the current fragmentation and compartmentalization of the health system. Wide-scale reform is needed in order to ensure responsiveness, effectiveness and equity, especially when addressing the social determinants of NCDs. Intersectoral coordination and collaboration on NCDs prevention. Greater collaboration between ministries such as the Ministries of Health, Education, Agriculture, National Economy, Social Affairs, and Ministry of Planning is essential when talking about nutrition and NCDs prevention. Intersectoral collaboration remains a challenge within the Palestinian system of governance; however better coordination and collaboration between sectors as well as the governmental, NGO, private, and UNRWA health services to address the current problem of service fragmentation. In order to achieve greater unity in combatting NCDs, other ministries must be educated on the importance of NCDs prevention, why their involvement is critical, and what they can do. Political commitment from the Prime Ministers and other ministries is critical to this becoming a reality. Integrating NCD prevention and nutrition strategies in Primary Health Care. Evidence-based research has proven that NCDs can be prevented and controlled through an integrated
approach to primary health care, which includes participation of the community. As such strategies should be considered to further integrate NCD screening and health promotion in the primary health care setting, while at the same time strengthening the cliniccommunity and doctor-patient ties to effectively promote healthy lifestyle changes and health promotion. Developing policies that promote the production of healthy foods. For example, the Ministry of Health is promoting a policy of tax exemption for locally grown vegetables. Policies that include incentives for production of healthy food should also be considered. Focus on Lifestyle Approach to Nutrition and NCD Prevention. Policies for combatting NCDs should focus on adopting lifestyle and life cycle approaches. Behavior change is not a simple task. The Palestinian public is aware and educated on the negative health impacts of smoking and junk/fast food, however they still smoke and eat junk food. There needs to be a focus on attitudes and behavior and lifestyle change. In addition, youth should be specifically targeted in NCD prevention efforts, especially those related to tobacco use, energy drink, alcohol, diet (including skipping breakfast), and obesity. Need for more nutritionists and dieticians. According to the Ministry of Health Director of Nutrition, the country lacks expertise in nutrition and dieticians. He urged UNRWA, and NGO partners to invest in nutritionists and dieticians on their health staff. Focus on action. We are talking the talk, now we need to walk the walk, said one of the presenters. There is a plethora of data on nutrition and NCDs in Palestine. The time is now to identify implementable solutions at policy and programmatic levels to effectively combat NCDs and maintain the healthy nutritional status of Palestinians. There is hope that the next conference will focus on action and lessons learned. D. The Way Forward Based on the evidence-based research presented, and consequent discussions and recommendations, the conference participants agreed on two main action areas to move the priority recommendations forward: Activation of the NCD thematic group and specific task force if needed to tackle important issues such as implementing the national policy and strategic plan for NCDs, tobacco control issues, and nutrition related issues. The Task Force would consist of expertise from the governmental, NGO, private, and UNRWA sectors, and would include other ministries such as Education, National Economy, and Agriculture. They would undertake a mapping exercise and identify indicators of performance. Provide recommendations to the Cabinet. The task force should come up with 1 or 2 recommendations for the cabinet to discuss for implementation, for e.g. instituting a smoking ban, or relieving taxes on fruits and vegetables and on local farmers.