General comments on the draft Framework for Action
The Draft document contains many balanced recommendations that should be shared and acted on by the international community, particularly in the post 2015 environment. There are a few recommendations that seem not to be based on evidence (that I will identify below). For these recommendations, there should be a note of caution until further evidence is available and most importantly, identification of a need for further research to provide evidence in support or against these recommendations.
1. The following statement is extremely important as it reflects the nutritional ‘truth’ of the importance of diversity to prevent individual nutrient deficiencies and excesses. However, I would suggest adding the word ‘energy ‘ to the sentence
Current:
“Nutrition improvement requires the provision of balanced and diversified diets, meeting nutrient requirements of all age groups and all groups with special needs, avoiding excessive intakes of saturated fat, sugars and salt/sodium, and removing trans-fat”
Suggested Modification:
Nutrition improvement requires the provision of balanced and diversified diets, meeting nutrient requirements of all age groups and all groups with special needs, avoiding excessive intakes of energy, saturated fat, sugars and salt/sodium, and removing trans-fat.
2. The following sentence is also very important, but is slightly too general in referring to processed foods. I would argue that many processed foods are highly nutritious and provide many of the essential nutrients needed for health.
Original:
“Food systems need to promote healthy dietary patterns by providing year-round access to safe and nutritious foods including fruits, and vegetables, pulses, wholegrains and animal source foods such as fish, while limiting the consumption of processed foods that negatively affect nutrition and health.”
Suggested Modification:
‘Food systems need to promote healthy dietary patterns by providing year-round access to safe and nutritious foods including fruits, and vegetables, pulses, wholegrains and animal source foods such as fish, limiting the consumption of specific processed foods lacking in essential nutrients, that may negatively affect nutrition and health.’
3. In the section on Commitments, the word ‘reshape’ is used (see below). This word suggests that the current systems are broken and inadequare. I would suggest that ‘improve’ or ‘strengthen’ would be a more appropriate word. I would also suggest that the word ‘innovation’ or ‘innovative’ be included in the sentence.
Original
“Commitments
b) reshape food systems through coherent implementation of public policies and investment plans throughout food value chains to serve the health and nutrition needs of the growing world population by providing access to safe, nutritious and healthy foods in a sustainable and resilient way.”
Suggested Modification
b) Strengthened food systems through coherent implementation of public policies, [and] investment plans and innovation throughout food value chains to serve the health and nutrition needs of the growing world population by providing access to safe, nutritious and healthy foods in a sustainable and resilient way.”
4. In the statement below, I would suggest adding the a description of the target population
Original
“Framework for Action
Includes this statement:
Healthy diets contain a balanced and adequate combination of foods to ensure sufficient macronutrients (carbohydrates, fats and protein) and essential micronutrients (vitamins and minerals). Diverse diets that combine a variety of cereals, legumes, vegetables, fruits and animal-source foods will provide adequate nutrition for most people to meet their nutrient requirements, although supplements may be needed for certain populations, e.g., during humanitarian emergencies.
Suggested Modification
Healthy diets contain a balanced and adequate combination of foods to ensure sufficient macronutrients (carbohydrates, fats and protein) and essential micronutrients (vitamins and minerals). Diverse diets that combine a variety of cereals, legumes, vegetables, fruits and animal-source foods will provide adequate nutrition for most people to meet their nutrient requirements, although supplements may be needed for certain populations (infants and young children and women in the child bearing age) and during humanitarian emergencies.
4. In the Framework for Action, the following is written:
In order to promote optimal health, WHO recommends that diets should ensure:
- Daily needs of energy, vitamins and minerals are met, but energy intake does not exceed them.
- Consumption of fruit and vegetables is over 500 g per day.
- Intake of saturated fat is less than 10% of total energy intake.
- Intake of trans fatty acids is kept to less than 2% of total fat intake.
- Intake of free sugars is less than 10% of total energy intake or, preferably, less than 5%.
- Intake of salt is less than 5 g per day.
- Adequate intake of animal source foods is guaranteed in children under five.
I believe it is critical for the credibility of the Frameword to be accepted that all of these recommendations be based on evidence, and where evidence is lacking, that the document specifically say so and recommend further research. For example, there are many populations where for religious, cultural or philosophical reasons, intake of animal source foods is not acceptable. I would argue that it is possible to design nutritionally adequate diets for those who do not eat animal source foods. Thus to say that animal source foods should be ‘guaranteed’ to promote optimal health, is not based on good evidence.
A second example is the recommendation on free sugars being less than 10% or preferably less than 5%. I do not believe there is good evidence that if this recommendation is achieved that it would promote optimal health.
I may not have the expertise to comment on salt, but I wonder whether there is good evidence on the recommendation of 5 g/day.
I note that the following was included in the document:
“Dietary diversity is a key determinant of nutritional outcomes, but the consumption of nutrient-dense foods is very sensitive to income and price, especially for low-income consumers.
Strategies should aim to bring about a number of specific changes in the diet, as set out in the Global NCD Action Plan:
- Reduce the level of salt/sodium added to prepared or processed food.
- Increase availability, affordability and consumption of fruit and vegetables.
- Reduce saturated fatty acids (SFA) in food and replace them with unsaturated fatty acids.
- Replace trans fats with unsaturated fats.
- Reduce the content of free and added sugars in food and non-alcoholic beverages.
- Limit excess calorie intake, reduce portion size and energy density of foods.”
The language in the Global NCD Action Plan is quite different than the Framework for Action, in that it provides general guidance, rather than specific numbers. Given that there is not strong evidence for many of the specific numbers (as identified above), I would suggest following the Global NCH Action Plan language. For example, the Global NCH Action Plan says “reduce the level of salt/sodium..” rather than providing a specific number. It says, “reduce the content of free and added sugars..” rather than providing a specific number.
As an important general principle, recommendations in the the Frameword should be based on evidence where the evidence is available and should state when evidence is not available, in which case general statements (as was done by the Global NCD Action Plan) would be preferable in my view.
Stanley Zlotkin CM, MD, PhD, FRCPC
Chief, Global Child Health
Senior Scientist, Research Institute
The Hospital for Sick Children
Departments of Paediatrics, Nutritional Sciences and Public Health
University of Toronto
Canada
Stanley Zlotkin