kraisid tontisirin 2007, mahidol university trend and challenges in food and nutrition development...

Kraisid Tontisirin 2007, Mahidol University

Trend and challenges in food and nutrition development in Thailand

Kraisid Tontisirin Professor Emeritus, Mahidol University

Presentation at the 2nd National Health Promotion Meeting, Ministry of Health Thailand

15 June 2007

Overview of presentation

• Introduction • Nutrition and nutrition related chronic

diseases (NRCDs) in Thailand• Past achievement of nutrition improvement

in Thailand• Major global issues on food and nutrition• Life course approaches in nutrition

promotion• Conclusion

Fundamentals for human, animal and plant health

• Genetics

• Nutrition

• Prevention and control of diseases

• Environment

Factors influencing health and quality of life

• Genetics

• Nutrition

• Mental well being

• Physical activity and exercise

• Avoidance of toxicants i.e. smoking, excessive alcoholic consumption


Nutrition - a link between food and health enabling

Availability, access, consumption and utilization of food of adequate quality, quantity & safety

Meeting human nutrient and non-nutritient requirements during the life cycle


Major food and nutrition problem in Thailand

• Undernutrition: PEM ( underweight, stunting, wasting), hunger, micronutrient deficiencies ( iron, iodine, vitamin A…)

• Overnutrition and nutrition related chronic diseases (NRCDs): overweight, obesity, hyperlipidemia, diabetes mellitus, high blood pressure, CVD…

• Food safety (unsafe from hazards in food) and food high in fat (sat. FA and trans FA) sugar and sodium)

i

• ,

Mapping the Situation ofChildren and WomenFindings from theThailandMultiple Indicator Cluster Survey2006May 2007

[PLACE NAME AND LOGOOF IMPLEMENTING AGENCY HERE]

[PLACE NAME AND LOGOOF IMPLEMENTING AGENCY HERE]

Thailand Multiple Indicator Cluster Survey (MICS 2006)

• National samples of over 40,000 households (HH) plus over-sampling of an additional 30,000 HH

• In 26 focus provinces

*In 26 focus provinces in 4 regions

Thailand Multiple Indicator Cluster Survey 2006… Unicef May 2007*

Prevalence of Low Birth Weight (LBW)

9 % of infants born weighing less than 2500 grams

Top province (%) Weakest Province (%)

Phuket (4.89) Mukdahan (16.32)

Phangnga (5.510) Yala (17.83)

Mae Hong Son (5.911) Ubon (20.4)

Satun (7.812) Chiang Rai (27.15)

Pattani (7.913) Chiang Mai (27.2)

From Thailand Multiple Indicator Cluster Survey 2006… Unicef May 2007

Millennium Development Goal 4. (Reduce child mortality)

Reduce by two thirds, between 1990 and 2015 the under-five mortality rate.

• National Goal: No more than 6% of newborns weighing less than 2,500 grams (NPA, 2005-2014) from 18 %

• Indicators available in Thailand MICS3: -Birth weight


Percentage of Infants Weighing Less Than 2,500 Grams at Birth

05

1015202530


Low Birth Weight, Poor or Very Poor Wealth Quintile, Thailand MICS 2006

05

1015202530

% o

f in

fan

ts b

orn

in p

ast

two

yea

rs

Total Poorest Quintile


Prevalence of undernutrition of children under five years

• Underweight (wt/age) 9.3 %

• Stunted (ht/age) 11.9 %

• Wasting (wt/ht) 4.1 %


Millennium Development Goal 1.(Eradication extreme poverty and hunger)

• Eradicate extreme poverty and hunger. Reduce by half between 1990 and 2015 the proportion of people who suffer from hunger.

• National Goal: No more than 5% of children under five years underweight for age (10% in WFFC)

• National Status Thailand MICS 2006: • 9.3% of children aged 0-59 months underweight

for age

Prevalence of under weight of under five

Underweight prevalence: MICS 3, Indicator 6, Thailand MICS 2006

Rank Province % Rank Province %

1 TRANG 4.6 14 NAKORN PHANOM 10.7

2 CHIANG RAI 4.9 15 KANCHANABURI 11.5

3 PHAYAO 5.1 16 MUKDAHAN 12.6

4 BANGKOK 5.3 17 NAN 13.1

5 RAYONG 6.8 18 UBON 13.1

6 RATCHABURI 6.9 19 TAK 13.4

7 PHUKET 8.3 20 PHANGNGA 14.6

8 KHON KAEN 8.7 21 MAE HONG SON 14.8

9 SA KAEO 9.3 22 SATUN 16.6

10 KRABI 9.8 23 NARATHIWAT 20.3

11 RANONG 9.8 24 YALA 21.9

12 SONGKHLA 10.3 25 PATTANI 25.4

13 CHIANG MAI 10.7 26 SRI SAKET 26.3


Percentage Underweight, 0-5 Years, Total and Poor, Thailand MICS 2006

05

10152025303540

% o

f ch

ild

ren

0-5

yea

rs

Total

Poor


Map: Low Weight for Age of under five

Underweight for age, 0-5 years, Comparing Total to Poor and Non-Thai Sub-groups, Thailand MICS 2006

0

10

20

30

40

50

60

Un

derw

eig

ht

as %

of

ch

ild

ren

0-5

years

Total

Poor

% Non-Thai



Malaria7% ARI

29%

Measles8%

Diarrhea25%

Other31%

Malnutrition contributes

about 50% of this mortality


Underweight Children in Thailand*

• 8-12 % in preschool children (rural> urban)• 7-9 % in 6-14 years old children

(rural>urban)• 6-9 % in 15- 18 years old children

(rural>urban)

-----------------------------------------------------------* Div of Nutrition, MOPH, 2003


Stunted children in Thailand*

• 5-9 % in preschool children (rural> urban)

• 7-8 % in 6-14 years old children (rural>urban)

• 11-16 % in 15- 18 years old children (urban>rural)

-----------------------------------------------------------* Div of Nutrition, MOPH, 2003

Overweight and obesity (Thailand)

• National Goal: No more than 10% overweight in every group of 0-5 year old children (NPA 2006, p. 90)

• National Status: 6.9% of all children and 10.4% of municipal children under the age of 5 are overweight


Overweight for Height, Thailand, 2006

0

5

10

15

20

25

% o

f C

hild

ren

un

de

r 6

Ye

ars

Province rate: Left bar in each pair Municipal rate: Right bar



Childhood overweight and obesity in Thailand*

• 10-15 % in primary school children

• Over 50 % of obese children with hyperlipidemia ( high cholesterol and TG)

• Over 25 % of normal weight children with hyperlipidemia

*various sources of data from Dr Ladda, INMU (Dr. Uruwan) and Faculty of Public Health, Mahidol U. (Dr. Chutima); more data in various setting are still needed.

Exclusive breastfeeding

• Infants who received only breast milk and vitamins, mineral supplements or medicine in the 24 hours prior to the interview are classed as exclusively breastfed.

• Only 5 %of Thai infants benefit from ex.BF (vs. 46% of global figures)

• 8/26 focus provinces, no ex.BF was reported

MICS3 Indicator 15: Exclusive breastfeeding rate 0-5 mo.

0

10

20

30

40

50

60


Salt iodization( 15-29.9 ppm for adequately iodized salt))

• Only 10.4 % of samples of HH found adequate level of iodine

• Lowest rate (22.6 %) was found in the Northeast with adequate level

• 53.7 % in the Northern, 59.7 % in the Central, and 60.3 in the Southern region


Adequately iodized salt, Thailand MICS 2006

0102030405060708090

100


Ten leading causes of health burden in Thailand (MOPH 1999)

Male FemaleHIV/AID HIV/AIDSTraffic accident StrokeStroke Diabetes mellitusCA liver DepressionMurder/violence Traffic accident Suicide Low birth weightDiabetes mellitus CA liver COPD OsteoarthritisIschemic HD COPDLow birth weight Ischemic HD

13 leading causes of DALY in Thailand(Disability adjusted life years … MOPH 1999)

Male FemaleUnsafe sex Unsafe sexCigarette Smoking Overweight and obesityAlcoholic consumption High blood pressureNo helmet protection Cigarette Smoking High blood pressure High blood cholesterolDrug addicts Occupational accidentOverweight and obesity No helmet protection Inadequate intake of F&V Physical inactivityHigh blood cholesterol Poor hygieneOccupational accident Inadequate intake of F&V Poor hygiene Alcoholic consumption Air pollution Drug addicts Physical inactivity Air pollution

Nutrition situation and NRCDs in Thai adults(MOPH 3rd Physical examination surveys 2004)

Male FemaleBMI (kg/m2) 22.6 23.8Waist circ. (cm) 78.6 76.6Waist circ.>90 and 80 cm (%) 15.4 36.1Thinness (%) 11.6 9.6Overweight (%) 17.8 25.4Obesity (%) 4.8 9.0

Nutrition situation and NRCDs in Thai adults(MOPH 5th Food and Nutrition Survey 2003)

Male FemaleHigh LDL-C >130 (%) 13-33 13-44

LOW HDL-C <40 (%) 6-13 18-32

High TG >150 (%) 6-46 8-37

Prevalence of DM (%) 6.4 7.3

Prevalence of high BP (%) 23.3 20.9

Fruit & veg intake (g/d) 268* 283*

*MOPH 3rd Physical examination surveys 2004)

Food, nutrition and life style factors (Dada from various sources 2003-2005)

Sugar consumption in 2004 was 30.3 (kg/person/y) or 83 g/d or 16.6 % of energy intake from sugar.

Soft drink beverage intake was 102 bottles/person/y ( 816 in the US)

Increased consumption of sugary drink i.e. fruit juices, sweet tea and coffee

Increasing snack consumption particularly in children, 2 packs/person/day

Expansion of fast food services

Food, nutrition and life style factors (Dada from various sources 2002-2005)

Increasing snack consumption particularly in children, 2 packs/person/day

Expansion of fast food services

Increased alcoholic beverage intake, 81.7 liter/person/y in 2003

Only 35.7 % of male and 23.7 % female from 6 year onward exercised regularly (2002..Office of National Statistics)

Nutrition interventions

• Supplementation with micronutrients/food• Food fortification• Nutrition education/communication• Food based approach: ensuring food

security/consumption of safe and nutritious food

• Public health measures: basic services, immunization, sanitation, deworming …

• Community based (integrated) approaches

Multisectoral-community based strategies since 1981

• Under the umbrella of the Poverty Alleviation Plan (PAP) targeting to the poor areas to achieving BMN

• Primary Health Care (PHC) and Food and Nutrition Plan (FNP) have been incorporated in the PAP

• Nutrition has been used as goals and indicators

Forging the link between government and community

Minimum Basic Services(Health, Education, Agr. Extension)


Supportive System•Training•Funding

•Problem Solving•Supervision

Interface(service providers and

community leaders)•Plan/goals

•Implementation•Monitoring/evaluation

Community LeadersFamily

Individual

Basic Minimum Needs Goals/IndicatorsBasic Minimum Needs Goals/Indicators

Menus (Menus (ActivitiesActivities))•Food productionFood production•Nutrition educationNutrition education•Food sanitation & safetyFood sanitation & safety•ANCANC•GMPGMP•BF/CFBF/CF•Other activitiesOther activities

Mobilizers(1:10 households)

Facilitators

ComponentsComponents of a successful community based programof a successful community based program

Food and nutrition security

Individual/Family&

Community as Core

Consumption

Consumer protection

Food processingFood production

Utilization

Nutrition labelling

Food-based dietary guidelines

Food combinationFortification

Rice/cereals LegumesFish ChickenEggs VegetablesFruits Dairy

Monitoring and Surveillance

Health service &Caring practicesFood & Nutrition Programmes•Prevent & control malnutrition•School meals, etc.

Dramatic improvements are possible:

• Between 1960 and 2004, Chile cut its underweight rate from 37% to 2.4%

• Thailand reduced malnutrition rates from 36% to 13% in the 15 years to 1990

• Brazil decreased its child undernutrition by 67% between 1970 and 2000

• Malnutrition in India has declined by about 30% since 1960

• Between 1980 and 1990, Tanzania reduced reduce child malnutrition from 50% to 30%

Common factor: national leadership, focus on nutrition

From Ending child hunger and undernutrition initiatives (ECHUI, WFP 2007

Global problem 852 m undernourished people worldwide400 m undernourished children < 18149 m underweight children < 5 5-6 m preventable U5 deaths per year,

(where undernutrition is a key factor) 85 m families in need

(countries where U5 underweight ≥ 10%)

* Approximations and estimates, sources: FAO, WFP, WHO/UNICEF, WFP/UNICEF

Prevalence of undernourishment, 2000-2002

Region No. (millions) undernourished

% undernourished

World 852 13

Developing countries

815 17

Asia 519 16

South Asia 301 22

Source : FAO, SOFI, 2004

FAO’s Hunger map (2002-2004)

We are not on track to meet the World Food Summit Goal

What will it cost if we do nothing?

• Economic and social consequences of approx 45 million preventable child deaths by 2015 (at today’s rate of attrition)

• approx. 2 to 3 percent of GDP lost annually to undernutrition in high prevalence countries*

• $500 billion to $1 trillion in lost productivity and income over the lifetime of today’s undernourished children*

• Prospect of achieving other MDGs reduced.

• *Sources: UN Standing Committee on Nutrition, World Bank, FAO

Importance of nutrition in achieving the MDG’s

• Good nutritional status is essential to reduce poverty, improve human capital and enhance productivity

• Well nourished children will be better able to concentrate and learn in school

• Well nourished girls will be more likely to stay in school and gain maximum benefit from their education

• Well nourished children and mothers are much less likely to suffer premature death from illness and childbirth

Childhood overweight and obesity

• Affecting 10 % the world children

• 10-15 % of Thai children

• 20 % Chinese children

• 26 % of Canadian children and youth (8% obese)

• 33 % in the US, 6-19 yr of age (13% obese)

• 30 % in EC with 8 % obese


WHO’s Latest projection globally 2005

• 1.6 billion adults (age 15+) were overweight, 70% in low and middle income HH

• 400 million adults were obese• 20 million Under 5 children were obese• 60% of all deaths were due to Diet RCD and

80% of those deaths occurred in low and middle income countries (DC)

• By 2015, 2.3 billion adults will be over wt. and more than 700 million will be obese


*

*

**

**

Risks Associated to Global Deaths

2000

(x 000)

* Significantly determined by diet and PA

*


Main contributors to the world’s health burden as regards to the

NCDs (WHO Report 2002 & 2004)

• High blood pressure

• Increased blood cholesterol levels

• Low intakes of vegetables and fruit

• Physical inactivity

• Excessive weight gain

• Tobacco consumption


Double burden of malnutrition

Refers to the dual burden of under- and over-nutrition occurring simultaneously within a population or even in the same community or in the same household

Population nutrient intake goalsPopulation nutrient intake goalsPopulation nutrient intake goalsPopulation nutrient intake goals

From Ricardo Uauy


International Congress Foetal Origins of Adult Disease:

“Barker” hypothesis: programming of function

During early life nutrient exposure sets metabolic behaviour and thereby determines the risk of chronic disease during adult life.


Possible life course approaches in nutrition promotion in Thailand

• Aim of the plan/actions should lead to“Nutrition Security” for all as to p/c of double burden of malnutrition (under and over nutrition)

• Working principles: -people centered development -life cycle approach from intra uterine period -holistic and integrated approach -partnership, esp. between service providers and

community participation -decentralization of responsibilities and actions -best practices for actions -learning by doing• Develop (societal) plan with goals, targets and indicators

Life course approaches in nutrition promotion

• Antenatal care for pregnant mothers with proper nutrition support and education to reduced low birth weight (LBW)

• Infant and young child feeding:

-Promotion, protection and support for breast feeding

-Adequate and appropriate complementary feeding

-Growth and development monitoring and promotion


• Promotion of desirable eating habits: -Food based dietary guidelines (FBDGs) -Nutrition program in school: -nutritional assessment/surveillance -food services--school lunch/meals -basic food, personal and environmental hygiene -school gardens -nutrition education -promotion of physical activity and exercise -positive school environment for healthy diets

1. Eat a variety of foods from each of the five food groups and maintain proper weight 2. Eat adequate rice, or alternate carbohydrate rich food groups 3. Eat plenty of vegetables and fruits regularly 4. Eat fish, lean meats, eggs, legumes and pulses regularly 5. Drink sufficient amount of milk every day 6. Take moderate amounts of fat 7. Avoid excessive intake of sweet and salty foods 8. Eat clean and uncontaminated foods 9. Avoid or reduce consumption of alcoholic beverages

The 9 Thai FBDGs Recommendations

HEALTHY EATING

• Eat five food groups• Eat a wide variety of foods

• Eat proper amount of food• Eat balanced food

Energy distribution of food: Protein:Fat:CHO = 10-15 : 15-30 : 55-75


• Nutrition orientation to food production and supply as to response to the increased demands for “healthy foods” (promotion of healthier food supply)


• Regulatory approaches: Promotion and enforcement of Codex and national food standards, guidelines, recommendations and codes

•Nutrition labeling of foods in market shelves, canteens and restaurant menus, particularly snacks•Marketing including advertising: to protect children from all forms of marketing•Quality control of food for children in nurseries, schools and other government facilities•Pricing: falling cost for nutrient rich foods and increased cost for fatty/sugary drink and foods•Availability: restriction the availability of fast food /soft drink outlets in urban environment and near schools



• Example of Nordic Plan of Actions on better health and QL to stop pan obesity by 2011: healthy diet, one hr/day for PA and stop all advertising food directed at children, no vending machines in school

• Promotion of physical environments that facilitate active lifestyle (PA), exercise and sport at home, schools and public places

• Urban and rural planning to induce PA


• Community based program (CBP) at district level and below, and in school linking with national policy and strategy

• Effective micronutient deficiencies control programs by nutrition IEC (FBDGs for example), food fortification, targeted supplementation to PL mothers

• Special attention to IDD control through universal salt iodization: need business plan for high quality of iodized salt used by all HH



Supportive System•Training•Funding

•Problem Solving•Supervision

Interface(service providers and

community leaders)•Plan/goals

•Implementation•Monitoring/evaluation

Community LeadersFamily

Individual

Basic Minimum Needs Goals/IndicatorsBasic Minimum Needs Goals/Indicators

Menus (Menus (ActivitiesActivities))•Food productionFood production•Nutrition educationNutrition education•Food sanitation & safetyFood sanitation & safety•ANCANC•GMPGMP•BF/CFBF/CF•Other activitiesOther activities

Mobilizers(1:10 households)

Facilitators

ComponentsComponents of a successful community based programof a successful community based program

Food and nutrition security

Individual/Family&

Community as Core

Consumption

Consumer protection

Food processingFood production

Utilization

Nutrition labelling

Food-based dietary guidelines

Food combinationFortification

Rice/cereals LegumesFish ChickenEggs VegetablesFruits Dairy

Monitoring and Surveillance

Health service &Caring practicesFood & Nutrition Programmes•Prevent & control malnutrition•School meals, etc.

Forging the link between government and community


• Monitoring and evaluation: wt, ht, eating behaviors and social capitals, particularly in schools

• R&D and capacity building to support national plan of actions


Conclusion

• Prevention and control of undernutrion was a success experience in Thailand during the last 30 years

• Thailand is still facing with double burden of malnutrition (DBM) but more on overnutrition and NRCDs which are heavily burden to society and are the main causes of death.

• Need collective effort and actions now to prevent DBM particularly childhood obesity which are beyond health sector.

Conclusion

• Thailand past successful experience in p/c of childhood undernutrition sould be revitalized and adapted to p/c of overnutition and NRCDs

• Urgent need for effective actions in schools (Food and nutrition friendly school program) to p/c of childhood obesity ( nutritional assesment and surveillance, promotion of healthy diets, nutrition education for desirable eating behavior, physical activity and sports with a strong participation by parents and community

Conclusion

• Special attention to p/c of micronutrient deficiencies, particularly to IDD

• Need more positive environment to facilitate PA

• Periodic food and nutrition surveillances followed by actions are essential.

• Need research and capacity development to back up strategic development and actions

Conclusion

With strong commitment, proper resource mobilization, dedication, decentralization, community participation and best practices, Thailand could set up again an excellent example for prevention and control of DBM especially overnutrition and NRCDs to the global community.

3-5 ตุ�ลาคม 2550

ไบเทค บางนา

การประชุ�มโภชุนาการแห่�งชุาตุ�คร��งท�� 2The Second Thailand

Congress of Nutrition‘โภชุนาการพอเพ�ยง ... ความสุ�ข

เพ�ยงพอ’

‘Sufficiency Nutrition for Happiness’

สุนใจตุ�ดตุ�อ

จ�ดโดยสุมาคมน�กโภชุนาการแห่�งประเทศไทยในพระราชุ'ปถั�มภ) สุมเด*จพระเทพร�ตุนราชุสุ�ดาฯ สุยามบรมราชุก�มาร� & ชุมรมผู้'-ให่-อาห่ารทางห่ลอดเล.อดด/าและทางเด�นอาห่าร ร�วมก�บภาค�เคร.อข�ายด-านอาห่ารและโภชุนาการ

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kraisid tontisirin 2007, mahidol university trend and challenges in food and nutrition development...

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