|Implemented in this survey?|
A policy paper was prepared by a sub-committee of the National Council for Women?s Health. The recommendations aim at creating a healthy nutrition environment to promote family health emphasizing the role of women, and using windows of opportunity for counselling. The recommendations include educational, clinical and legislative measures as well as supervision and enforcement. The program includes financial and legal incentives and measures to increase intrinsic motivation for nutrition change.
The policy paper was prepared by a sub-committee of the National Council for Women's Health with the purpose of creating a healthy nutrition environment in order to promote the health of all family members throughout the life cycle.
The goal of the proposed policy is to achieve health nutrition standards througout the life cycle with an emphasis on women and family.
Specific objectives include:
1) Achieve healthy nutrition standards at the beginning of life
2) Empower women who have a leading role in adopting healthy nutrition habits by intervention in "windows of opportunity" during the life cycle
3) Create a healthy nutrition environment to promote the health of the population.
Women's nutrition during pregnancy affects their children´s risk for low birth weight and consequently long-term development of chronic conditions; the nutrition women prepare for themselves and their family affects the risk for obesity and its comorbidities such as high blood pressure, diabetes cardiovascular diseases. The outcomes of unhealthy nutrition have significant health as well as economic consequences, and therefore it is called for a national program for improving nutrition.
The policy paper consists of educational, clinical, legislative, supervision and enforcement, economic and social marketing measures to improve nutrition, emphasizing the role of women in achieving this objective.
The proposed measures include:
Education: 1) Empowering women by providing nutrition guidance to those planning pregnancy, pregnant women, women in maternity wards, women visiting well-baby clinics, women visiting child development centers, women's health centers and primary care clinics. 2) Educational programs on healthy nutrition will be provided to school teachers and staff, health care organization staff, and nutrition staff in the army and in the work place.
Clinical measures: Screen women and children at risk for unhealthy nutrition, deficiencies, obesity, and eating disorders during visits to well baby clinics
Legislation: 1) add "nutrition consulting" in the above sites (schools, hospitals, army etc.) to the mandatory basket of services; 2) Increase taxes on sweetened drinks, alcohol and unhealthy snacks; 3) Subsidize/lower the price of healthy food such as vegetables, fruit, low fat milk products, fish, whole grain foods, etc. 4) Compulsory marking of food for high salt, sugar, and saturated fat; 5) Forbid any advertising of food or drinks to children; 6) Instate and enforce a "nutrition standard" on foods served in public institions such as schools, army, hospitals, workplace, assisted living centers; 7) Forbid vendor machines for selling sweetened drinks in schools, hospitals and workplaces and enforce these regulations. 8) Enforce provision of healthy snacks at meetings, and meals in the public institutions mentioned above.
Supervision by dietician: The responsibility for management of nutrition in public facilities (schools, health organizations, army, workplace) will be assigned to a dietician who will prepare the menu and approve any new food introduced to the facility.
1.1. Achieve healthy nutrition standards at the beginning of life.
1.2. Empower women who have a leading role in adopting healthy nutrition habits by intervention in "windows of opportunity" during the life cycle.
1.3. Create a healthy nutrition environment to promote population health.
1) Financial (i.e. prices of healthy/unhealthy food; 2) Intrinsic motivation (e.g. providing information on importance of adopting healthy nutrition; marking products to facilitate healthy choices); 3) Legal - legislation and enforcement (e.g. banning vendor machines in public facilities; compulsory approval of menu by dietician).
1. Women in different stages of life will benefit from nutrition counseling, which is expected to improve their awareness and behaviors, 2. The next generation of babies and children are expected to have lower obesity rates and better nutritional habits as a consequence of their mother?s improved nutritional status at pregnancy and a healthier food environment at home, 3. The autonomy of managers in the food industry and in public facilities (schools, health care organizaitons, army etc.) in the area of nutrition will be decreased.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
Innovation - the policy paper is innovative in its comprehensive approach and in the central role envisioned for women. However, the individual policies have been recommended before in Israel and abroad.
Controversy - there has been some controversy in the process of preparing the policy paper (see stakeholder positions), and controversy is expected in the future process of implementation.
Systemic impact - is expected to be fundamental if the policies are implemented, as there will be changes in the roles of major stakeholders involved.
Public visibility - is low as there has not been media coverage of this policy paper.
Transferability - the comprehensive approach and the central role of women in initiatives to improve nutrition is transferable. The specific policies should be adjusted to the conditions of each country.
The policy is in line with national recommendations formulated in the Ministry of Health report "Health goals for 2020" (reported in survey (7) 2006 http://www.hpm.org/survey/is/a7/1). It is also in line with previous recommendations of commitees on prevention of obesity.
"Health Goals for 2020", Ministry of Health
|Implemented in this survey?|
At the initiative of a prominent dietician who is a member of the National Council for Women's Health, the council chair appointed a committee to prepare a policy paper with recommendations on healthy nutrition for women and their families. The committee included leading professionals in nutrition from hospitals, sickness funds, the army, the Ministry of Health, and academia. The policy paper was distributed to all members of the National Council for Women's Health. The members of the Council aroused a lively discussion, ammendments were suggested and incorporated, and the final version was presented to the Director General of the Ministry of Health.
This policy paper incorporates a wide range of strategies that were previously recommended in Israel as well as abroad. The main innovation of this paper is the emphasis on the crucial role of women in improving the nutrition of the whole family throughout the life cycle. Another unique aspect is the heavy emphasis on the expansion of the role of dieticians and their authority in diverse public facilities (e.g. schools, hospitals army). This policy paper also is unique in its scope - including a variety of measures (e.g. educational, financial, legal). Finally, unlike previous lengthy reports, this brief policy paper (seven pages including a rationale and recommendations) provides a clear and concise "action plan" to improve nutrition facilitating implementation.
The approach of the idea is described as:
renewed: Similar recommendations were issued by other commitees in Israel (e.g. MOH 2008, MOH 2009) as well as abroad (e.g. WHO 2003, WHO 2007).
National Council for Women's Health - supported the recommendations acknowledging the central role of women in promoting the health of the family.
Ministry of Health (MOH)
Dieticians - supported recommendations that strenghthen their role in health care organizations and other public organizations who provide food to their staff and consumers (e.g. schools, army).
Ministry of Finance - opposed the budgetary implications (adding funds for extra services).
Sick funds' position is that they support the recommendations. However, in order to implement them they need an increase in their budget to fund these activities. They also recognize the importance of the recommended measures to promote health (which is their mission and also serves their economic interests).
We should note that the food industry has not yet expressed a position as the recommendations were not publicized. They are expected to oppose them because of expected financial loss.
Hospital directors and other services who provide food at their facilities and will have to comply with the new regulations have not yet been consulted. They may oppose the initiative if they assess that no funds are available for extending the role of dieticians.
|Ministry of Health - Senior management||very supportive||strongly opposed|
|Ministry of Health - Head dietician||very supportive||strongly opposed|
|Ministry of Finance||very supportive||strongly opposed|
|Ministry of Health - Nursing division||very supportive||strongly opposed|
|Sick funds||very supportive||strongly opposed|
|National Council for Women's Health||very supportive||strongly opposed|
|Dieticians||very supportive||strongly opposed|
|Food industry||very supportive||strongly opposed|
The policy paper was presented to the health lobby at the Knesset (Israel's parliament) this summer.
It was also presented to the Director General of the MOH in September 2010. He requested his staff to prepare a draft for the legislation needed for implementing the policy. He said he would like to see progress in legislation within a few months. However, the legislation process has not yet begun.
|Ministry of Health - Senior management||very strong||none|
|Ministry of Health - Head dietician||very strong||none|
|Ministry of Finance||very strong||none|
|Ministry of Health - Nursing division||very strong||none|
|Sick funds||very strong||none|
|National Council for Women's Health||very strong||none|
|Food industry||very strong||none|
The implementation process has not yet begun. The recommendations were presented to the Director General of the MOH in September 2010. He endorsed them and promised to examine how to continue the process. It still is too early to assess how the MOH will indeed proceed with the implementation.
No evaluation is planned at this stage.
If the policy paper will be implemented, we expect to see an improvement in the nutrition of the population over time, and consequently a decrease in obesity rates. The policy paper depicts a comprehensive strategy to prevent unhealthy eating habits and consequent obesity. It employs a wide range of educational and legal measures, and financial incentives, and gives a central role in this effort to women, who are, to a high degree, responsible for their family`s nutrition.
However, there are doubts regarding the feasibility of implementing the policy paper, as it entails additional budgets for increasing the dietician workforce and other related expenses. The Ministry of Finance may not provide the needed funds. The policy paper envisions curtailing the autonomy of kitchen directors at hospitals and other institutions providing food to staff or patients. They, too, may oppose these policies and may not cooperate with the new regualtions. Finally, the policy depends on legislation that may arouse opposition from the food industry and consequently will not proceed.
However, there is a growing demand of the public to know the composition of food in restaurants, as well as a growing awareness of the necessity of providing healthy food at public institutions and restaurants (e.g. food without trans fats). Therefore, the policy paper may help hospital directors as well as directors of other institutions who provide food to improve the quality of their food even before the media and the public pressure them to do so.
Regarding unexpected or undesirable effects, it can be said that people of low socio-economic status may be negatively affected if the tax levels on unhealthy food will rise without supervision of prices on healthy core foods.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
Quality of care will increase if staff provides information and guidance regarding healthy nutrition and other lifestyle behaviors.
Equity in nutritional status will increase as a result of the following items of the proposed policy: lowering the cost of the healthy food basic basket; nutritional guidance in "windows of opportunity" to which most women (including those of low SES and minority status) will be exposed to; and the higher prices of junk food which will provide a disincentive to consume them, leading to better nutrition for all.
Cost-efficiency will increase if the proposed recommendations will indeed achieve the objective of reducing or preventing obesity, as this outcome will decrease future costs of obesity-related morbidity.
Although the intervention implies increasing costs for hiring more dieticians (not many) and other proposed measures, these costs are negligible compared to the expected costs of treating obesity and obesity related morbidity (e.g. bariatric surgery, diabetes), the rates of which are constantly increasing. While there is no guarantee that it indeed will yield the desired results, intervention among women at "windows of opportunity", such as maternity wards, still has the potential to be cost-effective. Nevertheless, it is still too early to assess the cost-efficiency of the recommendations which depend on the effectiveness of the intervention.
Gross Revital, Tabenkin Hava, Adler Dorit
Prof. Gross is Gross is a senior researcher at the Myers-JDC-Brookdale Institute and Bar Ilan University. Prof. Tabenkin is the Head of the National Council on Women's Health
Dr. Dorit Adler is the head of the Department of Nutrition and Dietetics at Hadassah Medical Center and Head of the sub-committee of the National Council on Women's Health for National Policy for improving women's nutrition