This document summarizes the main achievements and challenges of nutrition and physical activity policy in Bulgaria. It outlines key nutrition problems in Bulgaria including low rates of breastfeeding and high rates of overweight, obesity and diet-related diseases. It then discusses achievements of Bulgaria's 2005-2010 Food and Nutrition Action Plan in areas like breastfeeding promotion and school nutrition policies. Finally, it addresses ongoing challenges for Bulgaria's 2011-2015 policy including the need for multisectoral strategies and adequate financing to improve the food environment and support healthy choices.

1. ACHIEVEMENTS AND CHALLENGES OF NUTRITION AND PHYSICAL ACTIVITY POLICY IN BULGARIA Stefka Petrova National Center of Public Health Protection

2. PRESENTATION OUTLINE Main problems in nutrition & nutritional status and related diseases of Bulgarian population as a basis for Food and Nutrition Action Plan Achievements of Bulgarian Food and Nutrition Action Plan, 2005-2010 Challenges of Food and Nutrition Policy, 2011-2015 Policy on Physical Activity

3. MAIN NUTRITION/NUTRITIONAL STATUS PROBLEMS AND RELATED DISEASES Exclusive breastfeeding low rate; early introduction of complimentary foods; Negative characteristics of national nutrition pattern : high fat intake; low fresh fruit& vegetable consumption in winter and spring; high salt intake; low fish consumption; high sugary products & soft drinks intake from children; Low intake of a number vitamins and minerals ; High prevalence of overweight and obesity , including among children; Low physical activity among most of the population; High morbidity and mortality rates of diet related chronic diseases: CVD, cancer, diabetes, osteoporosis.

5. Average Sodium Intakes in 52 countries Average levels of excreted Na in urine – most reliable indicator for Na intakes: “Nutrition and stroke” study in Varna city, 2000 14 g salt / day

6. OVERWEIGHT AND OBESITY PREVALENCE AMONG ADULTS IN BULGARIA National nutrition surveys , 1998 and 2004 M 19-30 F19-30 M 30-60 F 30-60 Year M 60-75 F 60-75

7. OVERWEIGHT AND OBESITY PREVALENCE AMONG CHILDREN AND ADOLESCENTS OF AGE 7-19 YEARS National nutrition surveys , 1998 and 2004 M 7-10 M 10-14 M 14-19 F 14-19 Year F 7-10 F 10-14

8. MORTALITY RATE OF CEREBROVASCULAR DISEASE FOR MEN IN BULGARIA AND EU MEMBER STATES Source: WHO, 2003

9. INCIDENCE OF REGISTERED CASES OF COLORECTAL CANCER Source: National Center of Health Information, 2004

10. FOOD AND NUTRITION ACTION PLAN, 2005-2010 GOALS: To achieve positive changes in the national dietary pattern for decreasing the risk of nutrient deficiencies and diet-related chronic diseases; To decrease the health risk related to food contaminants and food additives; To improve food security through increased availability of health promoting foods and their accessibility for the whole population.

11. Национален план за действие “ Храни и Хранене” 2005-2010

12. SUPPORTING A HEALTHY START Promote optimal fetal nutrition : - Promotion of healthy nutrition for pregnant women – on national and local level - education materials, consultancies, national/local level campaigns, including media - Folic acid supplementation of women in prepregnancy – joint work of nutritionists and specialists in obstetrics & gynecology - Education of medical specialists (GP’s, nurses, etc.) – courses, education materials, seminars

13. SUPPORTING A HEALTHY START Protect, promote and support breastfeeding: - Internet web site , information materials - Consultative Center on Breastfeeding and Hot Telephone Line in Sofia - Accreditation of new Baby Friendly Hospitals - Organization, training and support of groups “Mothers support mothers” - Annually country-wide promotion of World Breastfeeding Week - National Conference on Breastfeeding with pediatricians, Pleven, 2008

15. SUPPORTING A HEALTHY START Improvement of pre-school and school nutrition: - Manuals for healthy nutrition with recipes for kindergartens and schools developed and mandatory used - Training of staff in kindergartens and schools, control on nutrition - Nutrition education modules developed, efficiency studied - Member of WHO Nutrition Friendly Schools Initiative - New regulation for foods & meals in school canteens and cafeteria , banning of sugary products and soft drinks, energy drinks, snacks with high fat and salt content, 2009 - New regulation on requirements for healthy nutrition in kindergartens , launched in 2010, under publication

19. ENSURING A HEALTHY SUSTAINABLE FOOD SUPPLY Improve the availability of fruits and vegetables - Regulation for mandatory availability of fruits & vegetables in school cafeteria, 2009 - Governmental Program for free breakfast (schoolchildren of 1-4 grade) – mandatory including fruits and vegetables, 2005 R eformulation of food products - Discussion forums on possibilities to reduce salt, added sugar and fats in foods, setting targets - nutritionists, food producers, food technology experts - Participation in WHO/EC Salt Reduction Initiative – setting target foods, working group, agreement with food manufacturers, national information campaign

20. PROVIDING COMPREHENSIVE INFORMATION AND EDUCATION TO CONSUMERS Development and Promotion of Food Based Dietary Guidelines for different population groups Food labeling : harmonization with EU regulation, introduction of GDAs (Guideline Daily Amounts) Information of the community : web pages of Ministry of Health and Ministry of Agriculture and Foods, involving of mass-media

21. Bulgarian Food Based Dietary Guidelines for different population groups

23. PROVIDING COMPREHENSIVE INFORMATION AND EDUCATION TO CONSUMERS National week for counteracting obesity – annual campaign since 2006: country-wide, variety of activities related to promotion of healthy nutrition and physical activity, organized by Ministry of Health, National Center of Public Health Protection and Regional Inspectorates

24. PARTNERSHIP IN REALIZATION OF THE NATIONAL OBESITY WEEKS Schools, kindergartens NGOs Food industry Professional organizations Municipalities Mass-media

25. DISCUSSION FORUMS DURING NATIONAL OBESITY COUNTERACTING WEEK

26. PROVIDING COMPREHENSIVE INFORMATION AND EDUCATION TO CONSUMERS Participation in EU Network on reducing marketing pressure on children - establishment of a working group, debatable forum with experts, producers, NGO’s World Food Day (16 October) – annually discussion forum, press conference European Day of Healthy Food and Cooking (8 November): target group- children, attractive events Избери плодове и зеленчуци вместо нездравословна храна

27. EUROPEAN DAY OF HEALTHY FOOD AND COOKING

28. MONITORING AND EVALUATION Established national nutrition monitoring system – including MH, NCPHP and 28 Regional Health Inspectorates - 5 national surveys carried out in 1997-2004 - 3 national surveys conducted in 2006-2010: infants and children under 5 -2007; adults – 2008; schoolchildren aged 6-19 years - 2010 - Participation in WHO/EU Childhood Obesity Surveillance Initiative, 2008 - New software for food consumption and nutrient intake assessment, up-dated picture book for determination of food consumption

30. Prevalence of stunting (< -2 SD, length/height-for-age) in children under 5 assessed by WHO and BG standards National survey, 2007 WHO (2006) Bulgarian standards

31. Prevalence of underweight (<-2SD, weight-for-age) in children under 5 years old assessed by WHO and BG standards National survey, 2007 WHO (2006) Bulgarian standards

32. Anemia in Infants and Young Children National survey, 2007 % Age Relative rate of children aged 6 months to 5 years with anemia ( Hb<11,0 g/dL) , differentiated by age and ethnicity

33. Prevalence of anemia in women ( Hb<1 2 ,0 g/dL) with children of age under 5, differentiated by age of children and ethnicity National survey , 2007 The most risk groups are the women during the first months after delivery and those with Roma ethnicity. % Age of children

34. Child Obesity Surveillance , 2008

35. Prevalence of overweight and obesity among schoolchildren aged 6-19 years National survey, 2010

36. National behavioral risk factor survey among population aged 25-64 , 2007 Intensive Physical activity: every day have only 5.9% of males and 2.8% of females . Moderate Physical Activity: every day have only 8% of males and 6.4% of females . 0 days 1 days 2-3 days 4-5 days above 6 days men women 0 days 1 days 2-3 days 4-5 days above 6 days men women

37. Mean daily stay in sitting position by gender (%) National behavioral risk factor survey among population 25-64 , 2007 About 50% of women and men spent in sitting position 2-5 hours daily . Above 5 hours daily in sitting position are 36.1% of men and 43.6% of women, at higher rate among office employees and students . Among persons who spent 5 hours daily in sitting position, about 1/3 are with elevated blood pressure . With increased BMI are 73.02% of men and 52.4% of women , and with increased cholesterol levels are 51.9% of persons, predominantly elderly. 0-60 min 61-120 min 121-300 min Above 300 min men women

38. IMPACT OF CINDI PROGRAM Relative rate of HYPERTENSION (≥140/90 mm Hg ) among Bulgarian population by gender ( %) in Tarnovo city

39. IMPACT OF CINDI PROGRAM Relative rate of subjects with high blood Cholesterol level (> 6 ,2 mmol / l) by gender (%) in Tarnovo city

40. Challenges in Food and Nutrition Policy Develop of adequate to the current problems FNAP 2011-2016 Multisectoral integrated approach Efficient strategies: Improve food/nutritional environment Create possibilities for informed choice Access to healthy nutrition Community involement Public-private partnership Focus on priority groups and settings Adequate financing

41. Physical Activity Policy National Strategy and National Program for Development of Physical Education and Sports, 2005-2008, 2009-2013: Urban planning for PA friendly environment Promotion of cycling and walking Improve and promote sporting facilities Improve and promote leisure facilities Program “Sports for children in leisure time”, 2005-2010 Campaigns on national/local level annually

42. Promotion of Physical Activity Partnership with NGOs Joint campaigns of professionals, municipalities, food producers Directed mainly to children but also to all age groups, including elderly people

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