Programming Guidance Overweight Prevention

UNICEF
PROGRAMMING
GUIDANCE
Prevention of Overweight
and Obesity in Children
and Adolescents
NUTRITION GUIDANCE SERIES

Acknowledgements
This publication was prepared by the Nutrition Section at UNICEF Programme Division
in New York.
Lead Authors: Maaike Arts, France Bégin and Víctor Aguayo.
Technical advisory group in UNICEF: Luisa Brumana, Kudawashe Chimanya,

David Clark, Cristina de Carvalho Eriksson, Stefano Fedele, Alison Fleet, Bernadette
Gutmann, David Hipgrave, Jo Jewell, Roland Kupka, Joan Matji, Zivai Murira,
Christiane Rudert, Deepika Sharma, Harriet Torlesse, Amirhossein Yarparvar.
UNICEF recognizes the support by the Government of the Netherlands for the
development of this programme guidance.
Designer: Nona Reuter (UNICEF); Editing: Cheryl Stonehouse for ProseWorks
Citation: United Nations Children’s Fund (UNICEF). Prevention of overweight and

obesity in children and adolescents: UNICEF programming guidance, New York:
UNICEF, 2019.
August 2019
Photo credits: Cover photo: Getty Images, page 10: Mahmud Hams/AFP/
Getty Images; page 14: © UNICEF/UN0304111/Arcos; page 17: © UNICEF/
UN040078/Pirozzi; page 20: © UNICEF/UN038720/Pirozzi; page 22: Getty Images;
page25: © UNICEF/UNI178926/Ramos; page 31: © UNICEF/UNI183010/Quintos;
page36: © UNICEF/UNI136079/Friedman-Rudovsky.
UNICEF
PROGRAMMING
GUIDANCE
Prevention of
Overweight and
Obesity in Children
and Adolescents
Abbreviations
BMI Body Mass Index
DRP Division of Research, Policy and Practice
ECD Early Childhood Development
FAO Food and Agriculture Organization
IYCF Infant and young child feeding
MICS Multiple Indicator Cluster Surveys
NCD Non-communicable diseases
PFP Private Sector Fundraising and Partnerships
PPD Public Partnership Division
SDG Sustainable Development Goals
SMQ Strategic Monitoring Questions
UNDAF UN Development Assistance Frameworks
UNSCN United Nations Standing Committee for Nutrition
WFP World Food Programme
WHA World Health Assembly
WHO World Health Organization
2 UNICEF Programming Guidance

Contents
Definitions 4
Executive summary 5
About this programme guidance 6
Part I: Overweight in children and adolescents: Prevalence, causes, consequences,

goals and guidance 7
1. Overweight in children and adolescents 8

1.1. Prevalence and burden of overweight in early childhood (0-5 years) 9
1.2 Prevalence and burden of overweight in middle childhood (5-9 years) and
adolescence (10-19 years) 11
2. Causes and consequences of overweight in childhood and adolescence 12
2.1 Causes of overweight in childhood and adolescence 13
2.2 Immediate and longer-term consequences of overweight in childhood
and adolescence 14
3. Global goals and guidance for the prevention of overweight in children
and adolescents 15
3.1 Global goals on the prevention of overweight in children 16
3.2 Global policy and guidance for the prevention of overweight and obesity 16
3.3 Implementation of global policy and guidance for the prevention of
overweight and obesity 18
Part II: UNICEF programming for the prevention of overweight in children

and adolescents 19
4. Prevention of overweight in children and adolescents UNICEF Strategic

Plan 2018-2021 and UNICEF Nutrition Strategy 2020-2030 20
5. Recommended actions for UNICEF prevention of overweight programmes 23
5.1 Conduct a situation analysis 24
5.2 Design and prioritize interventions 25
5.3 Promote multisectoral and multi-stakeholder coordination and collaboration 26
6. Priority interventions 29
6.1 Improve the enabling environment: policies, regulatory frameworks and strategies 30
6.2 Implement interventions across the life cycle 30
6.3 Lead knowledge generation and use 38
6.4 Monitoring and reporting 39
7. Conclusion 41
Resources for further reading 42

Endnotes 42
Prevention of overweight and obesity in children and adolescents 3

Definitions
Adolescents Children and young people between 10 and 19 years of age.1
Children Human beings under the age of 18 (Convention on the Rights of the Child).
Body Mass Index Calculated as weight in kg/(height in metres)2. In adults, a Body Mass Index
(BMI) <18.5 kg/m2 is in the underweight range, >18.5 and <25 kg/m2 is in the
normal range, >25 and <30 kg/m2 is in the pre-obese range, >30kg/m2 is in the
obese range.
Food systems A food system gathers all the elements (environment, people, inputs, processes,
infrastructures, institutions, etc.) and activities that relate to the production,
processing, distribution, preparation and consumption of food, and the output of
these activities including socioeconomic, and environmental outcomes.
Middle childhood 5 to 9 years of age2
Obesogenic An environment that promotes high energy intake and sedentary behaviour. This
environment includes the foods that are available, affordable, accessible and promoted; physical
activity opportunities; and the social norms in relation to food and physical activity.
Overweight in Weight-for-height above +2 SD (standard deviation) of the WHO Child Growth

children aged 0 to Standards median for children of the same height and sex. Severe overweight
59 months (above +3 SD) is referred to as obesity. See reference for this and the following
three definitions3
For this age group, a prevalence of overweight below 2.5 per cent is considered
‘very low’, between 2.5 and 5 per cent ‘low’, between 5 and 10 per cent ‘medium’,
between 10 and 15 per cent ‘high’ and over 15 per cent ‘very high’.4
Overweight in BMI-for-age above 1 SD (standard deviation) of the WHO Growth Reference

children and young median for children of the same age and sex. Severe overweight (above +2 SD)
people aged 5-19 is referred to as obesity, and a BMI-for-age above +3 SD is referred to as severe
years obesity.
School-age Children between 5 and 14 years of age.5

children

Executive summary
The prevalence of overweight among all children interventions, in coordination with the government
and adolescents, from infancy to the age of 19, and other partners.
is on the increase almost everywhere. Around
40 million under-fives around the world have The recommended actions for implementation by
overweight, almost 6 per cent of this age group. UNICEF programmes are:
Among children aged 5 to 19 years, it is estimated 1. Improve the enabling environment, including
that more than 340 million have overweight, almost policies, regulatory frameworks and strategies
18 per cent. and accompanying monitoring and enforcement
Overweight, including its severe form (obesity) measures.
in children and adolescents is the result of the 2. Implement interventions across the life
interaction between: 1) individual factors that cycle, specifically during pregnancy, the early
regulate physiological processes, food preferences, childhood period (under age 5), school age (5-9
and physical activity patterns over the life course; years of age), and adolescents (10-19 years of
and 2) an obesogenic environment that promotes age). The prevention of overweight in children
high energy intake and sedentary behaviour. is a multisectoral undertaking and collaboration
Overweight impacts children’s immediate physical between the Nutrition sector and other UNICEF
and emotional well-being. It also increases the risk programme sectors and areas is crucial. It is also
of overweight later in life, a condition associated important to use a systems approach, engaging
with non-communicable diseases and considerable the food, health, wash, education, and social
health and economic disadvantage for individuals, protection systems, as well as communities
families and society. and having an appropriate involvement of the
Overweight is a form of malnutrition. It does not private sector.
happen in isolation and nor does it occur only in 3. Knowledge generation and use on the
certain people or certain countries. Different forms prevention of overweight in childhood by country
of malnutrition (stunting, wasting, micronutrient offices as well as HQ and regional offices.
deficiencies, overweight and diet-related non- In addition, data collection and surveillance
communicable diseases) can coexist in the same systems need to be established for documenting
country, the same community and even in the overweight in children over 5 years of age, at the
same family or individual. In 2017, to address this national and global level.
‘double burden’ of malnutrition, the prevention
of overweight in children and adolescents was 4. Monitoring and reporting of interventions and
integrated into the UNICEF Strategic Plan (2018- progress is crucial. For internal monitoring
2021) as part of Goal Area 1: Every child survives purposes, questions on interventions for
and thrives. The aim is to reduce malnutrition in all the prevention of overweight in children are
its forms. incorporated in the Strategic Monitoring
Questions (SMQs) and in Nutridash.
This document offers a step-by-step framework
intended to guide country level interventions.
The first step is to undertake a situation analysis
of overweight in children of all age groups, after
which UNICEF needs to select a relevant set of

About this programme guidance The first part of this document provides an
overview of key dimensions of overweight in
This document is intended to serve as a guidance childhood and adolescence broken down into three
for UNICEF regional and country offices as sections:
they plan and implement interventions for
the prevention of overweight in children and • Section 1 summarizes the global situation of
adolescents aged 0 to 19 years. It describes the overweight in early childhood (0-5 years), middle
current situation of overweight in childhood and childhood (6-10 years) and adolescence (11-19
adolescence, its causes and consequences and years)
provides an overview of how UNICEF country • Section 2 offers an overview of the main
programmes can support the policy and programme causes and consequences of overweight
actions of host country governments and in childhood and adolescence and outlines
development partners. the specific role of the food system as a key
determinant of increasing trends in childhood
The progamme guidance is intended for use by overweight
UNICEF Regional Directors and Deputy Regional
• Section 3 outlines the most relevant global
Directors, Country Representatives and Deputy
goals and guidance for the prevention of
Country Representatives, and programme advisers,
overweight in children and adolescents
technical specialists and managers in programmes
such as Nutrition; Health; HIV; Early Childhood
Development (ECD); Education; Water, Sanitation The second part of the guidance outlines UNICEF’s
and Hygiene (WASH) and Social Policy. role in efforts to prevent overweight in children and
adolescents:
The actions recommended are based on existing
global evidence and recommendations. Country • Section 4 presents an overview of the
offices will want to select the interventions most prevention of overweight in children and
relevant to their country context and setting adolescents as set out in the UNICEF Strategic
assisted by technical support from regional offices Plan 2018-2021 and UNICEF’s Nutrition Strategy
and headquarters where needed. 2020-2030
This document complements the UNICEF • Section 5 describes the recommended actions
programme guidance for early life prevention for UNICEF programmes that seek to prevent
of non-communicable diseases.6 At the time of overweight and obesity in children
writing, UNICEF is developing detailed programme • Section 6 details the priority interventions for
guidance on the nutrition of school-age children UNICEF programmes
and adolescents with reference to overweight
prevention. In addition, UNICEF and partners are
A final section provides concluding remarks and
developing tools to support government institutions,
offers a list of resources for reference and further
officials, regulators, policymakers and civil society
reading.
to understand, develop and implement regulatory
and fiscal measures that address childhood
overweight. These tools will be accompanied
by detailed guidance on their use in UNICEF
programmes.

PART I
Overweight in children
and adolescents
Prevalence, causes, consequences,
goals and guidance

1
Overweight in
children and
adolescents

1.1. Prevalence and burden of The region with the highest absolute burden is East
over weight in early childhood Asia and the Pacific, with overweight in 9.7 million
(0 - 5 years) children under age 5; next highest are the Middle
East, North African and South Asia regions with
Data from household surveys show that an over 5 million children with overweight each. The
estimated 5.9 per cent of the world’s children under regions with both the largest increase since 2000
the age of five – around 40 million – had overweight and the highest prevalence are Eastern Europe and
in 2018. This means a 33 per cent increase in Central Asia (up from 8.2 per cent in 2000 to 14.9
the burden, from an estimated 30 million under- per cent in 2018), while the prevalence in West
fives with overweight in 2000. There is significant and Central Africa is lowest at 2.8 per cent in 2018.
regional variation in the prevalence, from 14.9 per Figures 1.1 and 1.2 show the changes in prevalence
cent in Eastern Europe and Central Asia to 2.8 per and burden of overweight in children under five
cent in West and Central Africa.7 between 2000 and 2018 by UNICEF region.
Preschool children (<5 years)

Preschool children
Eastern Europe Middle East
North
(<5 years)
Latin America East Asia and Eastern and West and
and North South Asia GLOBAL
30
and Central
Eastern Asia* Middle
Europe EastAfrica America
North and Caribbean
Latin America the PacificEastern Southern
East Asia and and Africa West and Central Africa
and Central Asia* and North Africa America and Caribbean the Pacific Southern Africa South Asia Central Africa GLOBAL
30
25
25
20
20
Percent
15 14.9
Percent
15 14.9
11.2
10 11.2
10 8.9 8.8
8.9 8.8 7.5
8.2 6.7 6.6 7.5 6.3
8.2 6.7 6.6 6.3 5.9
5 5.2 4.6 4.2 4.95.9
5 5.2 4.6 4.2 4.2 4.9
4.2 3.1
2.5 3.1 2.8 2.8
2.5
00
2000
2000 20182000
2018 2000 20182018
20002000 2018 2018
2000 2000 2018 2018
2000 2000 2018 20002018 2000
2018 2000 2018 2000
2018 2000 2018 2018
2000 2000 2018 2000
2018 2018
Figure 1.1: Percentage of overweight in children under five by UNICEF region (2000-2018)
Source: UNICEF/WHO/World Bank Group Joint Malnutrition Estimates, May 2019 edition. 8
Note: The shaded areas represent the 95 per cent confidence intervals.
15
15
14
14 2000 2018
13
2000 2018
13
12 GLOBAL
11
12 GLOBAL
11
10
40.1
10
9 million 40.1
(millions)
89 million
(millions)
2018
78
Number
2018
67
Number
5
6 30.1
4 million
5 30.1
3 2000 million
4
2
3 2000
1
2 7.8 9.7 3.4 5.4 4.4 5.2 1.6 4.5 3.8 4.0 2.8 3.6 2.4 2.5 1.4 1.9
0
1 East Asia and Middle East and South Asia Eastern Europe Latin America and East and West and North America
the
7.8Pacific
9.7 North
3.4Africa
5.4 4.4 5.2 and Central
1.6Asia 4.5the Caribbean Southern Africa
3.8 4.0 Central Africa 2.4 2.5
2.8 3.6 1.4 1.9
0
East Asia and Middle East and South Asia Eastern Europe Latin America and East and West and North America
Figure 1.2: Number
the Pacific (millions)
North Africa of childrenand under
Central Asiafivethewith overweight;
Caribbean Southern Africa2000 and
Central 2018
Africa
Source: UNICEF/WHO/World Bank Group Joint Malnutrition Estimates, May 2018 edition
Note: The bars represent the 95 per cent confidence interval

School-age children (5–9 years)
Northern Latin America Middle East Europe and East Asia Sub Saharan South Asia
America and the and North Central Asia and the Africa
Caribbean Africa Pacific
50
42.2
40
35.9 33.5 33.1

30 28.8
27.5
Percent
20 23.7 21.0
20.9
11.5
10 10.4 8.7
4.8 2.6
0
2000 2016 2000 2016 2000 2016 2000 2016 2000 2016 2000 2016 2000 2016
Figure 1.3: Percentage of school age children (5–9 years) who are overweight, by UNICEF regions,
2000–2016
Adolescents (10–19 years)

Northern Latin America Middle East Europe and East Asia Sub Saharan South Asia
America and the and North Central Asia and the Africa
Caribbean Africa Pacific
50
40.4
40
34.3
30 29.0 29.1
Percent
24.7
20.6
20 20.4 17.5
18.3
10.5
10
7.6 7.0
4.7 2.2
0
2000 2016 2000 2016 2000 2016 2000 2016 2000 2016 2000 2016 2000 2016
Figure 1.4: Percentage of adolescents (10–19 years) who are overweight, by UNICEF regions, 2000–2016
Of the 638 million Of the 1 billion

school-age children adolescents
globally, a total of globally, a total of
131 million 207 million
are affected by are affected by
overweight overweight
or 20.6%. or 17.3%.
Source: NCD Risk Factor Collaboration (NCD-RisC), based on Worldwide trends in body-mass index, underweight, overweight and obesity from
1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128.9 million children, adolescents, and adults. The Lancet
2017, 390 (10113): 2627–2642

Overweight has in the past mostly been a concern in adolescents), followed closely by Latin America and
higher income countries, predominantly an urban and the Caribbean and the Middle East and North Africa
middle-class phenomenon of higher middle-income regions.
countries. In established overweight epidemics,
the burden of overweight has affected lower The lowest prevalence (8.7 per cent among school-
socioeconomic groups disproportionally. aged children; 7.0 among adolescents) is observed
in the South Asia region. Trend data from 2000
New evidence suggests that these patterns are reveal that overweight has increased across all
changing, with increasing prevalence of overweight regions. The steepest increases, across both age
among both urban and rural poor children and groups, have been observed in East Asia Pacific
children in low-and-middle-income countries.9 region. These figures are broadly similar to those
Middle income countries account for over three provided in an analysis of DHS data for 15-19-year
quarters of all children with overweight: 38 per cent olds, which also show a rise in overweight and
of all children with overweight live in lower middle- obesity in parts of Latin America and the Caribbean,
income countries while 39 per cent live in upper- the Middle East and North Africa, Europe and
middle income countries. Since 2000, the increase Central Asia.13 It also aligns with other analyses of
in the number of under-fives with overweight has global and regional trends in the nutritional status
been highest in lower middle-income countries of young people that have found that one in three
(from 9.8 million in 2000 to 12.5 million in 2017).10 adolescent girls has overweight, and the prevalence
Overweight does not happen in isolation and nor of obesity among 5 to 19-year-old girls to be 5.6 per
does it occur only in certain people or countries. cent, and 7.8 per cent in boys in 2016.14,15
Different forms of malnutrition (stunting, wasting,
micronutrient deficiencies, overweight and diet-
related non-communicable diseases) can coexist in
the same country, the same community and even
the same family and individual. This is called the
‘double burden’ of malnutrition.11
1. 2 Prevalence and burden of

over weight in middle childhood
(5 -9 years) and adolescence
(10 -19 years)
The data on overweight in children between 5 and

19 years of age are collected in multiple surveys,
each with their own age group disaggregation and
methodology (for example household surveys or
school-based surveys). Globally the prevalence
of overweight in this age group is increasing. In
2016, nearly one in five school-age children and
adolescents (18.4%) were overweight, representing
338 million children aged 5-19 years worldwide.12
Figure 1.3 shows the data for school-aged

children (5–9 years) according to UNICEF region,
while Figure 1.4 shows the data for adolescents
(10–19 years). Northern America has the highest
prevalence among both age groups (42.2 per
cent among school-aged children; 40.4 among

2
Causes and
consequences
of overweight in
childhood and
adolescence

2.1 Causes of over weight in childhood 3. Inadequate breastfeeding practices.
and adolescence Breastfeeding (be it ever breastfeeding,
exclusive breastfeeding or a longer duration
Overweight in children and adolescents is the of breastfeeding) reduces the risk of
result of the interaction between: 1) individual overweight.24,25 A recent meta-analysis
factors that regulate physiological processes, food calculated a 13 per cent reduced chance of
preferences, and physical activity patterns over overweight for children who were breastfed.26
the life course; and 2) an obesogenic environment Among the pathways for the protective role
that promotes high energy intake and sedentary of breastfeeding is better gut health, achieved
behaviour.16 Overweight is primarily driven by a by population of the child’s body and gut
persistent imbalance in dietary energy intake and with maternal microbiome during skin-to-skin
energy expenditure, and the excess consumption contact and early and exclusive breastfeeding.27
of “ultra-processed” foods high in calories, fats, Breastfeeding also establishes better satiety
free sugars and/or salt has been particularly patterns which are related to the nutrients in
implicated. However, overweight and obesity breastmilk. It also helps avoid the disadvantages
should not be viewed entirely in isolation from other of bottle feeding.28
forms of malnutrition. Rather, the various forms 4. Inadequate complementary feeding
of malnutrition, and risks thereof, are intertwined practices and food habits in older children.
throughout the life cycle. Undernutrition can give Contributing to poor diets are foods and liquids
rise to increased risk of overweight later in life, for children aged 6-23 months that do not
especially when confronted with the obesogenic secure the minimum dietary diversity and/or
environment. The main risk factors for overweight foods with a high content of sugar, salt or fat.
in children and adolescents are summarized here. They predispose children to overweight and
1. Maternal and paternal overweight. Maternal unhealthy food preferences in later life.29,30,31
overweight and/or diabetes before and during Furthermore, feeding practices that are not
pregnancy predispose the child to increased responsive to children’s hunger and satiety cues
fat deposits, which in turn are associated with can contribute to unhealthy eating patterns.32,33,34
child obesity and metabolic disease – including 5. Unhealthy food habits in older children and
high blood pressure, high density lipoprotein adolescents. These are being increasingly
cholesterol and excess abdominal fat – later in documented35,36 and contribute to overweight.
life.17, 18 There is also increasing evidence that Adolescents are developmentally and socially
paternal overweight during spermatogenesis vulnerable to unhealthy diets. They are often
could increase the risk of overweight in more impulsive and they are typically more
children.19 subject to peer influence, and are less likely to
follow guidance on healthy eating.37,38,39
2. Maternal undernutrition and undernutrition
in early life. Maternal thinness before and 6. Obesogenic food environments. Major
during pregnancy can result in poor foetal drivers of food choice include price, availability,
growth, low birth weight and stunting in convenience, product taste and marketing.
early life, which can predispose children to Unhealthy food environments include: a)
accumulate fat later in life, thereby increasing low availability, accessibility, desirability and
the risk of overweight, obesity and metabolic affordability of healthy foods;40 b) marketing of
disease.20,21 In children who were small at birth, unhealthy foods, snacks and beverages, and
rapid weight gain after the age of 2–3 years increasing portion size41,42 and c) inadequate
can lead to a higher risk of overweight and labelling of industrially-prepared foods that
chronic disease in later life.22 Wasting in the prevents caregivers, children and adolescents
first two years of life can also be a risk factor for from understanding whether such foods
overweight and non-communicable diseases contribute to a healthy diet or not.43 Recurring
(NCDs), also referred to as thrifty growth.23 exposure to the same unhealthy food

environment can shape preferences and lead to Child obesity and, to a lesser extent, overweight in
routine or habitual behaviours. childhood may contribute to cognitive, behavioural
and emotional difficulties including lower scores in
7. Inadequate physical activity. There is
cognitive tests and low self-esteem, and may also
incontrovertible evidence that predictors
lead to stigmatization, poor socialization, depression
of overweight and obesity in children and
and reduced educational achievement.52,53,54,55
adolescents are: a) lack of physical space or
opportunity for an active lifestyle or physical It is difficult to slow weight gain during child growth
exercise and sports; and b) increasing and achieve and maintain weight loss at the end of
acceptability of sedentary behaviours and screen growth, especially without professional support.
time among children from early childhood Obesity in childhood is therefore associated with a
through middle childhood and adolescence.44,45,46 higher risk of adult obesity56,57 and premature death
and disability in adulthood.58 Other consequences of
8. Obesogenic cultural environments are
overweight are cardiovascular diseases (principally
characterized by low levels of parental
heart disease and stroke), Type 2 diabetes and
knowledge about healthy feeding, eating and
certain cancers.59 Obesity in adulthood has severe
nutrition; low levels of nutrition literacy among
health consequences and has a direct economic
school-age children, adolescents, teachers, and
impact on families because of treatment costs and
health professionals; and social norms pertaining
on society because of losses in productivity.
to body image that include appreciation of
overweight body shapes for boys and/or girls.47 Obesity is becoming increasingly common in
low- and middle-income countries and is affecting
9. Epigenetic mechanisms – changes in gene
women and the poor in particular.60 Taking a broader
function caused by external or environmental
picture, nutrition-related NCDs account for nearly
influences – possibly also play a role in the
half of all deaths and disability in low- and middle-
relationship between parental overweight and
income countries.61
maternal undernutrition and overweight in
children.48,49 The global economic impacts of obesity are
estimated at USD 2 trillion, or 2.8 per cent of global
10. Socioeconomic status determines income,
gross domestic product (GDP), a similar economic
and low income and lack of access to good
impact to that of smoking or armed violence, war
quality food have an impact on the likelihood
and terrorism.62 The lifetime costs of overweight
and severity of each of these risk factors.
and obesity in childhood and adolescence depend
Overweight increasingly impacts poorer and
on the country and the specific assumptions made
more disadvantaged groups.
but are likely to be substantial, as examples from
2. 2 Immediate and longer-term the United States and Europe show.63,64
consequences of over weight in Available evidence suggests that preventing
childhood and adolescence childhood overweight and obesity is cost-
effective.65
Obesity and even overweight in childhood and
adolescence can have adverse health and financial
consequences throughout life.
Children with overweight, and specifically those

who have obesity, are at a higher risk of developing
gastrointestinal, musculoskeletal and orthopaedic
complications, sleep apnoea, accelerated onset of
cardiovascular disease, fatty liver, impaired glucose
intolerance and Type 2 diabetes.50,51

3
Global goals
and guidance for
the prevention
of overweight
in children and
adolescents

3.1 Global goals on the prevention of 1. Implement comprehensive programmes
over weight in children that promote the intake of healthy foods and
reduce the intake of unhealthy foods and
In 2012, the World Health Assembly (WHA) sugar-sweetened beverages by children and
adopted the Comprehensive Implementation Plan adolescents.
on Maternal, Infant and Young Child Nutrition.
Its goals include achieving no increase in the 2. Implement comprehensive programmes that
prevalence of overweight among children under five promote physical activity and reduce sedentary
by 2025.66 The reduction of overweight is prioritized behaviours in children and adolescents.
in the Sustainable Development Goals (SDGs) as a 3. Integrate and strengthen guidance for non-
key objective to protect children, adolescents and communicable disease prevention with current
adults against obesity and diet-related NCDs. One guidance for preconception and antenatal care to
of the indicators of SDG2 for nutrition (indicator reduce the risk of childhood obesity.
2.2.2) is the prevalence of overweight in children
under five. 4. Provide guidance on, and support for, healthy
diet, sleep and physical activity in early
The Global Nutrition Report 2017, however, childhood to ensure children grow appropriately
indicated that the vast majority of countries (146) and develop healthy habits.
had no or insufficient data on the prevalence of
child overweight. Acceptable data was available 5. Implement comprehensive programmes that
for only 47 countries. Among these, 16 had shown promote healthy school environments, health
no progress or were experiencing a worsening and nutrition literacy and physical activity among
situation, and only 31 were on track to meet the school-age children and adolescents.
WHA target.67
6. Provide family-based, multicomponent, lifestyle
3. 2 Global policy and guidance for the weight management services for children and
prevention of over weight and obesit y young people who are obese.
The Commission published the Implementation

In 2014, WHO established the Commission
Plan for its recommendations in 2017.69 Figure 3.1
on Ending Childhood Obesity. In 2016, the
depicts the six recommended interventions and
Commission made six specific recommendations to
how they contribute to intermediate and long-term
address children’s obesogenic environments from
outcomes.
conception to adolescence.68
Figure 3.1: Action framework for the prevention of overweight and obesity in children
M O N I TO R I N G A N D AC C O U N TA B I L I T Y
Interventions Intermediate Long-term

1. Promote healthy diet Outcomes Outcomes
2. Promote physical activity
3. Preconception and Healthier environment
Reduced
pregnancy care Healthier behaviours prevalence of
4. Early childhood diet and
LEADERSHIP physical activity Reduced biological risk children with
factors obesity
5. Health, nutrition and
physical activity for
school-age children
6. Weight management
CA PAC I T Y B U I L D I N G
Source: Implementation Plan of the Commission on Ending Childhood Obesity

In most low- and middle-income countries, child double burden, a holistic set of double-duty actions
overweight co-exists with a larger/similar burden is required. These actions need to be integrated
of child undernutrition (stunting, wasting and and complement actions that are specifically
micronutrient deficiencies), a reality referred to as addressing the issue of overweight. Double-duty
the double burden of malnutrition. To address this actions fall into three categories:70
1. Do no harm with existing actions: Existing policies and programmes that aim to
reduce one type of malnutrition should not inadvertently increase the risk of other
types of malnutrition. For example, cash transfer programmes to reduce poverty and
undernutrition could contribute to increased overweight if targeting of vulnerable
groups is not done adequately, supplementary foods are not designed carefully, and
supplementation is not accompanied by guidance on healthy diets.
2. Retro-fit or design new actions to be double duty: These are actions that are re-
examined or pro-actively designed to deal with the double burden of maternal and child
malnutrition. For example, the promotion of adequate infant and young child feeding is
traditionally aimed at reducing child undernutrition but the messaging needs to adapt
to make sure the reduction of overweight in children is also seen as an integral part
of adequate nutrition. There are various ways in which this shift in messaging can be
supported through actions: the enforcing of the International Code of Marketing of
Breastmilk Substitutes and subsequent WHA resolutions (the Code);71 ensuring that
maternity facilities practice the Ten Steps to Successful Breastfeeding of the Baby-
friendly Hospital Initiative;72 supporting maternity protection regulations;73 providing
nutrition education, skills, guidance and support to caregivers around healthy diets for
children and the benefits of an active lifestyle; and growth assessments combined with
nutrition counselling.74
3. Overweight-specific actions: These actions will have less immediate impact on

undernutrition, but are important to create supportive environments for childhood
overweight prevention. They may also help minimise displacement of nutritious foods
from children's diets and have been referred to as "de novo" double duty actions. These
include: health-related taxes on sugary drinks and other unhealthy foods and beverages;
regulating the marketing of unhealthy foods and beverages to children;75 implementing
front-of-pack labelling; and requiring childcare settings, schools and events for children
to ensure healthy food environments. Of particular importance in this category is
the enactment and enforcement of national legislation aligned with WHO’s Set of
Recommendations on the Marketing of Foods and Non-Alcoholic Beverages to Children
published in 2010.76

The WHO Best Buys, which sets out the most While 61 per cent of 160 countries included
cost-effective interventions and other interventions nutrition education in the school curriculum, only 18
for the prevention and control of NCDs, also per cent had a ban on vending machines in schools
presents relevant guidance to address unhealthy and just 24 per cent had standards for regulating
diets.77 marketing of foods and beverages in schools.78 A
report by WHO’s office for Europe reported that 54
3.3 Implementation of global policy per cent of European countries have some form of
and guidance for the prevention of policy to restrict the marketing of high fat, salt and
over weight and obesit y sugar products to children, although the policies
documented were of varying scope and quality.79
The WHO Global Nutrition Policy Review
2016-2017, based on self-reporting by national By 2018, 136 of 194 countries had adopted
governments and verified by WHO, reports that legal measures to translate some or most of the
78 per cent of the 167 countries that included provisions of the Code into legislation. Of these,
nutrition-relevant policies, strategies and plans 35 countries have full Code provisions covered in
in their responses had a target to address law, 31 have legal measures that put many Code
overweight in children. However, only 16 per cent provisions into law. However, 58 countries had no
of countries had a regulation on the marketing legal measures in place.80 But by the end of 2018,
of complementary foods and 40 per cent had more than 40 countries were implementing some
policies on regulating marketing of food and non- kind of tax on sugary drinks, one of WHO’s Best
alcoholic beverages to children. Buys.81

PART II
UNICEF programming
for the prevention of
overweight in children
and adolescents

4
Prevention of
overweight in
children and
adolescents
UNICEF Strategic
Plan 2018-2021 and
UNICEF Nutrition
Strategy 2020-2030

Preventing malnutrition in all its forms, including
overweight, plays an integral role in guaranteeing
children’s right to food, health and nutrition as
a cornerstone of their human rights. Therefore,
working to prevent overweight in children and
adolescents needs to be part and parcel of
UNICEF’s work.
In recent years, UNICEF regional and country

offices and headquarters sections have started
to take action on the prevention of overweight.
This has led to the drafting of regional guidance
for East Asia and the Pacific;82,83 studies on the
marketing and advertisement of unhealthy food and
beverages targeted at children in Latin America and
the Caribbean (LAC);84 a study on food marketing
and children’s rights;85 a review of the regulations
and practices related to labelling of food and
beverage targeting children in LAC;86 an overview
report on the use of sugar taxes;87 and the drafting
of messages for behaviour change communication
(awaiting publication).
UNICEF’s Supply Division has started to monitor

and reduce excess sugar content in lipid-based
supplements for the treatment and prevention of
malnutrition. The division is also liaising with WHO
and other partners to establish a minimal level of
added sugar for these products to reduce sugar
content and still comply with treatment protocols.
In 2016, UNICEF organized a global meeting that

brought together a selected group of internal and
external experts to advise UNICEF on the key
focus of UNICEF programming for the prevention
of overweight in children and adolescents.88
The consensus reached by this group was that
UNICEF’s programmatic focus should prioritize the
following.
• Emphasis on the prevention of malnutrition

in all its forms, including both undernutrition
and overweight, while ensuring treatment for
children with severe forms of malnutrition
• Emphasis on the prevention of malnutrition

in early childhood, including through
strengthening the enabling environment and
adopting a life cycle approach to malnutrition
prevention from conception to adolescence

• Emphasis on improving the quality of children For the baseline data collection for the Strategic
and women’s diets – better diets for better Plan 2018-2021, the Nutrition Section at UNICEF
growth – from conception and birth through to New York asked country offices to report their
adolescence activities for the prevention of overweight in
children and adolescents in 2017. Twenty-one
• Emphasis on double-duty actions that help countries were already acting on one or more
prevent both undernutrition and overweight in policy actions or programme activities.
children and adolescents
The UNICEF Strategy for Maternal and Child
• Integration in UNICEF-supported programmes Nutrition 2020-2030 will take a fresh look at
of de-novo actions specifically directed how gains in maternal and child nutrition can
at preventing overweight in children and be accelerated. It will address malnutrition in
adolescents all its forms, including comprehensive action
In 2017, for the first time, the prevention of for the prevention of overweight in children
overweight in children and adolescents was and adolescents.
integrated in UNICEF Strategic Plan (2018-2021) This guidance aims to set out recommended
as part of Goal Area 1: Every child survives and actions for UNICEF country programmes that aim
thrives.89 The relevant outcome statement, output to support government efforts to develop policies,
statement and indicators are described in Table strategies and programmes for the prevention
4.1. of overweight in children and adolescents.
Table 4.1: Outcome and output statements and indicators related to the prevention of overweight in
children in the results framework of the Strategic Plan 2018-2021
Goal Area 1: Every child survives and thrives
Impact indicator: D. Percentage of children who have overweight (SDG 2.2.2)
Outcome Statement 1: Girls and boys, especially those that are marginalized and those living in
humanitarian conditions, have access to high-impact health, nutrition, HIV and ECD interventions.
Output statement 1.d: Countries have accelerated Output statement 1.i: Countries have developed
the delivery of programmes for the prevention of programmes to deliver gender-responsive
stunting and other forms of malnutrition. adolescent health and nutrition services.
Output indicator 1.d.4: Number of countries that Output indicator 1.i.1: Number of adolescent girls
are implementing policy actions or programmes and boys provided with services to prevent anaemia
for the prevention of overweight and obesity in and other forms of malnutrition through UNICEF
children. programmes.
Note: This table sets out the outcomes and outputs on overweight prevention mentioned in the results framework of the Strategic Plan.

5
Recommended
actions for
UNICEF
prevention of
overweight
programmes

The guidance covers the full process, from the 5.1 Conduc t a situation analysis
planning stage to implementation, monitoring and
learning. It is based on current evidence and global The first step is to undertake a situation analysis
guidance and is in line with UNICEF’s mandate and of overweight in children of all age groups, either
organizational strengths. as part of a broader situational analysis of the
fulfilment of children’s rights in a country or as a
A six-step process is recommended: stand-alone exercise, for instance when a country
1. Conduct a situation analysis. is considering interventions to prevent overweight
in children and adolescents. For details about the
2. Conduct a stakeholder analysis to identify the recommended timing and implementation of a
key actors implicated in the increase in childhood situation analysis, see the Programme Policy and
overweight and the key actors relevant to the Procedure Manual.90 There are a number of key
prevention of childhood overweight. aspects to include in the analysis.
3. Establish partnerships with key actors for joint a. Equity analysis: prevalence of overweight
advocacy and coordination of activities. and obesity and other forms of malnutrition
(stunting, wasting, micronutrient deficiencies)
4. Engage in dialogue with the government to
disaggregated by age or age group: under-fives,
design and prioritize interventions in three
5-9 years old, young adolescents (10-14 years
key areas (for further details of the priority
old) and old adolescents (15-19 years old), men
interventions, see Section 6):
and women of reproductive age; and by sex,
a. improvement of the enabling environment – geography, socioeconomic group, ethnic group,
policies, regulatory frameworks and strategies etc. If possible, analyse trends over time. Some
and their implementation; data sources that country offices may use are
the Global School-Based Health Surveys, Health
b. support for the design and delivery of
Behaviour Surveys, Demographic and Health
interventions across the life cycle (pregnancy,
Surveys and MICS Surveys. When resources
under 5 years, 5-9 years, 10-19 years); and
are available, country offices can consider
c. leading of knowledge generation, conducting a survey that combines multiple
dissemination and use. indicators.
5. Establish monitoring and reporting systems and b. Review existing laws, policies, current
track progress, including advances towards the circumstances and strategic planning
2025 and 2030 Nutrition targets. documents that are relevant for the prevention
of overweight, to understand:
6. Document progress and lessons learned (that is,
support a learning culture). • the food system in the country and its role in
contributing to, or preventing overweight in
In all UNICEF’s actions, interventions need to be
children and adolescents;
reviewed for a potential unintended increase in
risk of overweight and obesity (‘do no harm’; see • any policy, strategy, and/or programme/action
Section 3.2). Further guidance for specific situations plan already in place for the prevention of
can be provided when needed. overweight in children;
Detailed descriptions of these actions and the • strategies or policies on food and nutrition
suggested interventions follow. standards for school meals, sale of foods and
beverages in and around schools, nutrition in
school curricula and physical activity/physical
education in schools;
• whether the Code and enforcement
measures are implemented;

• what regulations are in place to restrict 5. 2 Design and prioritize inter ventions
the marketing of foods and non-alcoholic
beverages high in saturated fats, trans-fatty Using the context offered by the situation analysis,
acids, free sugars and/or salt, both to the UNICEF country staff should, in coordination with
general population and to children in particular government and other partners, select a relevant
– including whether they cover advertising, set of interventions. These can be included in the
sponsorship, product placement, packaging, country programme or inform the drafting of a
portion size, in-store and point-of-sale country programme.
promotions, price promotions discounting and
sales enticements and availability; This section offers an overview of possible relevant
interventions for the prevention of overweight in
• whether the composition of commercially- children (also summarized in Tables 5.1 and 5.2)
produced foods and snacks and foods that are that country offices can consider. The selection of
high in saturated fats, trans-fatty acids, free interventions needs to be based on the nutrition
sugars and/or salt is regulated; situation, the existing policy environment, the
capacities and opportunities available in-country
• whether nutrition labelling and the use of and UNICEF’s comparative advantage and value
nutrition and health claims are regulated; addition.
• what relevant fiscal measures are in place, A mix of interventions and actions that both
such as subsidies for specific foods or address the policy environment and have impact
taxes on items like snack foods and sugar- at every stage of the life course – from conception
sweetened beverages; and pregnancy up to the age of 18 – is vital. Efforts
• any other relevant laws, policies and strategic should not focus on the small part of the life
planning documents. course where overweight and obesity might be
most visible, such as among school-age children
c. Review the marketing of unhealthy foods and adolescents. In many instances, UNICEF’s
and beverages, specifically to children, and interventions will need to shift the balance to
the involvement in and influence of food and specific parts of the life course that are receiving
beverage companies on different sectors and less attention from the government and other
interventions. partners, such as prevention in early childhood.
d. Review the existing capacity for the Additional factors should be taken into account
prevention of overweight in children among when prioritizing interventions.
UNICEF staff, government policymakers, health
professionals, teachers and other relevant service Balance in interventions across the life course.
providers, including other implementing partners. Actions in the first years of life will have the most
impact on the rest of a child’s life. (see Figure 5.1).
e. Understand local social norms and/or
knowledge, attitudes and practices related to
healthy and unhealthy dietary patterns, physical
activity and overweight in children.
f. Review the obesogenic environment in

rural and urban communities, the food system,
schools and the home, including the availability
and accessibility of healthy and unhealthy
foods, the impact of urbanization on physical
activity and on access to healthy foods, and
opportunities for physical activity in general.

Impact of
Figure 5.1: The importance of early life interventions for the adult
prevention of overweight intervention
is small
Timely
intervention
produces substantial
risk reduction Chronic
disease
Fixed genetic risk
contribution
to risk is small
LIFE
COURSE
Source: Hanson M and Gluckman P. Developmental origins of noncommunicable disease: population and public health implications. Am J Cl
Nut, 2011; 94(suppl): 1754S-8S." 91
Note: In the authors’ words: ‘The maximum effect will be gained from timely interventions in early life when plasticity permits a sustained
reduction in the trajectory of risk to be attained’.
UNICEF staff capacity and/or the possibility alleviation of stunting, wasting and micronutrient
of attracting qualified or experienced staff. In deficiencies. However, it will still be important
countries where UNICEF has strong capacity for to make sure that policies and regulations
nutrition policy, social policy and social protection cover the prevention of malnutrition in all its
and/or where positions in these areas can easily forms, and to initiate nutrition awareness and
be filled, UNICEF has a clear added value. Where literacy interventions for school-age children and
a country programme has a stronger emphasis on adolescents. The aim will be to put a regulatory
systems-strengthening for service delivery, policy and knowledge infrastructure in place that can
advocacy will still be an important facet of any deal with all aspects of nutrition as food and
supported intervention even if the emphasis is more activity patterns transition. This will place a broader
on service delivery and ‘double-duty’ actions. package of interventions to hand when prevalence
of overweight and obesity begins to increase (most
Emphasis on a government’s nutrition-related
likely starting with adults).
investment and programmes, including
UNICEF-supported programmes. In countries
where IYCF (infant and young child feeding) 5.3 Promote multisec toral and
programmes have been considered as relevant multi-stakeholder coordination and
only for child survival, and investment in such collaboration
programmes has decreased, it is important to Collaboration with UNICEF sections
advocate for re-investing or investing more in
As mentioned earlier, the prevention of overweight
IYCF through the lens of preventing childhood
in children is a multisectoral undertaking. The
overweight. These activities need to be placed in
Nutrition Section will lead on the technical
a life cycle context and accompanied by relevant
engagement and policy dialogue with governments,
policies and interventions for other age groups.
and will provide overall guidance as to what
A country’s specific priority nutrition needs to happen. However, collaboration with the
challenges. For countries where undernutrition following UNICEF programme sectors and areas is
and child mortality are the main challenge, service crucial.
delivery efforts may still be focused on the

Communication for Development (C4D): support Multi-agency and multi-stakeholder
for the design and implementation of relevant coordination
C4D and social and behaviour change strategies UNICEF will seek opportunities for joint advocacy
and interventions, including for harnessing social with other actors on topics such as reducing
media and other channels for targeting various the impact of the commercial determinants of
stakeholders. overweight. UNICEF will also collaborate on the
ECD: support for the inclusion of nutrition literacy development of an investment framework for
in curricula, physical activity and physical education; overweight prevention, similar to the one that
and policies on meals and sale and promotions of was developed for the global nutrition targets on
foods and beverages in and around preschools and stunting, anemia, breastfeeding and wasting.93
ECD centres that can help prevent overweight and It is important to coordinate actions for the
obesity. prevention of overweight in children with other UN
Education: support for the inclusion of nutrition agencies at all levels (global, regional, country),
literacy in school curricula; for physical activity and depending on their regional and in-country
physical education; for policies on school meals and presence.
school feeding programmes; and on the sales and WHO is the lead technical agency for health and
promotion of foods and beverages in and around nutrition. It sets guidelines, norms and standards,
schools, to help prevent overweight and obesity in including for the prevention of NCDs, with a focus
the context of other life skills where possible. on policy advocacy. Collaboration with the Food
Health: support for inclusion of nutrition counselling and Agriculture Organization (FAO) is relevant for
in antenatal care, support for breastfeeding in a focus on nutrition-sensitive agriculture, Codex
maternity facilities and IYCF counselling in relevant Alimentarius (jointly with WHO) and agrifood
health centres, with counselling also incorporating systems.
the prevention management of overweight and Among others, WHO and UNFPA can partner on
obesity (where possible).92 interventions aimed at adolescents and World Food
Private Sector Fundraising: support in convening; Programme (WFP) on interventions in schools. At
reaching different actors, including via multi- country level, UN coordination will take shape in
stakeholder platforms; influencing business models the context of the UN Development Assistance
and calling for changes in industry practices; Frameworks.
improved accountability of business in relation to The Interagency Task Force on Non-communicable
child rights and food. Diseases (IATF-NCD) brings together about 25
Social policy: support with advocacy and technical agencies at the global level. The task force has
support for health-related taxes and other fiscal established a Nutrition Working Group under
measures and with nutrition-sensitive social coordination of the United Nations Standing
protection interventions. Committee for Nutrition and it has representation
from FAO, IAEA, IFAD, OCHA, UNEP, UNICEF,
Urban planning: improve opportunities for safe
UNDESA, UNHCR, UN Women, WFP and WHO.
physical activity by people of all ages, including
through improvements in the built environment. Coordination with multilateral institutions,
non-governmental organizations (NGOs) and
WASH: support for increased access to free safe
civil society organizations, including youth
drinking water in (pre-)schools and schools and
organizations, professional associations and
promote safe drinking water as core to healthy diet
consumer associations where these exist, is also
for children, adolescents and adults.
important. Engagement with the private sector
can be strategic for specific goals. In this regard,
UNICEF has developed Engagement with Business
programme guidance for country offices to help

determine how to engage most effectively with Where appropriate, the Regional Advisors will
business programmatically, including consideration connect and engage input directly from PD
of benefits and risks.94 Nutrition.
When selecting partners and collaborating with PD Nutrition also works in close collaboration with
other actors, it is crucial to avoid conflicts of other sections in the Programme Division, with the
interest, both real and perceived. A conflict of Division of Private Sector Fundraising and Partnerships
interest is a situation where there is a risk that an (PFP), the Public Partnership Division (PPD), the
organization’s or individual’s secondary interest Division of Analysis, Planning and Monitoring (DAPM),
unduly influences, or is perceived to influence, and Supply Division (SD). Some illustrative examples
the independence or objectivity of professional of collaboration include:
judgement or actions around a primary interest,
• liaison across Programme Division with relevant
or to undermine public trust in those operations.
sections to ensure programmatic alignment and
UNICEF has clear guidance on due diligence
strengthening of interventions across relevant
when considering engagement with private sector
systems, and contribution to the broader NCD
partners.95 Governments and other partners might
prevention agenda;
not have such guidance and it is important to make
them aware of the ‘conflict of interest’ concept and • coordination with other divisions, including
provide support to avoid it. DAPM for country data and guidance on relevant
indicators and surveys, PFP for actions related
to the private sector including guidance on
The role of UNICEF headquarters and regional
offices sugar taxes and labelling, and Supply Division to
ensure alignment between programme guidance
The Nutrition Section (Programme Division and products procured by UNICEF;
(PD), New York headquarters) leads the UNICEF
• collaboration with PFP and PPD to seek financial
approach to the prevention of overweight in
resources to support implementation of relevant
children. PD Nutrition will work closely with regional
activities at all levels within the organization.
offices to support country offices. Regional offices
will be the first port of call for country offices in Regional offices, jointly with headquarters, will
providing technical support to countries that are seek financial resources to support implementation
planning, designing or implementing interventions of relevant activities at all levels within the
for the prevention of overweight in children. This UNICEF organization.
support can be provided remotely or in person.
How can UNICEF engage with and support governments on overweight and obesity
prevention?
Overweight and obesity is an issue In some contexts, the ministry of • Coordinate and commission
that is multifactorial and requires health coordinates activities on evidence review to identify
a multi-sectoral response by behalf of the government, in others effective policy actions
government. Governments choose a whole-of-government approach is
• Facilitate policy dialogue with
to organize their work on childhood in place with a decision-making body
different sectors
overweight and obesity prevention chaired by the head of government.
in different ways, depending on UNICEF country programmes should • Organize national or international
traditions and context. The ministry consider and respond to the domestic meetings to position UNICEF
of health is often a key partner, but political structures. Ways in which as a thought leader and support
collaborations are equally important UNICEF can collaborate with different government with relevant expertise
with ministries with responsibility for government actors include:
education, planning, transportation, • Perform evaluations of key
• Lead research on determinants of policies and programmes, with
agriculture and food, social protection
overweight, such as obesogenic recommendations to government
and finance, as well as national
environments, breastfeeding
technical agencies or institutes.
practices or social norms

6
Priority
interventions

6.1 Improve the enabling environment: • implementation of the set of recommendations
policies, regulator y frameworks and on the marketing of foods and non-alcoholic
strategies beverages to children;97
The main relevant policies, regulatory frameworks • adoption of health-related food taxes, such as
and strategies for the prevention of overweight in increased taxes on sugary and sweet beverages
childhood include the following: and ‘junk food’ and subsidies for healthy
foods;98,99,100,101,102
General
• reformulation of processed foods including
• A national or sub-national strategy on the portion sizes;
prevention of NCDs and/or overweight, including
specific actions for children and adolescents. • adoption of front-of-pack nutrition labelling
This may be a stand-alone document or requirements that identify foods that are high in
embedded in a larger strategy on child health or salt, sugar and fats103,104; and
nutrition. The strategy should be fully costed. • use of urban planning regulations to promote
• Capacity-building of policymakers in the causes, healthy food and built environments for
consequences (including economic) and overweight prevention.105
prevention of childhood overweight. Capacity- All regulatory frameworks need to be accompanied
building should detail relevant actions policy- by monitoring and enforcement measures that are
makers can take for its prevention. free from commercial influences and conflicts of
• Advocacy and dialogue with policymakers interest.
and regulatory bodies on the adoption and
implementation of regulatory frameworks for the Government action in these areas
prevention of overweight in childhood. is needed to create supportive
environments for children to learn
• Develop business case and investment and aspire to healthy diets. Public
framework for childhood overweight to support policies are important to level the
advocacy efforts and policy dialogue playing field, positively influence
the availability, affordability and
Specific regulatory frameworks appeal of healthy food, and safeguard
These include: children from unhealthy foods and
beverages early in life.
• policies and standards on food, nutrition and
physical activity in preschools, primary and
secondary schools and for the sale of foods and
beverages in and around schools; 6. 2 Implement inter ventions across
the life cycle
• legislation and policies on parental leave and
maternity protection (including maternity leave Possible strategies and interventions for inclusion in
and breastfeeding breaks for women working UNICEF country programmes include the following
outside the home); (also see Tables 6.1 and 6.2 for a schematic
overview):
• implementation of the Code;
Pregnancy
• implementation of the Guidance on Ending the
Inappropriate Promotion of Foods for Infants and It is suggested that UNICEF focuses its work in this
Young Children;96 area on the nutrition of adolescent girls (outlined in
Section 4) and on the following aspects of care for
nutrition during pregnancy.

• Promotion of antenatal care visits (minimum • capacity-building of health care providers in
eight visits106) by pregnant women, in facilities and communities for counselling for
communities and through social mobilization. appropriate complementary feeding;
• Capacity-building and support for health • support for IYCF or complementary feeding
facilities to provide counselling and relevant counselling in facilities;
screenings (including for hyperglycaemia and
hypertension) and monitor weight gain. • support for IYCF or complementary feeding
counselling in communities; and
• Counselling about healthy eating to stay healthy
and prevent excessive weight gain. • social and behaviour change communication for
appropriate complementary feeding.
• In undernourished populations, nutrition
education on increasing daily energy and protein For children attending preschools and other ECD
intake with balanced energy and protein dietary programmes:
supplementation. • advocacy and technical support for adoption
• Preparatory breastfeeding counselling. and implementation of policies to support
interventions for the prevention of overweight,
• Iron and folic acid supplementation. and the creation of a healthy, non-obesogenic
environment in preschools, including through
• Counselling about adequate levels of physical advocacy for public procurements of healthy
activity. foods;
Early childhood (children under five) • advocacy for inclusion of nutrition education into
Protection, promotion and support of breastfeeding ECD curriculum;
through implementation of comprehensive
• capacity-building of preschool caregivers and
breastfeeding programmes based on formative
teachers on the prevention of overweight; and
research, including:
• support for interventions for the prevention of
• support for the implementation of maternity
overweight in preschools including nutrition
protection legislation and breastfeeding breaks
literacy classes, (increased) physical activity and
in the private and public sector;
others as relevant.
• capacity-building of health care providers on
In health facilities and other settings where infants
the protection, promotion and support for
and young children seek care:
breastfeeding, including counselling;
• weight and length or height measurements
• support for early initiation of breastfeeding in
in all infants and children under five and
maternity facilities (the Ten Steps of the Baby-
their nutritional status classified according
friendly Hospital Initiative);
to the WHO child growth standards (growth
• promotion and support for early, exclusive and monitoring);
continued breastfeeding in communities;
• infant and young child nutrition counselling for
• social and behaviour change communication for caregivers and families of infants and children
breastfeeding; and under five (promotion of healthy growth); and
• monitoring compliance with the Code. • referral for counselling of families of children
with overweight (promotion of healthy growth).
Support for appropriate complementary feeding
(healthy foods, responsive feeding) based on
formative research, including:

School age (5-9 years of age) Adolescents (10-19 years of age)
• Advocacy and technical support for adoption • Advocacy and technical support for adoption
and implementation of policies to support and implementation of policies to support
interventions for the prevention of overweight interventions for the prevention of overweight in
in children and the creation of a healthy, non- adolescents and the creation of a healthy, non-
obesogenic environment in primary schools. obesogenic environment in secondary schools
and communities.
• Advocacy for inclusion of nutrition education into
the primary school curriculum. • Advocacy for inclusion of nutrition education into
secondary school curricula.
• Social marketing and awareness-building in
schools and communities on the consequences • Social marketing and awareness-building in
and causes of overweight and underweight. schools and communities on the consequences
and causes of obesity and underweight.
• Sensitization and capacity-building for
primary school teachers on the prevention of • Sensitization and capacity-building for
overweight. secondary school teachers on the prevention of
overweight.
• Support for interventions for the prevention of
overweight in primary schools including nutrition • Support for interventions for the prevention of
literacy classes, encouraging healthy eating and overweight and obesity in secondary schools
counselling through school food and nutrition including nutrition literacy classes, (increased)
programmes, (increased) physical activity and physical activity and others as relevant, as part
others as relevant. of a package of life skills interventions where
possible.
• Screening and referral for management of
overweight and obesity in schools, health • Screening and referral for management of
centres or another relevant platform. overweight and obesity in schools, health
centres or other appropriate services.
• Support for infrastructural adaptations, where
relevant, to create healthy (non-obesogenic) • Support for infrastructural adaptations, where
environments in schools and communities and relevant, to create healthy (non-obesogenic)
a safe and supportive environment for physical environments in schools and communities.
activity.
• Promotion and support for physical activity in
• Promote and support physical activity in communities through channels such as social
communities, among others via social and media and behaviour change communication.
behaviour change communication.
• Use of social networks, peer groups and
• Involve and inform parents on healthy food influential media persons.
choices and physical activity.
It is important to use a systems approach that
engages with all relevant areas of influence –
policies, financing, management, implementation,
monitoring and evaluation – rather than focussing
on only one aspect of a delivery system. The aim
should be to improve the prevention of overweight
by strengthening promotion, implementation and
delivery across all processes.

Table 6.1: Overview of key interventions for the prevention of overweight in children
A) Advocacy and technical support for the introduction or strengthening of relevant policies,
regulatory frameworks and strategies, and their implementation
General
1. A national or sub-national strategy on the prevention of NCDs and/or overweight and obesity, including in children
and adolescents (this can be a standalone document or embedded in a larger (sub-)national strategy)
2. Capacity building of policymakers on the causes and consequences, including economic factors, of childhood
overweight and obesity and relevant actions for its prevention
3. Advocacy and dialogue with policymakers and regulatory bodies on the adoption and implementation of
regulatory frameworks, and for the prevention of childhood obesity and incorporation of overweight prevention in
urban planning
Specific regulatory frameworks, such as:

1. Policies and standards on food, nutrition and physical activity in preschools, primary and secondary schools
and the sale of foods and beverages in and around schools
2. Legislation and policies on parental leave and maternity protection (including maternity leave and
breastfeeding breaks for women working outside the home)
3. Implementation of the Code
4. Implementation of the Guidance on Ending the Inappropriate Promotion of Foods for Infants and Young
Children
5. Implementation of the set of recommendations on the marketing of foods and non-alcoholic beverages to
children
6. Adoption of health-related food taxes, such as increased taxes on sugary and sweet beverages and ‘junk
food’ and subsidies for healthy foods
7. Reformulation of processed foods including portion sizes
8. Adoption of labelling requirements that identify foods high in salt, sugar and fats.
B) Interventions over the life course for the prevention of overweight in children
Preconception Early childhood School age Adolescents
and pregnancy (under five years) (5-9 years of age) (10-19 years of age)
• Promote eight antenatal • Protection, promotion & • Creation of a healthy, • Creation of a healthy, non-
care (ANC) contacts support of breastfeeding non-obesogenic obesogenic environment
• Nutrition counselling • Support for appropriate environment in primary in secondary schools
(including capacity complementary schools (including policies (including policies and
building of staff) feeding (healthy foods, and capacity building of capacity building of staff)
responsive feeding) staff) • Nutrition literacy and
• Nutrition literacy and • Nutrition literacy and physical education in
physical education in physical education in secondary schools
preschools (including primary schools • Promote and support
policies and capacity • Promote and support physical and nutrition
building of staff) physical activity in literacy activity in
• Weight and length or communities communities
height measurements • School food and nutrition • Promote messages
in primary health-care programmes to promote through peer group
facilities healthy eating approach, social networks,
• Infant and young child • School health sports clubs, youth
nutrition counselling for programmes for networks etc.
caregivers/ families screening and referral for • Screening and referral for
management of obesity management of obesity

© UNICEF/UNI136079/Friedman-Rudovsky
Snapshot of national policy actions
In recent years, countries in the Latin America and the Caribbean Region have
been at the forefront of action to tackle childhood obesity. Mexico and Chile have
taken significant steps to rebalance food environments in favour of healthy diets.
East Asian countries are also ramping up their efforts to address childhood
obesity. At the same time, countries like the United Kingdom have been looking
to supplement existing policies with new measures in light of slow progress and
widening inequalities.
Tax on sugar-sweetened beverage (SSBs) reductions were largest for households of lower
in Mexico socioeconomic status.2
Almost three quarters of Mexican adults and

Chile’s food labeling and advertising law
1 in 3 children and adolescents are affected by
overweight or obesity in Mexico, putting them Chile faces high prevalence of overweight and
at increased risk of immediate and longer-term obesity among children and adults and is among the
health harm. SSBs account for an average 9.8% countries with the highest sales of processed food
of total energy intake in the Mexican population, and beverages globally. To address this challenge,
and have been identified as an important target the Chilean Law of Food Labeling and Advertising
for lowering the excess intake of free sugars that was adopted to improve nutrition information at
leads to weight gain.1 To reduce the consumption point of purchase via “easy to understand” front-
of SSBs, the Mexican government implemented of-package (FOP) warning labels for packaged
an excise tax of 1 peso/L on SSBs as of 2014 (an food and beverage products with high levels of
approximate 10% price increase based on prices in sodium, total sugars, and saturated fats and energy.
2013). By increasing the price on SSBs, the average Products carrying a warning label are also subject
reduction of SSBs purchased was 7.5% (with a to restrictions regarding both their marketing to
reduction of 5.5% in 2014, and 9.7% in 2015). The children (<14 y) and their sale and promotion in

schools.3 One year after the implementation, Malaysia’s tax on sugary drinks
studies found that caregivers widely understood
Malaysia has one of the highest burdens of
that the new regulations were instituted to combat
overweight and obesity in Asia. In 2006, 7.7%
childhood obesity, and they recognized that
of children and adolescents aged 5-19 were
products with the most labels were less healthful
overweight; a decade later, this had risen to an
choices. Children, particularly the youngest, have
alarming 26.5% among this age group.
positive attitudes toward the regulation and have
become promoters of change in their families.4 In In 2019, the new tax entered into force, covering
addition, the availability in schools of foods that non-alcoholic beverages containing more than
exceed the warning label cutoffs for calories, sugar, 5 grams of total sugar per 100 ml and fruit and
saturated fat or salt dropped from 90.4% to 15%.5 vegetable juice drinks that contain more than 12
grams of total sugar per 100 ml. Malaysia, along
Tackling unhealthy food retail with Brunei, the Philippines and Thailand, is one of
environments in the United Kingdom four countries in South-East Asia to impose a tax on
sugary drinks.9
The UK Government has set itself the ambition
of halving childhood obesity and reducing the gap UNICEF Malaysia played a significant role in
in obesity between children from the richest and advocating and lobbying for this important measure
poorest areas by 2030.6 To achieve this, the UK together with support from UNICEF’s East Asia and
has announced a suite of policy actions, including the Pacific Regional Office and WHO. To promote
introducing a sugary drinks levy and the world’s adoption of the new tax, UNICEF conducted joint
first sugar reduction programme aimed at a 20% advocacy with WHO and supported the Malaysia
reduction in the most popular products commonly Ministry of Health to host an ASEAN meeting
consumed by children7. The UK Government is aimed at developing a regional framework for
consulting on new legislation to ban the placement sugary drinks taxes. The results of UNICEF’s
of products high in fats, sugar and salt at checkout landscape analysis on child nutrition, conducted
areas, store entrances and end of aisles. A ban jointly with the Ministry of Health, shone the
on price promotions that specifically encourage spotlight on the double burden of malnutrition in
overconsumption of these products is also planned, Malaysia, with burgeoning obesity but persisting
such as buy one get one free and multi-buy offers significant rates of stunting and wasting.
or unlimited refills.8
References
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TG, Batis C, Rivera JA. Discretionary perceptions and behaviors of mothers government/uploads/system/uploads/
foods have a high contribution and fruit, of young children.” International Journal attachment_data/file/604336/Sugar_
vegetables, and legumes have a low of Behavioral Nutrition and Physical reduction_achieving_the_20_.pdf
contribution to the total energy intake Activity 16.1 (2019): 21. 8 Government Response to the House
of the Mexican population. J Nutr 2016; 5 Massri, C., Sutherland, S., Källestål, of Commons Health and Social Care
146(9): 1881s-7s. C. and Peña, S., 2019. Impact of Select Committee report on Childhood
2 Colchero MA, Rivera-Dommarco J, the Food-Labeling and Advertising obesity: Time for action, Eighth Report of
Popkin BM, Ng SW. In Mexico, evidence Law Banning Competitive Food and Session 2017–19, UK Government, 2019.
of sustained consumer response two Beverages in Chilean Public Schools, Available at: <https://www.parliament.
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(Millwood) 2017; 36(3): 564-71. 6 HM Government, Childhood obesity: a Childhood-obesity-Government-
3 Corvalán C, Reyes M, Garmendia ML, plan for action. Chapter 2, June 2018. Response-to-eighth-report-17-19.pdf>.
Uauy R. Structural responses to the Available at: <https://assets.publishing. 9 https://www.unicef.org/malaysia/
obesity and non-communicable diseases service.gov.uk/government/uploads/ press-releases/sugary-drinks-tax-
epidemic: update on the Chilean Law of system/uploads/attachment_data/ important-first-step-obesity-malaysia-
Food Labelling and Advertising. Obes file/718903/childhood-obesity-a-plan- demands-further-action
Rev. 2019; 20( 3): 367- 374. for-action-chapter-2.pdf
4 Correa, Teresa, et al. “Responses to 7 Public Health England, Sugar Reduction:
the Chilean law of food labeling and Achieving the 20%. Available at: https://

Table 6.2: Overview of key interventions by service delivery system
Policies Strengthened regulatory frameworks on a healthy school and community environment,

the marketing of breast milk substitute (BMS), the marketing of unhealthy foods to
children, food labelling, health-related taxes and reformulation.
Food system Promote adequate availability of and access to healthy foods including through public
procurements.
Health system Optimal ANC including: nutrition counselling, nutrition education, energy and protein
supplementation in undernourished populations, iron and folic acid supplementation,
weight monitoring, iron and folic acid supplementation, and counselling on adequate
levels of physical activity
Protection, promotion and support for breastfeeding during ANC and in maternity
facilities
Infant and young child nutrition counselling
Weight and length/height measurements of children under five
Screening and referral for management of overweight
Water and sanitation Promotion and support for increased availability of free and safe drinking water in
system communities, schools and health facilities, as a key component of a healthy diet.
Education system School food and nutrition programmes including nutrition literacy in preschools, primary
and secondary schools, for both children and parents, and implementation of policies for
the prevention of overweight and obesity
Improving the school food environments through the promotion of fruit, vegetables
and water, and reducing access to sweetened beverages and large portions of high-fat
snacks
Physical activity; physical education
Provision of safe drinking water
Screening and referral for management of overweight
Social protection In social protection programmes, ensure the promotion and support of a healthy diet
system (including ‘do no harm’). Discourage subsidy of unhealthy foods; consider subsidy of
healthy foods where relevant.
Communities Promotion of and support for ANC contacts
IYCF counselling
Social mobilization and social and behaviour change. Communication for families and
adolescents on healthy diet and physical activity through a range of channels such as
social networks, peer groups and social media
Promotion and support for a healthy, non –obesogenic environment
Private sector Comply with the UN Guiding Principles on Business and Human Rights, the Children's
Rights and Business Principles and national regulations, including for all actors to
prioritize the protection of children's rights and act in best interests of children. UNICEF,
government and civil society holding the private sector to account
Identify appropriate opportunities to engage with private sector actors, such as ICT and
finance sectors, to explore novel ways to promote healthier diets and incentivize better
business behaviour so that healthier foods are more available, affordable and accessible.

Children drink water, taking a break
from recreation, at Baan Bang
Muang school in Thailand.
© UNICEF/UNI43002/Mohan

6.3 Lead knowledge generation and The Nutrition Section at HQ is working with the
use Data & Analytics Unit to develop indicators for the
diets of school-age children and adolescents and
Country offices and HQ and regional offices will a global assessment of these diets. Indicators for
engage in knowledge generation and use on the unhealthy eating will also be developed and used in
prevention of overweight in childhood. the analysis of national and subnational surveys.
Since this is a new area of programming for Data collection and surveillance systems also need
UNICEF and the evidence base is still growing, to be established for documenting overweight in
it will be crucial to document ‘what works’ in children over five at the national and global level.
low- and middle-income countries in a robust
manner. UNICEF can emerge as a thought leader As part of the development of country programme
in the area of child overweight in lower and documents, country offices need to select relevant
middle-income countries by prioritizing quality indicators for measuring impact, outcomes and
evidence generation and knowledge dissemination. progress of activity implementation. Where
Priorities include documenting relevant situation there are no monitoring systems for overweight
analyses, establishing regulatory frameworks for in children and the coverage and quality of
the prevention of overweight, and monitoring interventions to address child overweight, it would
the impact of healthy practices and overweight be important to establish them, and they could
prevention interventions for specific target groups cover both routine systems and surveys. Ideally,
across the life course. Partnering with academic indicators should be integrated into existing
and research institutions may be useful to systems.
generate evidence.
Table 6.3: Examples of relevant indicators for country level monitoring

Level Examples of indicators
Impact indicators Prevalence of overweight and obesity in children under five, 5-9 years and
adolescents 10-19 years of age by country and region
Burden of overweight and obesity in children under five, 5-9 years and
adolescents 10-19 years by country and region
Outcome indicators Existence of relevant policies, regulatory frameworks and strategies (for the type
of policies, please refer to Section 6.1)
The number of countries working to develop or approve specific policies,
regulatory frameworks and strategies
Consumption of unhealthy snacks by children aged 5 to 19 years
Feeding practices of children between 0 and 23 months including consumption of
unhealthy foods
Caregivers’ knowledge of appropriate IYCF practices
Output indicators The number and percentage of community health workers trained in IYCF
(depending on counselling
interventions The number and percentage of children (disaggregated by age and sex) under
implemented in a five who have their height and weight measured at specific intervals (as
given country) determined by the country)
The number and percentage of children between 5 and 19 years old who have
their height and weight measured at specific intervals (as determined by the
country)
The number of preschools, primary and secondary schools implementing food
and nutrition literacy activities

6.4 Monitoring and repor ting From 2017 onwards, the Nutrition Section’s
monitoring system Nutridash also includes
Monitoring and reporting of interventions and questions related to interventions for the
progress is crucial. Questions on interventions prevention of overweight in children. These are:
for the prevention of overweight in children are
incorporated in the Strategic Monitoring Questions 1. IYCF Module:
(SMQs) and in Nutridash for internal monitoring • Is UNICEF working to prevent overweight and
purposes. obesity in preschool settings? [If the answer
The SMQs, which country offices need to report to this question is yes, then country offices
on annually, include two questions on overweight are asked to select the specific area(s) of
prevention, namely: intervention and the number of preschools
reached through UNICEF support, the number
• Has your country office supported policy of children reached in those preschools and the
actions or programmes for the prevention of total number of preschools in the country.]
overweight in children and/or adolescents
in the reporting year? If the answer to this 2. Module on school-age children, adolescents
question is yes, then country offices are asked and women:
to answer the following question: • Did the UNICEF country office provide technical
• Which policy actions or programmes for the or financial support to implementation of
prevention of overweight in children and/or interventions to improve the nutrition of school-
adolescents were implemented in the country age children/adolescents (5-19 years) in 2018?
in the reporting year? Respondents select the • Does the government have a policy, strategy
relevant answers from a menu. or plan of action to improve the nutrition of
school-age children/adolescents (5-19 years)?
[When the answer to this question is yes,
country offices are asked to select the specific
components of the programmes for school-age
children.]
• Did the government provide funding to improve

the nutrition of school-age children/adolescents
(5-19 years) (besides salaries) in 2018?

7
Conclusion
Overweight in children and adolescents is a reality

in all regions of the world. The inclusion of this
topic in the measures set out in the Strategic Plan
2018-2021 provides an excellent opportunity to
accelerate and scale up preventative actions. To
have an impact, efforts should start before
pregnancy and continue through infancy and
childhood and include the creation of supportive
environments and interventions throughout the life
course. Key to achieving this is an implementation
strategy based on strong knowledge generation
and use that takes a multisectoral and systems-
based approach.
Within a UNICEF-supported program, they had a chance

to participate in healthy food workshops, and to learn
the difference between healthy and unhealthy food.
Working with relevant ministries across Bosnia and
Herzegovina, UNICEF supported development of healthy
nutrition strategies and guidelines for promotion of
healthy lifestyles. © UNICEF/UN040452/Panjeta

Resources for further reading
Several NGOs and foundations have developed useful guiding documents for specific aspects of the
prevention of overweight and obesity in children, including the American Heart Association107 the Robert
Wood Johnson Foundation108 and the World Obesity Federation109. The website of the WHO Regional
Office for the Western Pacific region also has several relevant materials.110
The World Health Organization Global Coordination Mechanism on the Prevention and Control of
Noncommunicable Diseases (GCM/NCD) hosts a Knowledge Action Portal for information and engagement
of actors in this area.111
UNICEF is a member of the UN Interagency Task Force on NCDs, which has its own web page.112
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Programming Guidance Overweight Prevention

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UNICEF

NUTRITION GUIDANCE SERIES

Lead Authors: Maaike Arts, France Bégin and Víctor Aguayo.

Technical advisory group in UNICEF: Luisa Brumana, Kudawashe Chimanya,

Designer: Nona Reuter (UNICEF); Editing: Cheryl Stonehouse for ProseWorks

Citation: United Nations Children’s Fund (UNICEF). Prevention of overweight and

BMI Body Mass Index

DRP Division of Research, Policy and Practice

ECD Early Childhood Development

FAO Food and Agriculture Organization

IYCF Infant and young child feeding

MICS Multiple Indicator Cluster Surveys

NCD Non-communicable diseases

PFP Private Sector Fundraising and Partnerships

PPD Public Partnership Division

SDG Sustainable Development Goals

SMQ Strategic Monitoring Questions

UNDAF UN Development Assistance Frameworks

UNSCN United Nations Standing Committee for Nutrition

WFP World Food Programme

WHA World Health Assembly

WHO World Health Organization

2 UNICEF Programming Guidance

Part I: Overweight in children and adolescents: Prevalence, causes, consequences,

1. Overweight in children and adolescents 8

Part II: UNICEF programming for the prevention of overweight in children

4. Prevention of overweight in children and adolescents UNICEF Strategic

Resources for further reading 42

Prevention of overweight and obesity in children and adolescents 3

Adolescents Children and young people between 10 and 19 years of age.1

Middle childhood 5 to 9 years of age2

Overweight in Weight-for-height above +2 SD (standard deviation) of the WHO Child Growth

Overweight in BMI-for-age above 1 SD (standard deviation) of the WHO Growth Reference

School-age Children between 5 and 14 years of age.5

4 UNICEF Programming Guidance

Prevention of overweight and obesity in children and adolescents 5

6 UNICEF Programming Guidance

Prevention of overweight and obesity in children and adolescents 7

8 UNICEF Programming Guidance

Preschool children (<5 years)

Prevention of overweight and obesity in children and adolescents 9

35.9 33.5 33.1

Adolescents (10–19 years)

Of the 638 million Of the 1 billion

10 UNICEF Programming Guidance

1. 2 Prevalence and burden of

The data on overweight in children between 5 and

Figure 1.3 shows the data for school-aged

Prevention of overweight and obesity in children and adolescents 11

12 UNICEF Programming Guidance

Prevention of overweight and obesity in children and adolescents 13

Children with overweight, and specifically those

14 UNICEF Programming Guidance

Prevention of overweight and obesity in children and adolescents 15

The Commission published the Implementation

Interventions Intermediate Long-term

Source: Implementation Plan of the Commission on Ending Childhood Obesity

16 UNICEF Programming Guidance

3. Overweight-specific actions: These actions will have less immediate impact on