المنتدى العالمي المعني بالأمن الغذائي والتغذية

Draft Contribution on the ICN 2 Framework for action to the JWG

FIAN International – supporting struggles for the Right to Adequate Food

Questions:

Do you have any general comments on the draft Framework for Action?

Need to recognize that past and existing strategies:

did not deal adequately with structural causes of hunger and malnutrition

are not based on the human rights framework, and do not promote and protect the right to adequate food and nutrition as a human right, and due to that:

are fragmented in dealing with access to productive resources, social exclusion, poverty,  the different models of production and access to adequate diet, and the needed public services to guarantee adequate nutrition.

Are fragmented in sealing with the issue of wealth, income and access to adequate diet and the needed public services to guarantee adequate nutrition.

Do not regulate the activities of the powerful economic actors (TNCs and other business enterprises) that abuse and contribute to violations of the human right to adequate food and nutrition and related rights.

are fragmented in dealing with food and nutrition, which are inextricably linked; from a human perspective, the human right to adequate food is only fully realized when people achieve  highest level of nutritional wellbeing possible; (example of this is the totally separate national and global governance structures for food security and nutrition; the lack of discussion of the negative impact of  the hegemonic agro industrial model of production on working conditions, destruction of livelihoods, environment, biodiversity, climate change, food quality, nutrition, etc. ) (The preparation of ICN 2 is an example of this, totally dissociated from the CFS discussions)

are fragmented in dealing with women´s rights and mothers’ and children´s rights (Need to combat violence and discrimination against girls and women, from birth,  as a major measure to promote girls ´and women´s nutrition, autonomy and human dignity as a prerequisite for maternal and children´s rights, included the informed right of women to sexual and reproductive right s and to breastfeed; and inconsequence reduce maternal malnutrition, low birth weight, stunting, etc.)

do not guarantee full participation of public interest CSOs, social movements, indigenous peoples, in national

Breastfeeding promotion and protection must be a key priority throughout the FFA. However this priority should be clearly seen as a societal responsibility, in which the States have the obligation, at national and international level, to guarantee the enabling conditions for women  to make the informed decision to breastfeed , and the family to support her in this social task, free from the undue pressure from mega commercial interests. This means the full promotion and protection of women´s rights, including sexual and reproductive rights, reduction of child marriage, and for the reduction of violence; the regulation of  work related parental  leave; the integration into law of the Code of conduct on the marketing of breast milk, among other.

Promote and guarantee the participation of women in the ICN 2 process as well as in its follow up is central to ensure that women’s  rights are  fully respected, protected and fulfilled.

Any new Governance Mechanism for Nutrition , at international level, must be well coordinated, and probably institutional linked, with the Committee on World Food –Security and maintain working relations with key UN Human Rights System bodies, such as: CESCR,, CEDAW, CRC, HRC, among others.

The same principles would apply to the national level, and this mechanism should be government led and have the full participation of public interest CSOs.

Categories such as Stakeholders, or Non State actors, that tend to level off power inequities, as if they did not exist, and to treat “all”, on the same footing are unacceptable to public interest CSOs, social movements and indigenous peoples.

TNCS and business enterprises should not participate in policy discussion and decision in  intergovernmental  or governmental spaces.

Do you have any comments on chapter 1-2?

Chapter 1

1.1

Include, in first paragraph, page 1,  numbers on low birth weight,   wasting and stunting. Linking this to maternal undernutrition and women´s rights violations. (structural violence, child marriage, discrimination)

Para 3, page 1, mention the threats placed by the expansion of the unsustainable agro industrial model of production and the negative consequences in terms of land grabbing, destruction of livelihoods, evictions, climate change, monotonous diets, etc….

Para 4, page 1, it should read:

The challenge is to improve global and national nutrition and food system governance to ensure more nutritional wellbeing –enhancing food systems, and social economic environment.  In order to achieve this it is necessary to achieve political and policy coherence with human rights and coordination across all sectors, including in agriculture and food systems, health, social protection, education, employment, trade, investment, finances, environment, information, consumer affairs, planning and other sectors.

1.2

Para 1, page 2, should read:

This Framework for Action (FFA) is guided by the Rome Declaration on Nutrition, a collective commitment made at ICN2 , in coordination with the Global Strategic Framework for Food Security and Nutrition of  the CFS, to ensure that development, including that of the global food system and breastfeeding, is improving people’s nutrition in a sustainable way, particularly that of women and children.

Para 3, page 2 should:

Include:

The international Covenant on Economic, Social and Cultural rights (1976) at: http://www.ohchr.org/EN/ProfessionalInterest/Pages/cescr.aspx

The Convention on the eradication of all forms of discrimination against women ( 1979)    at: http://www.un.org/womenwatch/daw/cedaw/

The international Code of Marketing Breast-milk substitutes   (1981) at: http://www.who.int/nutrition/publications/code_english.pdf

The Convention on the rights of the child ( 1990) at: http://www.ohchr.org/en/professionalinterest/pages/crc.aspx

The Voluntary Guidelines for the progressive realization of the Right to Adequate Food in the context of national food security, approved by FAO council (2004) at: http://www.fao.org/docrep/009/y7937e/y7937e00.htm

The document of the Reform of the Committee on World Food Security (2009) at: http://www.fao.org/fileadmin/templates/cfs/Docs0910/ReformDoc/CFS_2009_2_Rev_2_E_K7197.pdf

Voluntary Guidelines on the  Responsible Governance of  Tenure of Land, Fisheries and Forests in the Context of National Food Security (2012)  at: http://www.fao.org/docrep/016/i2801e/i2801e.pdf

The Global Strategic Framework for Food Security and Nutrition (2013), approved by CFS plenary at: http://www.fao.org/fileadmin/templates/cfs/Docs1213/gsf/GSF_Version_2_EN.pdf

NOT include the Scaling Up Nutrition (SUN) movement and the Global Nutrition for Growth Compact since:

THEY ARE NOT DOCUMENTS, or GUIDELINES discussed and approved by intergovernmental multilateral bodies, therefore are not in the same standing with the other mentioned documents;

There are serious concerns in the part of many governments, and of civil society especially, about the potential for individual and institutional conflicts of interest linked to the participation of TNCs and other business enterprises in the policy making mechanisms of these initiatives, that can potentially lead to negative consequences to the enjoyment of nutritional wellbeing for many. 

Para 1, page 3 should go beyond World Health Assembly goals, and include

Eradication of land-grabbing by 2025

30% increase in public procurement, especially at local level, from small scale food producers;

30% reduction in use of agrochemical by 2025;

Eradication of use of forbidden agrochemicals by 2025;

30% reduction in child marriage rates by 2025;

20% reduction in youth and adult overweight and obesity;

30% of countries have incorporated Code  on marketing of Breast milk substitutes into binding national law;

Para 3, page 3, should read:

This FFA, building on the already cited documents, provides….

…acting in partnership with public interest civil society organizations (CSOs),  women´s organizations, and grassroots….

Para 4, page 3, should include at the end a sentence to this effect:

This also entails considering the impact of the development plans and activities of powerful economic actors, such as TNCs and other business enterprises, on the enjoyment of the right to adequate food and nutrition for all, and taking the necessary policy steps to respect and protect these rights, including the regulation of these activities

Chapter 2

2.1

Last para, page 3, should include two more elements:

Political will to ensure the principle of do no harm to the enjoyment of the right to adequate  food and nutrition for all;

Political will to protect the enjoyment of the right to adequate  food and nutrition for all, against undue interference  of private interest  initiatives led by powerful economic actors;

2.2

First para, page 4, should read:

Six elements are particularly important for improving for establishing human rights based governance of food and related systems to improve nutrition

Heading of Second para, page 4 should read:

Human rights coherent government-endorsed….

Second para, page 4, third, eighth and last line respectively, should read:

…establish policies to encourage nutrition justice promote and protect the right to adequate food and nutrition.

… producers, processors, distributors and retailers of food, and businesses whose activities positively or negatively affect nutrition;

… contexts in which these choices are made including the negative influence of advertising especially for children.

Last para, page 4, 1st and 2nd line, should read:

Regular assessments of progress towards the progressive realization of the Right to adequate Food and Nutrition,  by national and local governments, as well as the partners with whom they work,  in special public interest CSOs, can greatly enhance accountability

2.3

Economic arguments maybe taken into consideration, but it is a Human Rights obligation of States, to guarantee national and international realization of the right to adequate food and nutrition. And this should be reaffirmed.

Do you have any comments on chapter 3 (3.1 Food systems, 3.2 Social Protection; 3.3 Health; 3.4 International trade and investment)?

Chapter 3

Last para page 6,second line should read:

…includes coordinated, human rights coherent and complementary…

Aside from having national human rights obligations, States have extraterritorial obligations: a) to avoid causing, harm; b) as members of international organizations; c)  to protect, d) to regulate, e) to create an international enabling environment.; f) to provide international assistance g) to seek international assistance, h) to provide effective remedies and reparation

Therefore, a set of policy and programme options must be elaborated for the international level as well.

3.1.Food systems

Breastfeeding is integral part of the short circuit family food system, in which the woman needs the support of the family and of social mechanisms to make an informed decision and carry out this action in a way that the house chores are shared, and she is protected by labor legislation to guarantee that she can exclusively breast feed her baby until 6 months of age, and not lose her job or pay.

The importance and role of breastfeeding and its promotion for infant nutrition and health in adulthood should be highlighted in the beginning of this section.

The potential of the traditional small scale food producers to be more sustainable, biodiverse, adjusted to the local eating patterns, and more labor intensive, should be more emphasized.

The risks of the agroindustrial model in terms of environmental , working conditions, contamination of workers, water and food, food monotony, reduced food diversity, etc, should be highlighted

The presence of extreme power imbalances between coexisting food systems , and between the hegemonic food system and the other social actors (small scale food producers, workers, communities, women, and consumers, in general) all right holders,  demands different sorts of regulation measures in the part of the State, to break the cycle of concentration of power, wealth, and land.

Priority actions

The issue of power imbalance and abuses of power, as one of the social economic determinants of hunger and all forms of malnutrition, must be addressed by the FFA. Therefore, the following  priority actions should  be added to the existing ones:

Promote the full respect, protection and fulfillment of all girl´s and women´s rights, including sexual and reproductive rights, with special attention to protection against structural violence and discrimination, sexual violence, child marriage and to the promotion of the status of women in society, in equal standing with men.

Promote and protect the right of women, with the support of her family,  to an informed decision on whether to get pregnant and to breastfeed.

Promote and support small scale food producer food systems as more socially and environmentally sustainable, diverse and culturally adequate food system.

Protect small scale food producer systems against land grabbing, securing responsible governance of tenure and control over land, forests and fisheries.

Regulate the activities of powerful TNcs and other business enterprises, directly linked to food or not,  that abuse human rights and contribute to HR violations, with special attention to the right to adequate food and nutrition, right to health, right  to social security, women´s rights and child rights.

3.1.1.

Include breast milk as the first healthy diet,  that requires promotion, protection and guarantees. The woman needs the support of hear partner, family and form social mechanisms, including against pressures from medical personnel and baby food producers.

Priority actions

Include the need for legal regulation of maternal and parental leave, without losses for the woman

Translate the International code on Breast milk substitutes into national binding law.

3.2

Social protection should be seen as part of guaranteeing  the realization of the right to social security.

3.3. Health

Need to highlight the importance of the promotion of sexual and reproductive rights of women.

3.3.1.

Priority actions to address stunting, add as first

Promote girls’ and women’s rights, autonomy, nutrition, education, and sexual and reproductive rights.  Do not reduce girls to her possible role of “future mother”.

3.3.2.

Priorities on reproductive health and family planning, add as first

Protect girls and women against structural and sexual violence

3.3.4.

Nutrition education should be associated to measure to regulate food and beverage marketing practices and publicity, especially those directed at children.

3.3.5

Invest on popular housing

Do you have any comments on chapter 4-5?

Chapter 4 Accountability

The accountability mechanism to be established should be human rights based and should be linked to the global governance of nutrition, which in its turn should be closely coordinated with the CFS, and related Human rights bodies.

Para 2, page 26.

SUN should not be in the list, it is not a UN or an international organization, and has not been fully discussed and approved by an intergovernmental body.

We would suggest the inclusion of OHCHR and UNWomen.

Para 2 and 5, page 26

The CFS must play a central role in the follow up together with FAO and WHO.

Chapter 5

Para 6, page 26

The FFA should be submitted to the CFS  for endorsement and harmonization with the Global Strategic Framework for Food and Nutrition security.

Para 1, page 27

The CFS and the Human rights Council, should be specifically requested to evaluate their contribution to the implementation of the Rome Declaration and FFA.

Para 2, page 27

The CFS should be the intergovernmental body to which countries should preferentially report on the follow up of ICN 2

WHO should join the CFS secretariat

The global governance mechanism for nutrition will be discussed and proposed by June 2015, in coordination with the CFS;

Para 1, page 28

The idea of establishing an Intergovernmental Panel on nutrition is interesting, but too whom it presents its reports and recommendations must be clearly spelled out.

FIAN proposes that the CFS could be the intergovernmental umbrella for the new intergovernmental governance mechanism for nutrition, composed of  governmental  country missions representative of the broad national  intersectoral food and nutrition coordinations/platform. This could be a subset of the CFS

The IPN could report to this governance mechanism. 

Does the Framework for Action adequately reflect the commitments of the Rome Declaration on Nutrition, and how could this be improved?

We have not had access to the latest version of the Rome Declaration. The last version we saw presented similar limitations to the ones we identified in the FFA.

Does the Framework for Action provide sufficient guidance to realize the commitments made?

FIAN understands that it is unacceptable that the CFS has not been involved in the preparation of the ICN 2, and has been basically excluded from the document and the follow up proposals.

The lack of recognition of the important role played by the CFS, since its reform, as the most relevant and inclusive intergovernmental platform for food and nutrition security by the ICN 2 Secretariat and, especially by the Joint Working Group raises several questions in our minds:

Is this linked to the intention of some governments to exclude public interest civil society organizations from any effective participation in the elaboration process of the outcome documents of ICN 2, and the eventual governance of the follow up, in total opposition to the CFS reform process?

This would be totally in line with the formal exclusion of Public interested CSOs  from the direct elaboration process of the Declaration and FFA.

How can civil society be convinced about the seriousness of the intention of the ICN 2 secretariat and JWG to promote coordination and policy coherence on nutrition, and build on what exists, when:

The ICN 2 process does not articulate with or involve the CFS, the intergovernmental body that deals with food and nutrition, and therefore is the closest to its central issues;

The Global Strategic  Framework for Food security and Nutrition, discussed at length and approved by the CFS State members, is not even mentioned either on the Declaration or in the FFA

Two of the main documents, related to food and nutrition, central to people on the ground, are not mentioned either: the Guidelines on the RTF, and the Land tenure guidelines.

There is no proposal for a clear  global governance mechanism to guarantee a minimum of coherence of the actions proposed by the outcome documents,

Does this reflect the powerful presence of the private corporate sector in the field of food and nutrition?

FIAN sees the ICN 2 process as an enormous setback in terms of CSO participation in the discussion of policies in areas that are extremely relevant to people. The lack of direct debate with government representations on key issues linked to the social determinants of hunger and all forms of malnutrition has led, in our understanding, to a very poor process, as well content wise.

Are there any issues which are missing in the draft Framework for Action to ensure the effective implementation of the commitments and action to achieve the objectives of the ICN2 and its Declaration?

The missing points and suggestions were already presented along the previous 8 pages.

Dear FSN Forum Members and ICN2 Secrtariat,

As a nutritionist, thank you to FAO for giving us an opportunity to provide our comments on the ICN2 draft document.

1. General comments on the Draft of the Rome Declaration on Nutrition

A entire clear and well prepared document but I have to provide some suggestions

The actions should be clear and specific, but not so narrow that they remove flexibility in implementation for countries. Countries should be able to tailor the actions to their own national contexts.

·      Comments on chapter 1-2

I believe that the private sector, governments and civil society must work together to identify and implement sustainable pathways to provide sufficient, nutritious and affordable food for all of the world. Furthermore a section on actions by international partners should be included (including civil society and producers ..)

All actions that will take place should be carefully studied with dietitians from academia and NGO’s from various countries using scientific data.

·      Comments on chapter 3

1. I partially agree with this recommendation in 3.1, paragraph 4 (Healthy diets contain a balanced and adequate combination of foods to ensure sufficient macronutrients (carbohydrates, fats and protein) and essential micronutrients (vitamins and minerals). WHO recommends that diets should ensure........ )

The most important issue is to educate people by experts so that they can be able to make choices in order to consume appropriate healthy food themselves. It is the dose of an ingredient or a certain kind of food that makes it harmful. It is very important so adjust the dose of certain food ingredient. Policy-makers must pay attention to make suggestions that is optimum for all of the world and paying attention to cultural and economic diversities. The WHO recommendations is a draft and it has not been approved by all member states so I think it is confusing to endorse firm limits that is not yet approved by member states.

2. Paragraph on “Food Environments” (3.1.1) and  Paragraph on “Nutrition education for behavior change” (3.3.4) :      

Healthy diet is important but I believe that the most important thing is dose. Especially portion size in nutrition is very important. So we should educate people about correct dose  of these.

For example, as we know milk is healthy but ıf you drink 2 litre of milk  per day, excess amounts of milk consumption may lead to iron deficiency anemia. So milk is healthy or unhealthy ? Of course, a healthy diet can be achieved with portion control. It is not possible to label food products as healthy or unhealthy, consequently promoting certain kinds of food or to dissuade people from consuming certain kinds of food by taxes or such should not be a wise action.

Another point is; correct information about healthy nutrition is very important. Unfortunately there is a lot of information about healthy diet and physical activity in the media in developing countries, mostly not relevant to scientific studies. We have to reach correct information about nutrition. This situation is misleading public opinion.  So public awareness is important, we should educate people about healthy nutrition and exercises.

We have to protect people from pollution nutrition information. Actually this problem is about a lot of things.  For example; Milk is healthy or unhealthy ? Which milk more healthy? Or bread/pasta is good food or bad food for people.  What is the true? We all know trues but people not.  I suggested that measures should be taken to educate people on nutrition and diet should be provided by professionals and academics. This should be regulated by government. Because this is a common problem in many countries and regions.  So  should be create policies about this.

Finally, the references to multi-stakeholder collaboration in this document are weak and do not adequately reflect the significant level of cooperation and partnership between governments, the private sector, and civil society that will be required to end obesity, malnutrition and hunger.  

1.       Do you have any general comments on the draft Framework for Action?

Save the Children would like to thank the organisers of ICN2 for drafting the Framework for Action (FFA) and for the opportunity to provide comments.

Save the Children supports the focus of the FFA on “malnutrition in all its forms”.  It would be helpful if this principle was applied throughout the document.

Save the Children feels that the draft FFA contains lots of background information that is not essential to include. Instead, the FFA should be concise and point to other relevant initiatives, documents and organisations.

Save the Children feels that the FFA should build on existing infrastructure and systems for nutrition. For example, the FFA should detail how it will work with and complement the efforts of the Scaling Up Nutrition (SUN) movement and the Global Nutrition Report.

The draft FFA as it stands contains too many priority actions. While Save the Children believes that urgent action on nutrition is required, we are concerned that the large number priority actions listed in the FFA will discourage member states from signing up. We would also like the priority actions to be clearer and timebound to improve accountability for commitments.

ICN2 is taking place one year ahead of the post-201 5 development agenda (hopefully) being agreed. The FFA should acknowledge that ICN2 is happening in the context of the development of the post-2015 agenda and there should be greater overlap between ICN2 and the post-2015 development agenda outcomes.

Do you have any comments on chapter 1-2?

Chapter 1

Save the Children is interested to learn more about the ‘Decade of Action on Nutrition’. As stated above, we believe that urgent action is required to address malnutrition. Details of exactly what this will involve should be included in this document.

We strongly support the alignment of the FFA with the WHA nutrition targets. This is a very important component of the FFA.

Chapter 2:

In addition to the four key elements of the enabling environment listed, we would add the need for strong and transparent accountability mechanisms to be in place.

Under ‘2.2 Better governance for nutrition’ we support the priority actions around establishing cross-government, inter-sectoral governance mechanisms and also multi-stakeholder platforms.  ICN2 is a chance to bring together relevant government ministries to work on nutrition. This should be a priority of the conference.

We support ‘Priority actions for financing for improved nutrition outcomes’.

Chapter 3

We welcome the inclusion of both direct and nutrition-sensitive interventions in chapter 3, however we feel that the current layout is a little confusing and there are too many priority actions. We suggest prioritising commitments towards direct nutrition interventions and also the need to review and integrate nutrition into other relevant sector policies, such as agriculture, education, WASH and social protection.

Chapter 4

We strongly suggest that the ICN2 accountability  framework be integrated into the Global Nutrition Report and other existing structures, such as SUN and the Global Panel on Agriculture and Food Systems for Nutrition.

The organisers of ICN2, together with other relevant UN agencies, should organise regular follow-up meetings to check progress against the commitments made.

The accountability framework should be developed in the context of the post-2015 development agenda discussions and outline how the two processes will align.

Save the Children believes that the Global Panel proposed in the FFA has a different remit to the Global Panel on Agriculture and Food Systems for Nutrition but this should be clarified.

Q 4:

Delivery & long term Sustainability is missing:

The economic activities of the rural smallholder producer communities  following their low cost ecological agriculture systems, mostly ensures access to their nutritious food requirements at little or no cost, thus reducing hunger, Malnutrition, poverty, suicides and the effects of climate change whilst improving livelihoods, purchasing power and net incomes. The intervention of their PC, staffed by professionals (general practitioners [GPs]/ MBAs in agriculture) to take over all risks and responsibilities other than on farm activities, is essential for proper convergence between the supply side and demand side institutions providing  services related to agricultural production, management, training, extension, value addition, etc., considering that it has become more difficult with passing of time. Evidence in this regard is available in the working papers available on this link:

https://www.google.co.in/?gws_rd=ssl#q=economies+of+scope%2C+Amar+kjr+Nayak

Given the required support, producers can then access low cost finance, management, know how/ knowledge for producing inputs, optimizing production, value addition to increase shelf life of perishables for minimizing post harvest losses, marketing/ logistics and creating the required infrastructure. PCs are also helping strengthen the capacity of producers by negotiating for improved policies, ensure stable domestic markets and link with regional, National and International processes.

Government (Members of Parliament/ Legislators) have the responsibility and at all levels to fund, facilitate and assist in the setting up and staffing of PCs, thereafter mentor, if they are to succeed and for agriculture to contribute in economic development and growth in the long term. A model successfully implemented and in one of the poorest districts of Orissa, India: 

www.navajyoti.org.

Open discussion on the ICN2 Framework for Action zero draft to implement the Rome Declaration on Nutrition-Comments of Livio Luzi

The Draft document contains many balanced recommendations on which I agree on, but it also includes some recommendations which are not fully correct and, therefore, in my opinion should be modified.

Ø  Comments on chapter 1-2

The following references made in chapters 1 and 2 can be supported with some considerations:

The overall comment on Chapters 1 and 2 is that, although the Declaration has focused on Nutrition, too little emphasis is more in general on life-style and particularly on the relevance of physical activity in contrasting the development of obesity. More in detail, I would suggest not to use specifically the terms of “healthy and unhealthy” foods (a concept that is rather limitative). Instead, I would more appropriately use the terminology of “healthy or unhealthy life-style”. This would be a more comprehensive approach to face and combat obesity pandemic diffusion. From this general consideration stems as examples the following specific potential corrections:

• “nutritionally appropriate diets” (par. 1.1), without specificying the adjective “unhealthy”;
• “knowledge and evidence-based strategies, policies and programmes” (par. 2.1)
• “involve regular consultations among all implementing partners, including consumer groups, other civil society organizations, basic and clinical investigators in nutrition, producers, processors, distributors and retailers of food” (par. 2.2)
• “professional nutritionists, research scientists, educators, personal trainers ” (par. 2.2)

Ø  Comments on chapter 3 (3.1 Food systems, 3.2 Social Protection; 3.3 Health; 3.4 International trade and investment)

A point that require support (and expansion) is the fact: “interventions in isolation may have limited impacts within such a complex system, interventions that consider food systems as a whole are more likely to succeed” (par. 3.1). Accentuating the relevance of this point will allow the inclusion of more general aspect of life-style as well e.g. physical activity).

Please find some negative feelings on the following points made in chapter 3:

-          Paragraph on Food systems (3.1, paragraph 10): the reference to WHO recommendations on diets contained in this paragraph, appears partially incorrect because it refers to draft recommendations not yet approved by Member States, such as the one included in the 5th bullet point (“WHO recommends that intake of free sugars is less than 10% of total energy intake or, preferably, less than 5%”). These Guidelines are still in a draft version, recently put to public consultation and still under revision. I personally believe, and I already had the chance to comment on this, that giving clear-cut percentage is not supported by scientific data at present. Free-sugar, acutely, is well known to have also positive effects on energy metabolism and neurophysiological parameter. For this main reason, namely the lack of supporting scientific data, or in specific case paradoxically the opposite effect, the statement should be smoothened or deleted.

-          Paragraph “Nutrition education for behavior change” (3.3.4, page 21, 7th paragraph): “Nutrient profiling has been used as a tool to qualify the nutritional value of individual foods and help consumers make healthy choices, as well as governments design schemes to control food marketing and label food products”.  As science has shown, there is no such a thing as a “good” or a “bad” food in itself: it all depends on how the different foods are combined within the daily and weekly eating traditions and habits. Moreover and more importantly in my opinion is pivotal the relationship between the nutritional daily intake and the level of physical activity. Remember that marathon runners caloric intake rages between 3500 and 5500 daily calories most of them derived from fats! This sentence should, therefore, also be removed or significantly modified.

-          Paragraph 4.4. “International Trade and Investment”, (pag.24, third paragraph- it follows par. 3.3.6 and before par. 4): “The availability of and access to unhealthy foods should be effectively regulated and discouraged. International standards in regulations for nutrition content to promote compliance with nutrition requirements should be established, implemented and enforced.”  Regulating the nutrition content of food products with pre-set standards applicable to International Trade would not only be most likely against applicable competition rules, but also is in contrast with more basic psicologic approach to any “addiction” conditions (obesity can be considered a food addiction condition). In fact, prohibitionist period teaches us that is ineffective to prohibit alcohol, smoking, drugs etcetera, to avoid diffusion. In fact, this would only results in illegal diffusion and selling of the prohibited product. Instead, a positive reinforcement on global aspects of life-style interventions will more easily reach the target and limit unhealthy life-style habits. This sentence should, therefore, also be removed or significantly modified.

Comments on Implementation: Add considerations and data on the correlation between nutrition and other aspect of life-style (mainly the level, quality and quantity of physical activity in relation to quality and quantity of daily calories).

Sincerely,

Livio Luzi, MD,

Professor of Endocrinology,

University of Milan,

Milano, Italy

Tel: +39 02 5277 4635

Cell: + 39 340 8435693

The Second International Conference on Nutrition (ICN2) Framework for Action zero draft

Comments from the Gender Team, Social Protection Division (ESP)

8th August, 2014

Comments on Chapter 1 INTRODUCTION

Gender equality is a key factor in the achievement of food and nutrition security. We therefore propose to add the following paragraph in the section 1.1 Background to make reference to prevailing inequalities in food security and nutrition,  gender inequalities in particular:

“Problems of malnutrition reflect pervasive inequalities in the access to food and awareness about nutritious diets. Women and children tend to be more vulnerable where access to food is limited. In agrarian contexts, many women are both primary producers and providers of food, but often find obstacles in accessing productive resources, services and information, thus limiting their capacity in contributing to food security and nutrition.”

Comments on Chapter 2 INSTITUTIONAL MECHANISMS TO IMPROVE NUTRITION

Gender inequalities should be addressed in the effort to enhancing governance of food and related systems to improve nutrition. In promoting consultations with partners in developing nutrition related policies and strategies, women’s adequate representation should be ensured. Therefore, we propose to add these aspects in the section 2.2 Better governance for nutrition (please see the attached draft document for proposed modifications made in the text).

Comments on Chapter 3 FROM COMMITMENT TO ACTION: POLICY AND PROGRAMME OPTIONS

3.1 Food systems

Given the role that women play throughout the food systems, special efforts are needed to strengthen their integration in the agro-food value chains. There should also be an emphasis on ensuring more sustainable and equitable food systems in the text (please see the attached draft document for proposed modifications made in the text).

The following bullet point should be added as one of the priority actions:

·         Raise awareness among policy-makers and the public on the health and economic impacts of giving women equal access to productive inputs and services and the benefits of investing in the economic empowerment of women.

3.2 Social Protection

There should be an emphasis that nutrition-related interventions must be well-targeted and equitable in order to have significant results. Therefore, one of the proposed priority actions on social protection should read as follows;

·         Improved targeting, using a nutrition lens to identify needs, preferences and disparities among different individuals by age and sex, households and/or communities who are most nutritionally vulnerable can increase the effectiveness and impacts of any intervention.   

Comments on Chapter 4 ACCOUNTABILITY MECHANISMS

It is suggested to include some gender-sensitive targets and indicators in the monitoring and accountability framework which will be defined through an inclusive process by June 2015 and relevant data must be disaggregated by sex and age.

The implementation of activities recommended in the Rome Declaration and the Framework for Action should be carried out by the Governments in a gender-sensitive way, taking into consideration the different needs and priorities of men and women.  This should also be taken into consideration when relevant UN and other international organizations decide on ways to give appropriate priority to their nutrition-related policies, strategies, programmes and activities aimed at ensuring the implementation of the activities recommended in the Rome Declaration and the Framework for Action.

Detailed comments are inserted in the attached draft ICN2 Framework for Action document.

The US Council for International Business (USCIB) appreciates the opportunity to submit comments to the FAO consultation on the Framework for Action for ICN2 Draft. The private sector believes it is essential that all stakeholders work together to develop holistic, impactful and sustainable solutions. We are committed to public-private partnerships that support public health strategies. We believe that collaborative multi-sectoral actions represent one of the most cost-effective ways to address public health challenges. In the past, USCIB has submitted comments to the FAO regarding the role of non-state actor, as well as regarding the ICN2 Political Outcome Document draft. As a follow up, we have a several concerns with the language in the Framework for Action Draft.

Enabling environments (Page 3): USCIB agrees with these 4 key elements, and would recommend that the comments underscore the importance of employing “knowledge and evidence-based strategies, policies and programs”, and that this reflects industry’s view as well. 

“Nutrition Justice” (Page 4): This phrase is not defined and the boundaries of this concept are unclear; USCIB would recommend removing, and the document focus on the action steps on policies to achieve explicit nutrition targets. 

Engage implementation partners (page 5):  The language in this paragraph could be misconstrued, in particular the “subordination of interests which conflict with government policies, agreed implementation…” in a way that continues to denigrate the role and contributions of the private sector. This language speaks to a larger point within the document in that there is limited language that acknowledges the importance of the food industry and the need to engage as a full partner in deciding strategies, actions and common goals for moving forward. The private sector is noted, including on page 27, but this is an area where we think the document could be significantly enhanced. 

Priority Actions for nutrition governance (page 5): In this section as well as in sections on “recommendations for follow-up” (pages 26-27), there is a lack of clarity as to how all these platforms, mechanisms, processes and reporting relate to similar activities either in place or proposed by WHO and the UN – for example, the WHO Global Coordinating Mechanism and the UN HLM periodic “Progress Reports” on the 2011 Political Declaration.  There appears to be significant potential for redundant, duplicative and overly burdensome processes that could present significant obstacles to achieving real progress.  At a minimum, greater clarity is required regarding roles and responsibilities among the various multi-lateral organizations.

Language on lost productivity (page 5/6):  important point that could be elaborated upon further in comments as a key driver for companies to engage in nutrition/wellbeing to mitigate productivity losses and support the health and wellbeing of our consumers/communities. 

Page 6 and elsewhere on incentives/taxes:  Fiscal policy is complex, often has unintended consequences, and requires caution, especially as food prices continue to rise. Unintended consequences include an effect on informal and illicit products and markets, problems of tax evasion, corruption, smuggling and product switching. The introduction of a fiscal approach can very quickly become cumbersome to manage and complex to administer. 

Furthermore, fiscal measures also have potentially large re-distributive effects and would most likely hurt lower-income individuals who spend a larger proportion of their income on food. Tax rates should be kept low on products that account for a relatively high proportion of spending by the poorest groups in society. In this instance, taxes on food will discriminate against low income households. 

Finally, the impact on consumption patterns from implementing fiscal measures is unpredictable. Changes in consumption will depend on the price elasticity of each good (assuming the tax is passed on to consumers). How consumers’ behavior changes in light of relative price changes is not always obvious and inherently difficult to estimate. The more likely impact is that consumers will switch to alternative goods that have characteristics that are closer to the originally purchased item and that remain exempt from the new tax regime, or taxed at a lower rate.

Comments on Section: From Commitment to Action: Policy and Programme Options Role of “highly processed foods of minimal nutritional value” (page 7): There are no definitions of “highly processed foods of minimal nutritional value” in this document or by other reference and yet the conclusion is drawn that they have “contributed to obesity and diet-related NCDs”.   The lack of either a definition or an evidence base linked to those definitions, should dictate that this statement is not appropriate for inclusion in the WHO/FAO Framework For Action document.

Characterization of WHO recommendation on “free sugars” (page 8): The document appears to misstate WHO recommendations on free sugars –specifically with respect to the “5%” language.  It is our understanding that the WHO is currently conducting a peer-review of proposed recommendations and in March 2014 requested public comments on those recommendations.  With regard to a recommendation of intake below 10%, the authors of the WHO review noted that the relationship observed between free sugar intake and dental caries was based on evidence that was judged to be of very low quality.  At that time, the Grocery Manufacturers Association (GMA), a USCIB member, commented on the proposed recommendations and concurred with WHO that more scientific substantiation and full engagement and collaboration of the many concerned stakeholders is required before a conditional recommendation of reducing sugar intake to 5% can be considered for adoption as policy.  Furthermore, since the request for comments in March, WHO has issued no public statement with regard to its proposed sugar recommendations and the results of its peer-review process, so the statement in the Framework for Action seems premature at best.

Additionally, the private sector understands that many consumers are increasingly seeking ways to improve their dietary quality and manage their calorie intake, including reducing sugar consumption. For example, to meet these needs, members of the International Food and Beverage Alliance (IFBA) have been formulating products with less added sugar, using alternative sweeteners and other ingredients as alternatives to sugars and reducing calories by offering smaller portion sizes and providing portion guidance. Reducing sugar levels is complex and challenging, both technically and in terms of consumer acceptance. 

Empowering Consumers to make healthy dietary choices (page 9): We agree that nutrition education is key, and that we need to collectively work to effectively educate consumers through labeling and nutrition programs about food, how to combine them into diets (quality and quantity) that fit their needs as well as address other aspects of a healthy and productive lifestyle including physical activity, energy balance, etc. 

Role of women in food systems (Page 9): Another crucial issue includes ensuring the empowerment of women and girls both economically and socially. These members of society have an important role in the decisions made at the household level with regards to food and nutrition. Therefore, we believe that it is important to promote policies that help women become farmers, traders and business owners. Equally important is that these members of society are educated and properly informed to make healthy choices for their households. The private sector can play a crucial role in empowering women and girls.

Backyard farming/gardens (Page 10):  This is certainly one small element to the overall approach, but recommend that we provide a caution given huge global demands on food, increased production/yields, change in diets, demographic shifts (move to cities) that will all require a more robust approach. 

Regulating marketing and financial incentives/disincentives (pages 11-12): It is not clear what the evidence base is for the specific strategies noted in this section, raising the question of why national governments should rely upon this analysis. This section references the WHO Set of Recommendations on Marketing Food and Non-alcoholic Beverages to Children in the context of “Regulating Marketing” despite the fact that these WHO recommendations also note the role that industry self-regulation can and has played in this arena.

Priority actions to improve the food environment (Page 12): USCIB is concerned about the language on Priority Actions to Improve the Food Environment; the Framework for Action document should highlight how the food and beverage industry is already responding to the WHO‘s 2004 Global Strategy by:

--Offering healthier products through product innovation and reformulation

--Providing more information to consumers through nutrition labeling so that they can make informed choices

--Adopting responsible marketing policies, particularly with respect to children

--Working with other stakeholders to promote physical activity and nutrition education

Page 22, access to safe water:  USCIB strongly supports work in access to safe water and would like to highlight some of the efforts that industry/TCCC are already undertaking to ensure access to clean water: http://www.coca-colacompany.com/water-stewardship-replenish-report/

International trade and investment (page 24): There appears to be a presumption underlying this section that the impact of trade and investment is primarily negative, despite the fact that no evidence is offered to support this presumption and despite significant evidence to the contrary, including FAO and WTO reports, indicating that increased trade, particularly in agriculture and food, increases the standard of living in developing countries and improves the performance of national economies.  This section continues this presumption with respect to trade and nutrition specifically, not by providing any evidence of harm, but by implication simply constructing each proposition in the negative.  Without any science or evidence basis, this entire section should be reconsidered.

Providing evidence for the definition of a healthy diet (Page 26):  This is an area in which the private sector could contribute. USCIB would like to recommend and welcome a dialogue between the private sector and FAO and WHO on the subject. 

Intergovernmental Panel on Nutrition (Page 28):  USCIB would support such a panel and would like to recommend inclusion of representatives with substantial expertise from the food and beverage industry. 

Chapters 1-2:

These chapters are commendable summaries of the vision, actions and resources necessary to achieve the goals outlined. In particular, the chapters emphasize the need to solve the unacceptably lingering nutrition problems of the 20th Century. All of the public health measures necessary to do so have been known for at least 100 years and all of the recognized essential nutrients have been known for more than 50 years. Likewise, ancillary aids such as antibiotics necessary to treat the common infectious agents associated with the malnourished state have also been available for nearly as long. In practice, the proof-of-principle experiments were completed long ago. Under-nutrition is largely non-existent in Nations that have been able to implement the public health foundations required for clean water and food and that have been able to provide diverse foods in amounts that allow adequate intakes of the essential nutrients in healthy diets. As such, then, the 20th Century’s lingering nutrition problems are not the result of a lingering deficit in nutrition science. They are the consequence of the lingering investment, financing, policy facilitation, and implementation deficits. Chapters 1 and 2 highlight the action elements necessary to turn these issues around. All are critically important, but explicit commitment to the knowledge and evidence-base is the foundation for effective conduct of all of the other recommendations.

Because the fundamental biological causes of under-nutrition are largely understood, final solution to the nutrition problems of the 20Th Century is achievable on a global scale. On the other hand, in Chapter 1, the draft aligns its commitment with the 66th WHA goal of reducing NCDs by 25% by 2025. While certainly commendable, this goal is potentially less tractable. First, on the whole, neither the knowledge nor evidence-base for NCDs are as complete or as convincingly clear and unambiguous as is the information on essential nutrient deficiencies. The pathophysiological bases of NCDs, the nutrition problems of the 21st Century, are not nearly as well understood as the biological causes of under-nutrition. Secondly, proof-of-principle experiments in developed countries have not been nearly as demonstrably effective for prevention of many NCDs, cancers for instance. Third, in NCDs where success has been achieved, it is plausible that these accomplishments were achievable because the overall environmental, societal, public health and economic problems that remain impediments to successful elimination of under-nutrition were corrected first.  Fourth, in many NCDs medical/pharmaceutical preventive and therapeutic advances have been responsible for a significant fraction of the successes. The past and future scientific, technological and industrial contributions to medicine get little mention in the draft. Fifth, in large part, behavioral change underlies correction of most modifiable NCD risk factors and science and society have been remarkably poor at changing behaviors in almost any sphere of life. Finally, the large, 25% reduction in NCDs must be accompanied by a corresponding reduction in all-cause mortality. If not little net human benefit results. Thus, for instance, if reduction in cardiovascular deaths is accompanied by an increase in deaths from cancer and other causes (as has been the case in some cardiovascular disease trials), how does one measure success or recommend pubic health policies?

Chapter 3 (Section 3.1):

Chapter three provides insightful guidance by recognizing the critical interplay of food systems, supply chains, economic incentives, income growth, and food-system based policies as necessary elements in any overall action plan.  Most importantly, the chapter explicitly recognizes that healthy diets and diverse diets are necessary for any nutritional success, either in eliminating under-nutrition or in reducing the risk of NCDs. The absolutely critical word here is “diets” and in whole diets, not individual foods. Despite regular and repeated forays into dietary and/or nutrient fads that have promised long-term beneficial returns, the field of nutrition has demonstrated over and over again that overall health maintenance is a function of an individuals whole diet pattern, not of any specific, individual food or class of foods.

More than fifty years ago, expert nutrition advice was that there are no good foods or bad foods, only good or bad diets.  Nonetheless, in the intervening decades, various “bad food” hypotheses were tested repeatedly. Over time, the integrated results of these studies have provided proof that the overall diet pattern is what is critical to maintaining optimal nutritional health, not the presence or absence of specific nutrients in any individual food. Thus, for instance, egg were once vilified as a “bad food” by the American Heart Association because consumption of the cholesterol in eggs would lead to increased serum cholesterol and, consequently, to increased cardiovascular risk. Rather quietly when compared to the highly vocal AHA campaigns to reduce cholesterol intake, in its 2013 Guideline on Lifestyle Management to Reduce Cardiovascular Risk, the AHA now says in a single short sentence that “There is insufficient evidence to determine whether lowering dietary cholesterol reduces Low Density Lipoprotein Cholesterol” (1).

Likewise, in the current framework draft (bullet list, Section 3.1), simplified recommendations for reduction in salt, saturated fat and sugar intakes no longer adequately or transparently reflect the complexity of the current state of nutrition science in these areas.

Specifically:

·         Intake of saturated fat is less than 10% of total energy intake: This item fails to address the accumulated evidence that the macronutrient replacements for the saturated fats removed from the diet are critical in regard to the overall health consequences, that there are profound differences in the health effects of individual saturated fatty acids, and that the consequent health risks are dependent on the individual fatty acids, not saturated fats as a class, and that effects of reducing saturated fats, per se, on heart disease risk may not be as profound as once suspected, once the effect of the presence of trans-fats in earlier studies is removed (1-24). Recently, published data led Dr. Frank Hu at Harvard to remark that, “The single macronutrient approach is outdated… I think future dietary guidelines will put more and more emphasis on real food rather than giving an absolute upper limit or cutoff point for certain macronutrients.” (25)

·         Intake of free sugars is less than 10% of total energy or, preferably, less than 5%: This recommendation is just not supportable from current evidence. There are no direct human experimental data to support a 5% intake level. As far as I can determine, the 10% level is an arbitrary one based on the subjective opinion of a WHO Study Group that met in Geneva in 1989 when, without any systematic evidence-based assessment, the “Group judges that the upper limit of the population nutrient goal for free sugars should be about 10% of energy” (WHO Technical Report Series 797, page 113).  Earlier this year, in response to the WHO draft sugars guideline, I submitted formal comments on the lack of evidence basis for this guideline. To my knowledge, this document remains a draft with recommendations that are not yet formally approved.  Rather than duplicate in detail here the evidence I sent to the WHO in March, I have attached my earlier comments as an Appendix  at the end of the current comments and supporting citations. Since my earlier comments to the WHO on this issue, an additional related meta-analysis has been published (26). This analysis demonstrated statistically significant increments in circulating triglycerides, LDL-Cholesterol and blood pressure as a function of dietary sugars intake. However, the changes in surrogate variables were quite small and their clinical significance is surely arguable without further data, especially hard clinical endpoints (26).  

·         Intake of Salt is less than 5 g per day: New data question the advisability of severe restrictions in dietary sodium intake based on risk/benefit ratio of salt restrictions beyond modest decrements in intake (27-33). These data continue to show that individuals who consume very high quantities of sodium as salt will have significant, beneficial effects on blood pressure and support the findings of the DASH diet study of hypertensive individuals. However, they question extrapolation of DASH data to populations as a whole since very low sodium intakes are not only associated with little additional benefit but the adverse risk profile increases. In an editorial accompanying the most recent reports in the New England Journal of Medicine, Dr. Susan Oparil discusses the new data and concludes that the articles “highlight the need to collect high-quality evidence on both the risks and benefits of low-sodium diets.” (33) Thus, the current Framework for Action draft needs to reconsider the absolute value chosen for its recommended salt intake.

Chapter 3 (Section 3.1.1):

Food Environments: Additionally, as a consequence of the necessary modifications of the Section 3.1 bullet items discussed above, there will be a corresponding need to reword the related bullet items in Section 3.1.1

Summary:

The current ICN2 Zero Draft Framework for Action represents a thoughtful document overall and one that provides comprehensive and inclusive recommendations on the whole. However, the draft overstates the level of the today’s evidence when it makes simplified recommendations about individual foods. Several of these specific restrictions are no longer supported convincingly by hard scientific data. Moreover, this negative approach fails to emphasize more positive approaches that focus on healthy dietary patterns as a whole. Not only are these more scientifically sound based on current evidence, healthy whole diet patterns will permit each of the 193 Nations in the U.N. to more readily adapt their individual dietary guidelines to local foods available within these Nations and to food patterns and consumption habits that continue to support the unique social and cultural contexts of the citizens of these countries.  

Comments Submitted by

Dennis M, Bier, M.D.

Director, Children’s Nutrition Research Center

Baylor College of Medicine, Houston, TX, USA

Editor-in-Chief, The American Journal of Clinical Nutrition

Evidence for commitments made - UK research on nutrition through agriculture:

Through this email I would like to respond to the invitation to an open discussion on the draft ICN2 Framework for Action to implement the Rome Declaration on Nutrition.

1. Do you have any general comments on the draft Framework for Action?

In 2010 the 63rd WHA adopted the Birth Defects resolution “to redress the limited focus to date on preventing and managing birth defects, especially in low- and middle-income countries. ... The resolution calls on Member States to prevent birth defects wherever possible...”

http://www.who.int/maternal_child_adolescent/news_events/news/2010/17_5_10/en/

http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R17-en.pdf

The Framework for Action currently lacks any reference to the prevention of birth defects, such as neural tube defects. While their incidence may not be as high as non-communicable diseases such as obesity or diabetes, birth defects do contribute considerably to stillbirths, neonatal deaths and under-five mortality. Those born with Spina Bifida, one of the most severe neural tube defects, also have long-term healthcare needs.

·         Do you have any comments on chapter 1-2

Adding the reduction of neural tube defects to the list of commitments in chapter 1 would seem in line with the WHO Birth Defects resolution. A nutritious diet, with foods that contain folates, and folic acid supplements are essential to lower the risk of neural tube defects such as Spina Bifida developing during the first weeks of pregnancy. Women of childbearing age need adequate folate/folic acid levels before becoming pregnant (the “1000 days” should start before conception).

Strategies should indeed address people’s dietary choices, and the context in which these choices are made (chapter 2, element 1). However, up until now public health campaigns to improve the uptake of folate rich foods and use of folic acid supplements seem to have a limited effect and only changes the choices of women of high(er) social economic status.

Fortification of (a) staple food(s) with folic acid reaches all women of childbearing age, yet this is not enough to reach adequate folate/folic acid levels. A nutritious diet and folic acid supplementation remains essential too. Strategies should reach all women of childbearing age, regardless of education or income.

Do you have any comments on chapter 3?

3.1 Food systems

In addition to the availability of highly processed foods of minimal nutritional value, they are often also the most affordable. This adds to the malnutrition due to micronutrient deficiencies. The fact that it also leads to obesity and diabets is another increased risk for neural tube defects such as Spina Bifida. The cooperation of the private sector is desperately needed to help change people’s dietary choices. As long as cheap “junk food” is easily available, it will remain a challenge to get people to buy healthier foods, such as fruits and (green) vegetables and meat. Even when there is income growth, it is not evident that this money will be spent on nutritious food products. “Popular nutrition education” might make a difference, but the risk remains that only women of high(er) social economic status will be reached. It remains important to take cultural differences into account and involve local authority figures and/or elderly family members to create change in people’s dietary choices.

The list of “Priority actions” only mentions “Encouraging bio-fortification”. It would seem logical to add “Encouraging food fortification”, which is far less controversial and is already being used in many countries to reduce micronutrient undernutrition.

In “Priority actions to address stunting” it says “Improve micronutrient intake through food fortification, including complementary foods, and use of supplements when and where needed”. As neural tube defects also begin “in utero”, fortification with folic acid and folic acid supplementation is of great importance. It would be excellent opportunity “to redress the limited focus to date on preventing birth defects” to include food fortification with folic acid to prevent neural tube defects.

3.2 Social Protection

Indeed “Special attention needs to be given to the ‘first 1000 days’ when vulnerability to nutritional deficiencies is greatest”. However, it needs to be made clear that these ‘first 1000 days’ start before conception, with regard to the prevention of neural tube defects (birth defects). Women of childbearing age need proper folate/folic acid levels before becoming pregnant.

3.3 Health

Health systems also have to deal with the long-term health needs of those born with a neural tube defect such as Spina Bifida. Again this is an opportunity to include the prevention of birth defects in the Framework for Action. Overweight, obesity and non-communicable diseases aren’t the only health consequences of malnutrition. Their incidence may be higher, and they may even increase the risk of birth defects, but malnutrition, and specifically folate/folic acid deficiency, by itself also contributes to a higher incidence of neural tube defects.

3.3.1 Delivery of effective nutrition interventions

On page 16 is the first and only mention of “improving maternal nutritional status before and during pregnancy”. This is an issue which deserves far greater attention in the Framework, more explicit then the referral to ‘the first 1000 days’, especially with regard to the prevention of neural tube defects. Especially when the website www.thousanddays.org refers to the 1000 days as “ the 1,000 days between a woman’s pregnancy and her child’s 2nd birthday”. It is essential for women of childbearing age to have adequate folate/folic acid levels before they conceive.

It should be included that folate/folic acid deficiencies increase the risk of “neonatal adversities”, similarly to Anaemia. Likewise, folate/folic acid deficiency should be added to “Priority actions to address anaemia in women of reproductive age”. The same actions will help reduce the risk of neural tube defects. (Again this would be in line with the WHO Birth Defects resolution and increase the focus on preventing birth defects.)

3.3.2 Delivery of health interventions with an impact on nutrition

Priority actions on reproductive health and family planning

“Enable services such as family planning to become more nutrition-sensitive” is a good start, but in low- and middle-income countries these type of services will possibly not exist or not be accessible to all. Yet it is of the utmost importance that women of childbearing age learn about the importance of a healthy diet and folic acid supplementation before becoming pregnant. “Pre-pregancy advice” by local authority figures and/or elderly family members could be more feasible.

3.3.4 Nutrition education for behaviour change

Governments, international organizations, the private sector and civil society are indeed all responsible for helping consumers make healthier decisions with regard to their diet. However, it will remain a challenge to “lead by example” when we allow the production, distribution and sale of “junk food”, which has little to no nutritional value.

The “social determinants of health” also determine people’s dietary choices.  To change the “consumer’s choice” from cheap, highly processed foods to more nutritious but often more expensive food products will require more than nutrition education. The food industry, the “food system”, will need to be changed too.

With kind regards,

Renée Jopp

Renée Jopp - Information officer

International Federation for Spina Bifida and Hydrocephalus

Cellebroersstraat 16 - 1000 Brussels - Belgium