We are very honoured to participate to this discussion and we will try to give our commentaries based on our field experience and on the lessons learned in our work to fight malnutrition in multiple countries worldwide
1. Do you have any general comments on the draft political declaration and its vision (paragraphs 1-3 of the zero draft)?
The draft approaches the malnutrition problem with a wide perspective and we think some improvements could be done.
· The obesity problem is mentioned only in the paragraph 2, while it could be better to introduce it already in the first paragraph.
It is important to underline the linkage between malnutrition and obesity because nowadays most of developing countries face a double burden of malnutrition that includes both undernutrition and overweight.
In our opinion in this document is not very clear clear that maternal and child malnutrition in low-income and middle-income countries encompasses both under nutrition and a growing problem with overweight and obesity.
· It is not mentioned the impact of malnutrition on maternal and child mortality, this is an important data to underline. Stunted, underweight, and wasted children have not only an increased incidence but also an increased risk of death from diarrhea, pneumonia, measles, and other infectious diseases. In the last estimates (Lancet 2013) more than 1 million deaths can be attributed to stunting and about 800 000 to wasting, about 60% of which are attributable to severe wasting.
· The linkage between maternal nutritional conditions (micronutrient deficiencies, short stature and low BMI) and child undernutrition is not clear.
It is written that a third of all women suffer from anemia but in our opinion this information is not explaining clearly the complexity of the problem. The document should underline that nutritional status at the time of conception and during pregnancy is crucial for fetal growth and that babies with fetal growth restriction, are at increased risk of death throughout infancy and have an increased risk of growth faltering in the first 2 years of life ( 20% of stunting might be attributable to fetal growth restriction).
· As regards the statics on malnutrition an important point to underline that is lacking in the document is the socioeconomic inequality in the rate of reduction of malnutrition that means the degree to which childhood malnutrition rates have improved differ between more and less socially and economically advantaged groups inside and within countries.
(This is a very different concept from what is written as “large socio-economic differences in nutritional status and exposure to dietary risk factors exist in most populations”)
In a draft like this, that will act as guidance for future policy-making, should be clear that a focus on reducing the average malnutrition level does not seem to lead to obvious generalized benefits. Presenting this problem in this first part of the draft can justify the message that programmes targeted at specific population groups, namely the poorest, are urgently needed to achieve pro-equity outcomes while in other instances.
· Concerning the paragraph 3 where is written “ Recognize that the causes of malnutrition are complex and multidimensional, while food availability, affordability and accessibility remain key determinants”
According to us these could not be considered the key determinants of malnutrition but are the key determinants of Food Security. Talking about malnutrition and Food Security is very different and this point should be clarified. Improving availability, affordability and accessibility of food could not improve at all malnutrition rate if we not improve food utilization. This reflects, to some extent, the complex nature of malnutrition which is the results not only of the effects of food insecurity but also of those of poor health and inadequate infant feeding practices (breastfeeding and complementary feeding).
If we want to explain the key determinants of malnutrition we have to underline the importance of dietary, behavioral, and health determinants of optimum nutrition, growth, and development and how they are affected by underlying food security, caregiving resources, and environmental conditions, which are in turn shaped by economic and social conditions, national and global contexts, resources and governance.
2. Do you have any comments on the background and analysis provided in the political declaration (paragraphs 4-20 of the zero draft)?
· Paragraph 5 “Recognize that nutritional needs change over the life cycle, and certain groups, including women and children, have specific needs, especially during particular phases of life”
In this paragraph it should be emphasized what are the life cycle period more vulnerable to malnutrition because in this form is too generic. According to us is important to underline at least:
· The windows of opportunity: this is the crucial period of pregnancy and the first 2 years of life or the 1000 days from conception to a child’s second birthday during which good nutrition and healthy growth have lasting benefits throughout life
· Adolescent nutrition: this period is important to the health of girls and is relevant to maternal nutrition Adolescents have as high a prevalence of anaemia as women aged 20–24 years and a preventive intervention will be effective for future mothers nutritional state.
· Paragraph 12 “ Recognize that appropriate policy packages are needed to adequately tackle the multiple burdens of malnutrition in different situations. Food and nutrition should be addressed across several sectors: agriculture, industry, health, social welfare, education. Nutrition should be a goal of all development policies. Public policies should deal simultaneously with both food supply and demand while policies on investments and subsidies should be aligned with nutrition goals.”
In this part, according to us, is important to mention the concept of nutrition-sensitive interventions and programmes in agriculture, social safety nets, early child development, and education instead of “ food and nutrition should be addressed across several sectors: agriculture, industry, health, social welfare, education” Nutrition-sensitive programmes draw on complementary sectors such as agriculture, health, social protection, early child development, education, and water and sanitation to affect the underlying determinants of nutrition, including poverty; food insecurity; scarcity of access to adequate care resources; and to health, water, and sanitation services.
ü Paragraph 17 “Further recognize that nutrition policy and programme implementation is poorly developed, coordinated and monitored at both national and international levels. Government responsibility for and leadership on nutrition is often partial and fragmented, or even non-existent. National nutrition strategies should involve and coordinate all relevant ministries and departments in complementary interventions, supported by the necessary financial, human and other resources. “
As regard the international level of coordination is important to mention the Scaling Up Nutrition (SUN) movement, which started in September 2010 and is now the most important symbol of the increased interest in nutrition. Even if it is too soon to evaluate the effect of SUN on rates of undernutrition reduction, several countries have made advances in terms of building multi stakeholder platforms, aligning nutrition-relevant programmes within a common results framework, and mobilizing national resources.
ü Paragraph 18: “Reaffirm that high-level political commitment and pro-active efforts as well as improved governance for more effective concerted actions by various key stakeholders across sectors are essential for food systems to enhance nutrition and food safety on a sustainable basis. Governments should take responsibility for leadership on nutrition. Institutional capacity should be built, and effective coordination across sectors implemented. Governments’ investment plans should target food systems with the aim of improving the availability, accessibility and acceptability of healthy food.”
As regard the political commitment issue we think is very important to underline that political commitment can be developed in a short time, but commitment must not be squandered because conversion to results needs a different set of strategies and skills as there are three factors that shape enabling environments for nutrition : politics and governance but also knowledge and evidence and capacity and resources. Acceleration and sustaining of progress in nutrition will not be possible without national and global support to a long-term process of strengthening systemic and organisational capacities. According to us” Governments’ investment plans should” prioritise investment in scale-up of nutrition-specific interventions, and should maximise the nutrition sensitivity of national development processes.
ü Paragrapgh 19: “Recognize that eradicating malnutrition in all its forms depends on the active engagement of citizens working with committed, responsible and proactive governments, civil society and the private sector through interaction among stakeholders, often involving new modes. Scientists, educators, the media, community groups, food producers and processors, retailers, farmers, consumer organizations, and faith organizations need to contribute to the common agenda to reshape the food system. The United Nations system must work more effectively together to enhance international cooperation and solidarity to improve nutrition and support national efforts to accelerate progress against malnutrition. “
Civil society and private sector should be given a more important role.
There are at least 4 very important roles of civil society that must be outlined : (1) global and national advocacy to call attention to nutritional deprivation and galvanize commitment to act (2) ensuring of accountability for nutrition-relevant service coverage and quality (3) generation of context-specific knowledge about key drivers of undernutrition and relevant remedial options, and (4) implementation of nutrition programmes and provision of delivery platforms to maximize scale-up and ensure equity by reaching the unreached.
As regards the private sector we want to stress the concept that this sector (including agri-food businesses, medium-scale and small-scale processors of staple foods, and private health networks)has the substantial potential to contribute to improvements in nutrition, but efforts to realize this have to date been hindered by a scarcity of credible evidence and trust especially around infant feeding. Both these issues need substantial attention if the positive potential is to be realized.
· According to us in general in this document there is no particular attention to the importance of infant and young child feeding practices on nutrition. Community-based interventions to improve maternal, newborn, and child nutrition in particular regarding IYCF (Infant and Young Child Feeding Practices) are now widely recognized as important strategies to deliver key maternal and child survival interventions121 and have been shown to reduce inequities in malnutrition. Even the extreme importance of adequate breastfeeding and complementary feeding is not sufficiently clear in the document.
3. Do you have any comments on the commitments proposed in the political declaration? In this connection, do you have any suggestions to contribute to a more technical elaboration to guide action and implementation on these commitments (paragraphs 21-23 of the zero draft)?
Please provide your comments in the appropriate fields relating to these commitments:
Commitment I: aligning our food systems (systems for food production, storage and distribution) to people’s health needs;
Include the transformation phase ( production, transformation, storage and distribution) in order to give importance to a value chain approach