Integrating agriculture and health to improve nutrition outcomes in low resource settings.
ICN2 provides a great opportunity to build on the current momentum for investing in nutrition. Compared to ICN (2 plus decades ago), how can this document capture advances, challenges and new knowlegde in a dramatically different global environment to advance nutrition interventions and create action?
1. Do you have any general comments on the draft political declaration and its vision (paragraphs 1-3 of the zero draft)?
I would like to see a more current and disaggregated description of the advances in the past 25 years and in the threats to malnutrition in global development. First, a recognition that the past two decades have shown remarkable economic growth and reduction in child mortality (and a lesser degree) maternal mortality in many developing countries, with many of these countries graduating from low to middle income classification. Second, although this is true throughout Asia, Latin America and Sub-Saharan Africa, recognition that countries are at different stages of economic development and nutrition transition. Even in low or middle-income countries, there is variation in economic prosperity and nutrition transition, where some urban areas thrive and face threats similar health, environment and market threats to those in higher income countries. Recognizing these differences up front and introducing language to be more specific to country typologies would be helpful. Within this context, stunting rates have declined 35% globally since 1990, and wasting has reduced 36% since 1990. It will be important to identify where the gains and progress have been made and how. This should help to make the vision, reshaping food systems, and action more specific and relevant to the diverse exposures to risk factors.
The global environment has changed drastically since 1992, contributing both progress and new and emerging threats to nutrition. The bullets in number 2 are predominantly negative and almost dismissive of what progress has occurred. Have there really been no advances worth noting? I would suggest some recognition of progress, advances or successes. What about a bullet that recognizes advances that explicitly include improvements in nutrition outcome trends in some countries, regions, parts of regions, etc.? What about recognition that the awareness and attention to nutrition in the past decade has increased, and then have a vision to leverage and build on that unprecedented momentum (i.e. two Lancet issues on child nutrition in 2008 and 2013, SUN, donor support to nutrition –USAID & DFID).
The focus is very much on food, and fails to recognize more immediate determinants of malnutrition (food intake and disease), and some of the more critical underlying determinants of malnutrition (healthy environment, health services, access to health care, caring practices) and the enabling environment, which is mentioned later, but should be in the introduction (education, water and sanitation, infrastructure, markets). Also, in number 3, this would be a good place to explicitly recognize how urbanization, globalization, & income growth have changed food availability, physical activity levels, diets, etc.
Recently, a number of reviews have identified what works for nutrition specific interventions (Lancet 2008 and 2013), and systematic reviews have also identified weaknesses in methods for looking at links between agriculture and nutrition—the latter being a major threat to designing and improving programs to address nutrition in the future. The global environment that conditions nutrition and our knowledge base for nutrition are very different place from 1992, but the background does not capture that.
2. Do you have any comments on the background and analysis provided in the political declaration (paragraphs 4-20 of the zero draft)?
Make the life-cycle approach to nutrition more central to this document. Can there be a vision for global action that embraces and evolves around nutrition over the life-cycle? Can this be expanded to be explicit—reference the first 1000 days and other critical age groups. For instance, we know that maternal nutrition may be difficult to improve once a woman is pregnant, and recognition that we need to reach girl adolescents is emerging, as a way to prepare for 1000 days. Similarly, from a macro perspective, recognize that countries are in different stages of the nutrition transition. So, individual target groups have different needs, and countries have different needs.
Add a new vision that explicitly commits actions by other sectors. For instance a vision that commits to increase access to health care, to immunize children against preventable diseases, to increase access to education, water and sanitation, to improve the quality of national, household and individual diet. This may have the effect of reaching across the aisle to other sectors that affect nutrition (agriculture, education, water & sanitation, health). This is a great opportunity to expand the vision for global action to end malnutrition. If these are explicit, then those sectors may also have a vested interest in success. This links to number 12 and 13.
The focus of ‘Reshaping the food system to improve people’s nutrition’ is too strongly on food systems and should be renamed to capture the complexity of different sectors, governments, and other actions listed in that section. For instance numbers 12 and 13 actually reference other sectors that have independent affects on nutrition, not necessarily through food systems. These seem out of place where they are placed in the document. Similarly, number 15-20 focus on govenance, and other issues. Also, number 13 which addresses an important issue of equity combines a number of different aspects, but could be rewritten to highlight this issue more clearly explain factors affecting supply and demand and what it means to make a food system more equitable. This gets lost in the current version.
I’d love to see a header that promotes integration nutrition as part of public health programs, community outreach, agriculture policies and programs. What would that look like? How can strengthening policies, investment, integrated programs maximize nutrition outcomes?
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)?
The commitment to action is heavily focused on food systems to improve nutrition. This is a limited view of improving nutrition, and must recognize the other pathways that affect nutrition, including health services, health environment, caring practices, etc.
It is hard to align the commitments to the numbered points in 4-20. I think each commitment should be clearly and strongly linked to specific numbers 4-20, so the reader can fully understand the commitments.
Lastly, I found many of the terms within commitments, i.e. ‘aligning food systems’ or ‘making food systems equitable’ or the commitments themselves too vague, and further crafting of the commitment could strengthen the full set.
Carol Levin
Hi,
I happen to also be working on this topic, so found it very useful to review your document. It is great to see this effort and it is a very good start.
I hope you will find my comments useful as you move forward with this important initiative.
All the best,
Carol
Carol Levin, Ph.D.
Senior Health Economist and Clinical Associate Professor
Disease Control Priorities Network | Department of Global Health
University of Washington | Seattle, WA