Foro Global sobre Seguridad Alimentaria y Nutrición (Foro FSN)

Dear Moderator and other members in FSN team

A general comment: A racial document

A fair policy document gives high focus (special acknowledgement of issues and action plans)  on the problem of disadvantaged groups. In terms of nutritional requirement, indigenous ethnic groups are special need groups globally- in both developed and developing countries. This has been proven in experimental and social researches. There are low priorities in policy and research for increasing nutritional resources of the groups at national and international levels. The food sources of the groups are encroached, destroyed or criminalised in uses to benefit power groups. Even FAO has the regressive programmes in the communities of the ethnic groups such as in Congo. However, this draft document has not acknowledged the nutritional issues of special need groups. It has focused on the issue of mainstream society. Based on the facts this document can be termed racial. 

Thanks.

Bhubaneswor Dhakal

The International Life Sciences Institute (ILSI) is pleased to offer the following information to support specific activities included in the draft ICN2 Framework for Action to implement the Rome Declaration on Nutrition.

Comments on Chapter 3

3.1 Food Systems – the ILSI Center for Integrated Modeling of Sustainable Agriculture and Nutrition (CIMSANS) has developed a working paper (submitted for publication) that may be useful in addressing most of the priority actions.

·    Acharya, T. et al. June 2014. Assessing Sustainable Nutrition Security: The Role of Food Systems.

ILSI Research Foundation, Center for Integrated Modeling of Sustainable Agriculture and

Nutrition Security. Washington, DC. Accessible at:  http://goo.gl/gEyQ1F.

This paper proposes an integrated food systems modeling approach to advance assessments of global food security. The methodology incorporates farm-to-fork activities (as opposed to a focus on production) including critical nutrition (both macro- and micronutrient) and sustainability considerations

– both of which are overlooked in current assessments. Development of this methodology is useful for addressing FAO’s priority actions in two ways: 1) the integrated food systems model improves understanding of food system interconnections and 2) the assessment methodology created can be used by all stakeholders (government, industry, and academia) to assess the impact of food system interventions.

CIMSANS is currently developing this Sustainable Nutrition Security assessment methodology via global public-private partnerships.  More information is available here:  http://goo.gl/t3eXHn.

3.1 Food Systems – Priority Action – “addressing micronutrient deficiencies through sustainable food- based approaches” – ILSI Europe has several publications that may be useful in implementing this action.

·    Flynn A. et al. (2009) Intake of Selected Nutrients from Foods, from Fortification and from

Supplements in Various European Countries. Food & Nutrition Research Supplement 1, 2009 –describes robust and innovative methods for setting maximum levels for food fortification and supplements.

·    Casala E. et al. (2014) Monitoring and Addressing Trends in Dietary Exposure to Micronutrients through Voluntarily Fortified Foods in the European Union. Trends in Food Science & Technology

37:152-161 – presents general limitations of the current food consumption surveys and food

composition databases. In addition, other approaches that could be used to monitor and evaluate trends in dietary exposure to micronutrients through voluntary food fortification are illustrated.

·    Mensink GBM   (2013) Mapping Low Intake of Micronutrients across Europe. British Journal of Nutrition 110:755-773 -- presents the prevalence of low micronutrient intakes in different European countries by comparing recent nationally representative dietary intake survey data.

A new project being managed, entitled “Contribution of Dietary Supplements, Nutrient Dense Food and Food Fortification to the Micronutrient Intake and Status of the Elderly”, is beginning through ILSI Europe. The main objective of this new project is to generate data that support the optimization of dietary guidelines specific for (healthy) elderly individuals. Initial data will be presented in September

2015 and a paper submitted for publication in early 2015.

ILSI North America has also sponsored studies related to the contribution of fortified foods to nutritional status for the US population.

·    Fulgoni VL, et al. (2011) Foods, Fortificants, and Supplements: Where Do Americans Get Their

Nutrients.  Journal of Nutrition 141 (10):1847-1854.

·    Berner LA, et al. (2014) Fortified Foods Are Major Contributors to Nutrient Intakes in Diets of US Children and Adolescents. Journal of the Academy of Nutrition and Dietetics 114:1009-1022.

·    Murphy MM, et al. (2013) Revising the Daily Value May Effect Food Fortification and in Turn

Nutrient Intake Adequacy. Journal of Nutrition 143(12):199-2006.

3.1.2 Sustainable healthy diets –The CIMSANS Sustainable Nutrition Security working paper and proposed assessment methodology noted above (Acharya et al. 2014) is intended to 1) improve the understanding of the food system in order to 2) better understand key variables and the impact of modifications so that 3) the system moves closer to sustainable healthy diets on a global scale. Related to the priority actions outlined in this section, policy and practice modifications can be supported by improved understanding of the food system and the impact of potential changes. The methodology described in Acharya et al. 2014 offers a science-based approach.

Thank you for the opportunity to share this information with you. Sincerely,

Suzanne S. Harris, Ph.D. Executive Director

Attached are two articles (1/2) for consideration regarding three recommendations in the ICN2 Framework for Action-zero Draft to Implement the Rome Declaration on Nutrition. The specific recommendation pertaining to nutrient profiling/nutrient-rich foods cannot be supported because of the research gaps that still exist before there can be a consensus on how best to define nutrient density. The recommendation to “create fiscal incentives and disincentives to encourage healthy diets” opens the discussion on food taxes which cannot be supported because of potential unintended consequences. However, the references made to “nutritionally appropriate diets, without singling out any specific type of food as unhealthy” can be supported because the value of a food should be determined within the context of the total diet.

Sincerely,

Theresa A. Nicklas DrPH

Professor

Children’s Nutrition Research Center

Baylor College of Medicine

Department of Pediatrics

Houston, Texas

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

Concern welcomes the opportunity to comment on the Framework for Action (FFA). A tremendous amount of work and consideration has gone into the draft and its focus on malnutrition in all its forms and its comprehensive nature is to be commended. We welcome the balanced consideration between the food, health and care environment dimensions that are crucial to addressing the underlying determinants of malnutrition.

·    Do you have any comments on chapter 1-2?

1.2 Framework for Action

Ensure nutrition security and the eradication of malnutrition will require collective and aligned efforts by all stakeholders, with all having their respective roles to play. As such, we recommend that the second paragraph be expanded to read as follows: ‘… led by the UN General Assembly and taken forward by Member States in partnership and collaboration with all stakeholders’.

2.2 Better governance for nutrition

Coherent government endorsed policies with explicit targets and situation-specific strategies

The reference and focus on nutrition justice is most welcomed. To establish the requisite policies and  incentivize  actions to  address  the  causes  and underlying determinants  of malnutrition will require commitment and ownership of all stakeholders. While it is encouraging that reference is made to the development of strategies through regular consultations among all implementing partners, this language could be stronger. It should go beyond regular consultation – strategies should be developed in collaboration with and among all implementing partners. Participation of civil society as well as participation of communities and those most affected, is vital to the formulation of policies that are locally appropriate and socially inclusive.

Institutional arrangements that encourage effective multi-sectoral working

Increased collaboration including joint planning, implementation and monitoring among ministries will be crucial for realising synergies and sustainable impact on nutrition outcomes. What gets measured gets done – the FFA should emphasis the need for explicit nutrition objectives and indicators to be adopted for all key ministries that have an impact on nutritional status.

The involvement of the private sector also should come out more and their responsibility and ability to influence e.g. the consumption of sugary drinks on the negative side and fortification on the positive side.

2.3 Financing for improved nutrition outcomes

Priority action for financing for improved nutrition outcome

The creation of a central, public, and updated database within each national government that can account for all off-budget allocations to nutrition i.e. from civil society, private sector, donors, should also be considered.

·    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)?

3.1 Food Systems

-      We welcome the clear emphasis on the critical role women play in nutrition, as well as the implication and importance of raising women’s income.  It would also be important to stress the need for equal access and control over other productive assets/resources (i.e., land, agricultural inputs, and agricultural services).Improving women’s land and property rights also help improve food and nutrition security.

-      Men also have an important role to play in improving nutrition. As such the FFA should recognise the role of men in decision making and need to raise their awareness about nutrition.

-      The private sector, like other stakeholders, has a role to play in food and nutrition security.

We welcome the emphasis on appropriate regulation and the subsequent reference to the Code  of  Marketing  of  Breast  milk  substitutes.  The  SUN  movement  has  developed  a Reference Document on Preventing and Managing Conflicts of Interest which is currently being piloted. It contains a number of key principles that should govern engagement in the movement. While focused on the SUN, it could also provide a useful reference, and guide action on engagement of the private sector, and all actors, during roll out and implementation of the FFA.

-      One of the priority actions outlined is to ‘support extension services to support dietary diversity in collaboration with researchers, small scale farmers and local communities’.  We would propose that this be expanded, or an additional priority action be added, to include improving coordination and collaboration between agricultural extension workers/services and Community Health Volunteers/health services. This point could alternatively be added under 3.3 on Health.

-      There is little focus on actual fresh foods, with language more focused on processing, etc. We recommend this be amended. Similarly, there is a strong focus on plant foods and less on animal source foods, which, however, play an important part in fulfilling micronutrient requirements. Affordable ways to produce, access, and ultimately consume animal source foods by all household members in an equitable way, should be emphasized.

-      While the 1,000 days features in other parts, it would be important to also consider this within food systems in relation to targeting. The highly prioritized school-related activities (near top of the list) might need to be slightly deprioritized.

-      In terms of food environments, focus should not only be on nutrient related considerations stemming from the NCD Action Plan and rather be widened to include fertilizer or pesticide residues, preservatives with harmful side-effects, etc.

-      Capacity  within  the  Government  system  needs  to  be  considered,  ensuring  adequate nutrition staffing within the Ministry of Agriculture, at national/ provincial/ district levels, who are nutrition experts.

3.3 Health

-      Stunting:  ‘Stunting  begins  in  utero,  and  it  results  from  a  complex  web  of  individual, household, environmental,…’ It would be good to add ‘individual’ given the mother’s physiological/ nutrition status also plays a role and that is not necessarily well described by a household’s situation. In addition, increasing attention is drawn to also ensuring optimal nutrition status among adolescent girls (who are likely to get pregnant at some point in the future) and programmatic focus on that is likely to increase further over the course of the FFA. The priority actions should be adjust to span across pre-pregnancy, pregnancy, lactation and early life of the child.

-      The monitoring of stunting as a priority action is very much welcomed. This will require further health capacities, equipment and motivation to ask the mother to visit the health facility beyond the usual period when immunization is being administered. Flexible systems will need to be designed for that, which allow detection of length growth faltering at the same time. This action should not be a standalone one but requires tailored and one-on one counselling, an aspect currently missing.

-      Anaemia: we recommend to mention micronutrient powders/ home fortification so that the door  is  at  least  open  for  that.  We  assume  this  is  not  considered  as  ‘fortification’  or ‘supplementation’ and meant to be included among those. Establishing such a system might have additional benefits for similar systems for children, beyond the current focus on maternal anaemia.

Section 3.3.1 delivery of effective nutrition interventions

-      The priority actions under this section only refer to three focus areas of the WHA Nutrition targets and should approach this more holistically. For example control of all major micronutrient  deficiencies  and  for  women,  children  (and  men)  instead  of  focusing  on anaemia in women of reproductive age.

Section 3.3.2 Delivery of health interventions with an impact on nutrition

-      It would be good to recognize the currently discussed important issue of environmental enteropathy, which might also require health systems to react. The trials that are currently on-going will be concluded at the early stages of the period this FFA will cover. A provisional priority action, pending the outcome of the trials, should be included.

Section 3.3.4 Nutrition education for behaviour change

-      It would be good to change the language from a very ‘message’/‘education’ dominated focus towards an approach that promotes optimal behaviours through behaviour change. There is wide-spread acceptance now that ‘educating’ people by giving them ‘information’ does not work, and that more tailored approaches are required to enable an individual/ household/community to change their behaviours. The work of non-governmental organisations as well as large scale research projects on infant and young child feeding provide  ample  examples  for  this,  which  have  the  potential  to  influence  national  level delivery approaches. A mere focus on nutrition education and information campaigns would be a too ineffective approach to change maternal, infant and young child nutrition behaviours.

Overall section 3.3 Health: It would be good to revise the structure of the sub-sections of 3.3. They vary from very broad (e.g. 3.3.2, 3.3.5) to very specific (e.g. 3.3.6 (where addressing AMR seems to be a key concern) or 3.3.3 – and how is breastfeeding on a same level of importance as AMR), from addressing  symptoms/special  forms  of  malnutrition  (3.3.1),  to  approaches  to  promote  good nutrition (3.3.4).

·    Do you have any comments on chapter 4-5?

4. Accountability Mechanisms

-      The FFA proposes the production of a biannual report as well as international meetings to help guide interventions. Following the Nutrition for Growth event in London in June 2013 it was agreed that a Global Nutrition Report (GNR) would be produced annually. This report is intended to be comprehensive, capturing overall progress and trends on nutrition, progress against the WHA 2012 nutrition targets and in SUN countries, monitor commitments made by all stakeholders, as well as analyse data and propose recommendations. In a number of respects,  the  GNR  has  the  potential  to  be  the  global  monitoring  and  accountability framework for nutrition. The FFA should clearly lay out how its reporting approach will align with existing processes such as the GNR and seek to minimise the reporting requirements of states and other stakeholders so as not to over burden those who have a responsibility to account for nutrition impacts and outcomes.

-      There is a clear need for additional resources for nutrition, with the 2013 Lancet Series on Maternal and Child Nutrition estimating a funding gap of $9.6 billion. As such, we welcome the idea of a global trust fund to mobilise resources. We would suggest considering a feasibility study for such a global fund, and potential for integrating such a fund within an existing mechanism such as GAFSP. RESULTS UK current research exploring the optimal aid architecture could be useful in this regard.

4.1 Responsibilities for Action

There are now over 53 countries that have agreed to scale up nutrition interventions and have joined the SUN movement. These countries are already working on establishing multistakeholder platforms, appointing Country Focal Points, developing or updating nutrition plans and costing same, and updating sector strategies/policies.  In addition, at the Nutrition for Growth summit June 2013, a Global Nutrition for Growth Compact was endorsed by a total of 94 stakeholders, including 26 Governments addressing undernutrition. Fifteen Governments committed to increase the domestic resources for scaling up nutrition, and 12 Governments announced national stunting-reduction targets. The FFA should draw on and reflect these existing processes rather than creating a parallel process and mechanism.

5. Recommendations for follow up

We welcome the suggestion of periodic reports on overall follow up to ICN2 and would suggest that this in fact goes beyond this to consider hosting follow up ICN meetings and reviews in 5 to 10 years.

It would be useful to clarify how the Intergovernmental Panel on Nutrition could/should link with the Stakeholder group of the Global Nutrition Report, and the work that the Independent Expert Group that that group is overseeing.

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

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

We welcome the commitment to a Decade of Action on Nutrition. The FFA however fails to provide additional clarity on what this would entail and what it could look like and include. Key priorities that should be considered under such a Decade of Action include i) ensuring that nutrition prominently and adequately features in the Post-2015 framework, through a dedicated goal as well as integrated within other relevant goals as targets and indicators, ii) ensuring sustained political will and action on nutrition through support for local and global campaigns, and iii) the potential hosting of an ICN3 and regular reviews of ICN2 outcomes.

4.   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?

More practical actions and emphasis could have been placed on WASH as well as obesity; we therefore  recommend  that  the  FFA  goes  beyond  focusing  on  food  systems  and  address  other complex and important issues such as these.

With over 60 ‘priority actions’ throughout the FFA, some guidance and clarification should be provided on which should actually be prioritised, as well as by whom, considering the different roles and responsibilities of different actors. Being clearer as to timelines and responsibilities around priorities will help ensure effective implementation.

While there is reference to the WHA 2025 targets and a Decade of Action it will be imperative that the momentum and ambition is sustained through 2030, aligning with and helping support and feed into the transformational change being sought through the Post-2015 framework. Much more emphasis is needed in the FFA on Post-2015, and particularly on the need for nutrition to be prioritised within the new framework, with a stand-alone goal and inclusion of ambitious targets to address all forms of malnutrition by 2030.

Submission by the Ecumenical Advocacy Alliance

Based on our long experience working with food- and nutrition-insecure communities around the world, and with our governments at national and international levels, EAA welcome this opportunity to submit the following points for consideration to the Framework for Action (FFA) document.

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

Since the FFA is to be guided by the Rome Declaration on Nutrition, and to offer guidelines on how to implement the Rome Declaration on Nutrition, then it would be ideal if a final version of the declaration be made available in a timely manner.

Regarding the priority actions, while it is important that they are relatively imprecise to allow governments to tailor them to their specific context, they cannot be so vague that they fail to mention which actors should carry out the action and by when. Governments should be firmly in the driving seat of policy setting.

The FFA should also specify the role of civil society in the implementation of these actions.

For systematic reasons and to keep the text legible, goals should not be mentioned in the introduction. Instead they should appear in the respective chapters of the FFA, their source indicated in a footnote.

Specific text recommendations are attached as an Annex.

•             Do you have any comments on chapter 1-2?

Section 1.1 can be significantly shortened or deleted as we would imagine that most of this material will be covered in the Rome Declaration on Nutrition and/or is repeated again later in the text.

Section 1.2: While it is useful to include, at the top of page 3, a brief summary of the commitments from the 65th World Health Assembly, as was done in the following paragraph dealing with the commitments from the 66th World Health Assembly, we suggest the following shortened formulation without bullet points. “This FFA aligns…. by the year 2025, in particular to halt increase in childhood overweight and to increase exclusive breastfeeding rates in the first six months up to at least 50%.”

Section 2.1 lacks substantial content.

Section 2.2: Please define the term ‘nutrition justice’ and eliminate redundancies.

The element ‘Engage implementation partners’ mentions the need for trust and mutual accountability but it is not clear about who needs to be accountable to whom. According to some, mutual accountability is “to act so all stakeholders feel responsible for and are held collectively accountable to the joint commitments" but this is not feasible in multi-stakeholder processes when actors have diverse set of interests. Do not assign roles to governments that are not compatible with democratic processes.

The element “International support for national nutrition governance” should be merged with "Institutional arrangements that encourage multi-sector working" to avoid duplication.

EAA welcomes the emphasis on monitoring and evaluation but it would also be important to clearly state the need for greater availability of baseline information.

Section 2.3: This issue is about human development and health and not the economy. The paragraph "more money for nutrition" should explain in which ways signatories should mobilize more money for nutrition and not how to make money with nutrition.

“Priority actions for financing for improved nutrition outcomes” should be more concrete. For example, what kind of taxes could be suitable? Taxes on high processed food and other products that are inconsistent with a healthy diet?  What innovative financing tools are being referred to? Access to credits (possibly microcredits), subsidies and other economic incentives for activities promoting nutrition should be mentioned. Subsidies that promote production of highly processed food with low nutritional value should be eliminated. The financial actions remain too vague. Existing systems of agricultural subsidies have to be reviewed in order to take.

•             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)?

The structure of the text is not systematic. Paragraph 3.1.2. should be merged with the first part of food systems (3.1), the paragraph food environment would be a separate paragraph (3.2), social protection (3.3).

While we agree that all these elements are important components to achieve nutrition security, we do not believe they all need to be listed in this section. For example, WHO dietary recommendations and the need to increase consumer awareness should not fall under the subtitle of Food Systems.

The paragraph "food systems" is too long and should not go into detail for consumption and diet recommendations.

The dimension of agricultural production is not sufficiently considered in the Priority Actions. The importance of reinvestment in agriculture and rural development, as well as progress towards sustainable modes of agricultural production for food security and nutrition, is neglected. Agroecological farming and the need of support for small-holder farmers (who are most affected by malnutrition by strengthening local and national markets and establishing cooperatives and other producer organizations) is not addressed.

3.1.1. Priority actions to improve the food environment - Standards in public institutions and the workplace: Standards are not the only way for public institutions to impact the food environment. Public institutions (schools, kindergartens, hospitals, administration etc.) have a significant market power that has to be used in order to improve nutrition. Canteens and cafeterias in public institutions should provide healthy and diverse food and quotas and better prices for high quality and locally produced food should be guaranteed.

3.1 Recommend to add “Integrate early warning, early actions to monitor vulnerability of people in order to anticipate food and malnutrition crisis and to put in place adequate resources such as social protection schemes.”

3.1.2 Recommend to add “Integrate sustainability and climate change resilience into agricultural plans and strategies and encourage small holder farmers to practice agro-ecological farming approaches that reduce dependence of chemical inputs and increase biodiversity.”

3.2 Priority actions on social protection: As the first 1000 days are key for the improvement of nutrition, recommendations of actions have to be more concrete and ambitious. How do signatories want to tackle this problem? What support can be given in terms of access and information/education? Examples for well-targeted interventions would be helpful. What role can hospitals and health care systems play to give advice and support? How can nutrition during early childhood be improved?

3.3 The importance of nutrition for recovery and the immune system has to be highlighted in the “Priority actions for health systems” and the procurement of nutritious food in hospitals, nursing homes and other health care institutions has to be addressed.

3.3.1. This is where the WHO goals and recommendations for stunting and wasting belongs.

Stunting, wasting and anemia should be briefly explained (especially difference between stunting and wasting) before introducing required actions.

Priority actions to address stunting: It has to be stated clearly that stunting is best prevented by breastfeeding and nutritious food and that food fortification can only serve to abate the symptoms. Prevention should be clearly prioritized.

Priority actions to address anemia in women of reproductive age: Actions should not only address the symptoms but also the causes of anemia in women. The prevention aspect (especially the implementation of women’s rights, sexual and reproductive health as well as improvement of women’s access to nutritious food) has to be addressed.

3.3.2. The sub-section entitled “Reproductive health and family planning”

While the title can be perceived as being related to nutrition, the formulation mixes health focus with ideological language, i.e. “reproductive rights” that is not directly related to the topic at hand and that never has been formally recognized by all Member States. Such language risks a diversion of attention and could threaten the process of consensus that is being sought by this International Conference and subsequent process. Suggest that the first paragraph in this subsection be re-written as follows: “Access to sexual and reproductive health care, including family planning, is important for the health and nutrition of mothers and their babies, and can play an important role in breaking the intergenerational cycle of malnutrition.”

For the same reasons specified above, we suggest that the last sentence in the 2nd paragraph of this sub-section “A lack of access to sexual and reproductive rights …” be deleted.

For similar reasons, we suggest that the first sentence of the 2nd recommendation in this sub-section be deleted. Specific reason: the first recommendation already calls for access to sexual and reproductive health care, which includes family planning.

3.3.3. Priority actions on breastfeeding: Should be more concrete, even referring to ILO-standards.

Consider including “Transpose and implement into domestic legislation the International Code of Marketing of Breast-milk Substitutes and the WHO recommendations on the marketing of breast-milk substitutes and of foods and non-alcoholic beverages to children.”

3.3.4. Nutrition education for behavior change: The text is very comprehensive but does not contain any actions. Text should be summarized into a maximum of 2 paragraphs and actions extracted in bullet points.

EAA welcomes the emphasis on monitoring and evaluation.

3.3.5. Priority actions on water, sanitation and hygiene: Considering the importance of safe water, access to drinking water, adequate sanitation and hygiene to avoid infections, mal- and under-nutrition, this paragraph and the resulting actions are too general and don't live up to the challenges ahead.

3.3.6. Priority actions on antimicrobial resistance: Holistic view on food systems should be taken into account, especially the role of consumers. Consumer information and actions are key. Purely top-down approach to tackle the problem will not succeed. Labeling critical products is essential.

•             Do you have any comments on chapter 4-5?

4.4 International trade and investment: Trade and investment should either be treated precisely with concrete and binding actions (which is not likely to be agreed upon) or not appear as a distinctive paragraph.

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

Not able to answer since the final version of the Rome Declaration is not yet available.

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

Not able to answer since the final version of the Rome Declaration is not yet available.

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Background and Introduction

Inspired by Christian ethics and human rights principles, members and partners of the Ecumenical Advocacy Alliance (EAA) advocate for justice and dignity for all, and especially for the poorest and most marginalized who are typically overlooked in policy-making and implementation. Our international alliance represents tens of millions of Christians around the world who support smallholder farmers, whose production capacity is the foundation of food security in much of the developing world, but whose interests are routinely ignored in relevant policy and practice.

EAA together with our members and partners have been involved in the food and nutrition security discussions for more than a decade and will continue to follow developments within this context with high interest to ensure that global food security and the protection of basic human rights, including the right to food. We will strive to ensure that decisions taken during the ICN2 are consistent with what has been agreed within Committee on World Food Security.

General comments on the draft Framework for Action

The Draft document contains many balanced recommendations that should be shared and acted on by the international community, particularly in the post 2015 environment. There are a few recommendations that seem not to be based on evidence (that I will identify below). For these recommendations, there should be a note of caution until further evidence is available and most importantly, identification of a need for further research to provide evidence in support or against these recommendations.

1.      The following statement is extremely important as it reflects the nutritional ‘truth’ of the importance of diversity to prevent individual nutrient deficiencies and excesses. However, I would suggest adding the word ‘energy ‘ to the sentence

Current:

“Nutrition improvement requires the provision of balanced and diversified diets, meeting nutrient requirements of all age groups and all groups with special needs, avoiding excessive intakes of saturated fat, sugars and salt/sodium, and removing trans-fat”

Suggested Modification:

Nutrition improvement requires the provision of balanced and diversified diets, meeting nutrient requirements of all age groups and all groups with special needs, avoiding excessive intakes of energy, saturated fat, sugars and salt/sodium, and removing trans-fat.

2.      The following sentence is also very important, but is slightly too general in referring to processed foods. I would argue that many processed foods are highly nutritious and provide many of the essential nutrients needed for health.

Original:

“Food systems need to promote healthy dietary patterns by providing year-round access to safe and nutritious foods including fruits, and vegetables, pulses, wholegrains and animal source foods such as fish, while limiting the consumption of processed foods that negatively affect nutrition and health.”

Suggested Modification:

‘Food systems need to promote healthy dietary patterns by providing year-round access to safe and nutritious foods including fruits, and vegetables, pulses, wholegrains and animal source foods such as fish, limiting the consumption of specific processed foods lacking in essential nutrients, that may negatively affect nutrition and health.’

3.      In the section on Commitments, the word ‘reshape’ is used (see below). This word suggests that the current systems are broken and inadequare.  I would suggest that ‘improve’ or ‘strengthen’ would be a more appropriate word. I would also suggest that the word ‘innovation’ or ‘innovative’ be included in the sentence.

Original

“Commitments

b)  reshape food systems through coherent implementation of public policies and investment plans throughout food value chains to serve the health and nutrition needs of the growing world population by providing access to safe, nutritious and healthy foods in a sustainable and resilient way.”

Suggested Modification

b) Strengthened food systems through coherent implementation of public policies, [and] investment plans and innovation throughout food value chains to serve the health and nutrition needs of the growing world population by providing access to safe, nutritious and healthy foods in a sustainable and resilient way.”

4. In the statement below, I would suggest adding the a description of the target population

Original

“Framework for Action

Includes this statement:

Healthy diets contain a balanced and adequate combination of foods to ensure sufficient macronutrients (carbohydrates, fats and protein) and essential micronutrients (vitamins and minerals). Diverse diets that combine a variety of cereals, legumes, vegetables, fruits and animal-source foods will provide adequate nutrition for most people to meet their nutrient requirements, although supplements may be needed for certain populations, e.g., during humanitarian emergencies.

Suggested Modification

Healthy diets contain a balanced and adequate combination of foods to ensure sufficient macronutrients (carbohydrates, fats and protein) and essential micronutrients (vitamins and minerals). Diverse diets that combine a variety of cereals, legumes, vegetables, fruits and animal-source foods will provide adequate nutrition for most people to meet their nutrient requirements, although supplements may be needed for certain populations (infants and young children and women in the child bearing age) and during humanitarian emergencies.

4.      In the Framework for Action, the following is written:

In order to promote optimal health, WHO recommends that diets should ensure:

• Daily needs of energy, vitamins and minerals are met, but energy intake does not exceed them.
• Consumption of fruit and vegetables is over 500 g per day.
• Intake of saturated fat is less than 10% of total energy intake.
• Intake of trans fatty acids is kept to less than 2% of total fat intake.
• Intake of free sugars is less than 10% of total energy intake or, preferably, less than
5%.
• Intake of salt is less than 5 g per day.
• Adequate intake of animal source foods is guaranteed in children under five.

I believe it is critical for the credibility of the Frameword to be accepted that all of these recommendations be based on evidence, and where evidence is lacking, that the document specifically say so and recommend further research. For example, there are many populations where for religious, cultural or philosophical reasons, intake of animal source foods is not acceptable. I would argue that it is possible to design nutritionally adequate diets for those who do not eat animal source foods. Thus to say that animal source foods should be ‘guaranteed’ to promote optimal health, is not based on good evidence.

A second example is the recommendation on free sugars being less than 10% or preferably less than 5%. I do not believe there is good evidence that if this recommendation is achieved that it would promote optimal health.

I may not have the expertise to comment on salt, but I wonder whether there is good evidence on the recommendation of 5 g/day.

I note that the following was included in the document:

“Dietary diversity is a key determinant of nutritional outcomes, but the consumption of nutrient-dense foods is very sensitive to income and price, especially for low-income consumers.

Strategies should aim to bring about a number of specific changes in the diet, as set out in the Global NCD Action Plan:

• Reduce the level of salt/sodium added to prepared or processed food.
• Increase availability, affordability and consumption of fruit and vegetables.
• Reduce saturated fatty acids (SFA) in food and replace them with unsaturated fatty
acids.
• Replace trans fats with unsaturated fats.
• Reduce the content of free and added sugars in food and non-alcoholic beverages.
• Limit excess calorie intake, reduce portion size and energy density of foods.”

The language in the Global NCD Action Plan is quite different than the Framework for Action, in that it provides general guidance, rather than specific numbers. Given that there is not strong evidence for many of the specific numbers (as identified above), I would suggest following the Global NCH Action Plan language. For example, the Global NCH Action Plan says “reduce the level of salt/sodium..” rather than providing a specific number. It says, “reduce the content of free and added sugars..” rather than providing a specific number.

As an important general principle, recommendations in the the Frameword should be based on evidence where the evidence is available and should state when evidence is not available, in which case general statements (as was done by the Global NCD Action Plan)  would be preferable in my view.

Stanley Zlotkin CM, MD, PhD, FRCPC

Chief, Global Child Health

Senior Scientist, Research Institute

The Hospital for Sick Children

Departments of Paediatrics, Nutritional Sciences and Public Health

University of Toronto

Canada

Thank you for the opportunity to comment on the ICN2 Framework for Action zero draft.

We would like to share our comments in respect to question 1.

First, our principal comments relate to chapter 3.4 (International trade and investment).

·         While we do appreciate that the first paragraph reflects the complex and multifaceted relationship between trade and nutrition, we find that the second paragraph almost exclusively approaches the link with trade from the negative perspective, i.e. what trade should not do, without actually spelling out the positive aspects of what trade can do to improve nutrition. We are therefore suggesting some editorial changes to this effect, as well as some clarifications in relation to indirect references to WTO Agreements (eg. TRIPS, Agriculture, SPS, TBT):

[Please see the detailled changes proposed in the text in the attachment, Ed.]

Second, we would like to add a general comment on chapter 3.3.6 (Food safety and antimicrobial resistance).

·         This section has only a very brief paragraph regarding food safety and then gets into considerable detail about antimicrobial resistance (AMR). Although there is no doubt that AMR is a serious problem, in terms of the effects on global nutrition, there are much more serious food safety issues that should be flagged. Microbiological contamination, including e-coli, salmonella, and mycotoxins etc. pose much more serious health risks to malnourished people, and more needs to be done to assist governments to ensure uncontaminated food supplies. The Partnership for Aflatoxin Control in Africa (PACA) could be highlighted as an example - and many more initiatives of this kind are needed. The overwhelming focus on AMR gives the misleading impression that these other food safety issues are relatively unimportant.

Third, we have some comments regarding chapter 3.1 (Food systems).

·         Our comments relate to the paragraph on page 7:

Both traditional and modern supply chains offer risks and opportunities for achieving better nutrition. Traditional supply chains are the primary channel through which most low-income consumers purchase food. Enhancing the efficiency of traditional food value chains can enable better nutritional outcomes by improving the access of low-income consumers to safe, nutrient-rich foods, such as animal-sourced foods, legumes, certain vegetables and fruits.

·         By putting the word "certain" in front of vegetables, the impression is given that all animal-sources foods and legumes provide good nutrition versus only "certain" vegetables. I doubt this is the intention of the authors, who might either want to move the qualifier "certain" to before the list of food categories (… such as certain animal-sourced foods, legumes, vegetables and fruits), or delete it altogether. Nowhere else in the text are only "certain" vegetables recommended. We would also question the statement that most low-income consumers purchase food through traditional supply chains. While this may be true in most developing countries, it may not be the case in developed countries. In fact, it seems that one of the contributors to obesity among low-income consumers in developed countries is that they do not have easy access to traditional food supply chains.

These comments have been provided under the WTO Secretariat's own responsibility and are without prejudice to the positions of WTO members or to their rights and obligations under the WTO. These comments are non-exhaustive, and any absence of comments should not be construed as agreement with the concerned text.

3.3.6 Food safety and antimicrobial resistance

As a veterinarian I have a commitment to protect public health, animal health, food safety and ecosystem health.  It is clear that this draft also recognizes the need for a One Health approach to address this complex issue.  Balancing priorities outlined in other sections – such as increasing productivity and economic growth to improve nutrition outcomes, reducing net unit costs, increasing farmer’s incomes and lowering food prices – with the need to produce safe food while protecting public health, animal health and the ecosystem by using antimicrobials responsibly should be considered when making recommendations.

Meat is a nutrient rich component of the diet that provides an important source of iron and folic acid, along with other important nutrients.  Producing a safe and abundant supply of meat requires the ability to keep animals healthy.  To that end, I make the following specific comments on the draft priority actions found in Chapter 3.3.6:

·         Terminate non-therapeutic use of antimicrobials, such as the use of antimicrobials as growth promoters. 

I recommend that the language be consistent with the WHO Action Plan on Antimicrobial Resistance which addresses these concerns with the following point:  4.2. In the absence of a public health safety evaluation, terminate or rapidly phase out the use of antimicrobials for growth promotion if they are also used for treatment of humans.

 The rationale for this is that consistency between the two documents will minimize confusion.  In addition, the term non-therapeutic has different definitions from country to country, while the definition of growth promotion is more consistent.  Finally, there are certain antimicrobials, such as ionophores, that are only used in animal production and their use appears to have no potential negative effect on public health.

·         Restrict or eliminate the use in food-producing animals of antimicrobials identified as critically important in human medicine, especially the use of fluoroquinolones, and third-and fourth generation cephalosporins.

Since keeping animals healthy is an important part of safe food as well as an important animal welfare consideration I would recommend the following revision:  Restrict the use in food-producing animals of fluoroquinolones and third-and-fourth generation cepahalosporins to treatment of individual animals under the direction of a veterinarian who has given careful consideration to the use of these classes. 

The rationale is that this restriction will allow the treatment of individual sick animals identified by the veterinarian as appropriate for treatment with these compounds following careful consideration of other potential treatments.  It will prevent these compounds from being used to promote growth or other production purposes.  This will promote antimicrobial stewardship while also preserving public health, animal health and animal welfare.

The Institute of Food, Nutrition & Well-being at the University of Pretoria, South Africa, is grateful for the opportunity to submit our brief comments on the draft ICN2 Framework of Action to implement the Rome Declaration on Nutrition.

General comments (Chapter 3)

The "Background" (1.1, paragraph 1) and the "Framework for action "(1.2, p2 last paragraph and p3 second paragraph) clearly refer to NCDs. Furthermore, in the "Rome Declaration on Nutrition" (p 4, paragraph 13a) also reference is made to overweight in children. This, however, does not translate into Action (Chapter 3 of the Framework). We thus propose that childhood and adult obesity be included in 3.3 (Health) so as to address this public health concern worldwide, and in particular in societies in transition, for adults as well as children.

At 3.3.1 The priority actions to address anaemia in women of reproductive age should firstly include a food-based approach, before recommending supplements and fortification, e.g. increased consumption of small animal source foods in vulnerable groups could be a valuable and sustainable food-based approach to assist in combating anaemia.

At 3.3.4 Nutrition education is well covered, but economic incentives for having an abundance of affordable and healthy foods should be encouraged.