Forum global sur la sécurité alimentaire et la nutrition (Forum FSN)

Comments on the ICN2 zero draft political outcome document

WHO WESTERN PACIFIC REGION

The WHO Western Pacific Region welcomes the opportunity to provide comments in relation to the Second International Conference on Nutrition (ICN2) zero draft political outcome document.  We also reiterate our support for the Joint Working Group (JWG) and its work to develop a strong and relevant statement.

The document in its current form is not clear in its intention.  It does not successfully draw out all the drivers of good nutrition, nor adequately acknowledge the need for collective work or approaches.

• The document overemphasises the role of food systems but underplays the role of other drivers of good nutrition such as health, education and social welfare.

Overarching principles of good nutrition should be highlighted at the beginning of the document, so as to provide for a logical basis for commitments which appear later in the document. 

The document should also make early reference to the different sectors which must be engaged.

• The reference to different sectors in paragraph 12 needs to made earlier in the document.

The document should reference current WHO and FAO activities and commitments in the nutrition space (for example, the Global action plan for the prevention and control of NCDs 2013-2020) in a more strategic manner. 

• Where possible, language from existing commitments should be inserted to ensure the strength and relevancy of the document.

The commitments proposed in paragraph 21 do not sufficiently provide for actions in all relevant sectors.  Once again, there is a disproportionate focus on actions relating to food systems which affects the balance of the commitments statement.

The document should focus on promoting good nutrition - it is difficult to effectively address environmental sustainability in this forum.

The WHO Western Pacific Region looks forward to participating in the development of the document and will appreciate the opportunity to provide specific comments on further iterations of the draft as they become available.

1.      Do you have any general comments on the draft political declaration and its vision (paragraphs 1-3 of the zero draft)?  

I believe the vision is very much on target overall and the focus on different forms of malnutrition is exactly correct.  If anything, I would focus more on social disparities and on poverty. For example the last bullet from paragraph 2 could be brought further up and given more prominence. Many of the observed health outcomes - from under-nutrition to obesity – are linked directly to social and economic disparities, in both developed and developing countries.

Small comment on para 3 line 8.  Is the intent to say “processed foods containing sugars and fats, particularly saturated and trans-fats… etc”

Or is the intent to say “processed foods as well as sugars and fats, particularly saturated and trans-fats… etc.”

I am assuming it is the former, but the punctuation (comma) makes it ambiguous.

2.      Do you have any comments on the background and analysis provided in the political declaration (paragraphs 4-20 of the zero draft)?   

Paragraph 7.  “Halt the increase in the prevalence of overweight in children under 5”.

According to recently published data, obesity rates in the 2-5y age group in the US have gone down between 2004 and 2012.  Data from Europe seem to show “no obvious trend towards increasing prevalence” among infants and pre-school children (Cattaneo et al. 2010).   This could be very different in middle-income and low-income countries – one more reason to focus on their needs.

Paragraph 10.  Providing year-round access to safe, nutritious foods and balanced diets while avoiding food processing in general seems a bit contradictory.  After all, cheese is one way to have milk year-round.  That is how food processing developed in the first place and it does have a role in providing safe, affordable foods – year round.

Year-round access to fresh foods and fresh produce is not sustainable in many parts of the world, since it involves greenhouses, imports, air miles, refrigeration, cold storage, and of course waste. So there is a need for food processing – the good kind.    I would not dismiss it.

Paragraph 11.  One important concept is that agricultural production has sometimes been measured in terms of daily calories.  Nutrients need to be included as well.  That point is mentioned and reinforced in the following paragraph

Paragraph 14.  “Empowering the consumer to make healthy food choices” is a phrase that I associate with middle class supermarket shoppers in the US.  There are whole segments of society – globally - that have virtually no choice when it comes to foods, healthy or not  – how can this paragraph be refocused to better capture their needs?  What if there is no choice?

Paragraph 14.  Not all commercial messages promoting energy-dense but nutrient-poor foods are automatically “misleading”.  Often, such messages say that the empty calories are good tasting (true), cheap (true), and convenient (all true).  On the other hand, health and nutrition claims can be misleading.  For example, saying “this kale salad will give you sufficient energy for the whole day” – that is misleading.

I am not sure that the blanket statement that energy-dense nutrient-poor foods “induce addictions” is even correct.  Overconsumption by the poor can be readily explained in economic terms (low cost), with no need to invoke physiology.

Paragraph 17.  Hmm – isn’t this a sweeping condemnation of just about everybody?  Perhaps a bit strong.  I would argue for more health diplomacy.

Paragraph 20.  I like this.  I also think that there should be a mention that food and nutrition surveillance, indicators and metrics, are lacking when it comes to middle income and low income countries.  Perhaps there should be a mechanism for sharing resources, expertise, and data? And should such a mechanism involve public-private partnerships?

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:         

21.  Commitment I: aligning our food systems (systems for food production, storage and distribution) to people’s health needs;             

The agriculture and health industries often go their own ways, partly because people’s health needs and consumer preferences are not necessarily the same – in high income countries, health is a low ranking factor in food choice – well after taste, cost, convenience, and variety.  In lower income countries, hunger might take priority over health concerns.   So the real question is – how to achieve the agriculture – health convergence where people want to buy healthy foods?  Once that happens, food systems will follow.

Commitment II: making our food systems equitable, enabling all to access nutritious foods.               

This could be a good place to mention gender equity, poverty reduction and human right.

Commitment III: making our food systems provide safe and nutritious food in a sustainable and resilient way;      

Cannot argue with that. On the other hand, studies from the US and France show that the most nutrient-dense foods were not the most environmentally friendly, whereas foods associated with lowest greenhouse gas emissions were nutrient poor.  So nutrient density and environmental impact of foods may well be on collision course – what are we going to do about that?

Commitment IV: ensuring that nutritious food is accessible, affordable and acceptable through the coherent implementation of public policies throughout food value chains.  

 There is nothing wrong with wanting nutritious foods to be available, accessible, affordable, and acceptable.    However, some of the inherent contradictions need to be resolved – or at least fully addressed in an objective manner.  The problem that we face is this: grains, fats and sweets are good tasting, filling, available, accessible and inexpensive.  Many nutrient rich foods (not all, clearly) taste bad and cost more. What are food value chains going to do about that?

Commitment V: establishing governments’ leadership for shaping food systems.        

Just a caution here – in general, food systems are shaped by the private sector in response to consumer demand.  When governments take the lead in shaping food systems (e.g. through collectivization or central planning) it can turn out badly.  Besides, weren’t governments just slammed in Para 14 above?

Commitment VI: encouraging contributions from all actors in society;              

Yes – and here I would specifically mention the private sector that is involved in every phase of every food system mentioned above.  What is their role exactly in the Rome Accord??

Commitment VII: implementing a framework through which our progress with achieving the targets and implementing these commitments can be monitored, and through which we will be held accountable.        

Yes, a monitoring system will be good to have.

22. Commit to launch a Decade of Action on Nutrition guided by a Framework for Action and to report biennially on its implementation to FAO, WHO and ECOSOC.      

Yes, that is good also.

1.       Do you have any general comments on the draft political declaration and its vision (paragraphs 1-3 of the zero draft)?       

In my opinion the Zero Draft is rather comprehensive in including both sides of the malnutrition scale, and recognizes the co-existence of over- and undernutrition. This is especially significant seeing that the MDG’s was mostly related to undernutrition.

2.       Do you have any comments on the background and analysis provided in the political declaration (paragraphs 4-20 of the zero draft)?       

The recognition and emphasis on the importance of food quality in addition to quantity is well accentuated.

The recommendation of cross-cutting initiatives and collaboration between different sectors to enhance quality of food (produce more and increase availability of nutritious foods) (paragraphs 11 to 20), while improving the ability of people to acquire these foods (improved food security) (somewhat hidden in paragraph 13) highlights the importance of the whole food system, from agricultural activities to dietary guidelines.

Paragraph 10 – it could be valuable to specify industrially produced Trans Fatty Acids instead

Paragraph 10 – avoiding processing that reduces or adversely affects nutrition should not be taken out of context, and should refer to only those processing that negatively affects nutrition. Processing, i.e. fortification, freezing, drying etc. might in fact directly and indirectly improve nutrition.

Paragraph 14 – consider removal of the statement which can induce addictions and heighten risk of disease, as it does not add value to the statement and is questionable.

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;

This is a very powerful commitment – but it needs buy-in from various sectors who might not be sensitised to the importance and role of nutrition within their scope of work. A strong awareness component is required to inform i.e. agriculture on its role within nutrition, beyond food volumes, domestic production and GDP. Similarly health should also be aware and involved in nutrition, and not simply on the health-related consequences of malnutrition.

Commitment II: making our food systems equitable, enabling all to access nutritious foods.          

Access is a difficult aspect, as it relates not only to the physical availability of the nutritious food (through production or logistics), but also to the ability of people to afford or procure these foods. The food system also has a big role to play in job creation and improving food security through income generation.

Commitment III: making our food systems provide safe and nutritious food in a sustainable and resilient way;        

Sustainability is very high on the global agenda and it is important that it be included in the design.

Commitment IV: ensuring that nutritious food is accessible, affordable and acceptable through the coherent implementation of public policies throughout food value chains.          

Very ambitious, but predictable commitment

Commitment V: establishing governments’ leadership for shaping food systems.                

Very important – Adequate leadership is required

Commitment VI: encouraging contributions from all actors in society;               

It is pivotal to get all sectors in society involved, and high on the agenda should be creating awareness of the complexity and importance of nutrition within each sector.

Commitment VII: implementing a framework through which our progress with achieving the targets and implementing these commitments can be monitored, and through which we will be held accountable.

Although this is a very valuable commitment target, it is possibly the most difficult to attain as a baseline is required to measure progress.

22. Commit to launch a Decade of Action on Nutrition guided by a Framework for Action and to report biennially on its implementation to FAO, WHO and ECOSOC.

Agree

23. Commit to integrate the objectives and directions of the Ten Year Framework for Action into the post-2015 global development efforts.

Agree

I am sending below and enclosed compiled comments on behalf the UNSCN e-group on Nutrition and Climate Change.

1.      Do you have any general comments on the draft political declaration and its vision (paragraphs 1-3 of the zero draft)?  

The UNSCN working group on Nutrition and Climate Change welcomes the zero draft focus in all the forms of malnutrition and the recognition of the need to address current challenges in a multi-sectoral and sustainable way.

The ICN2 Rome accord needs to address all forms of malnutrition in a multi-sectoral way and to call for commitments for action related to the food, care and health considering that many of the observed health outcomes - from under-nutrition to obesity – are linked directly to social and economic disparities, in both developed and developing countries.

The current ICN2 zero draft political document focuses mostly on the need for improved nutrition sensitive food systems.  The document should focus on other key drivers of malnutrition related to care (e.g. maternal and child care, social protection, education etc), health (health access, water and sanitation , environmental health etc) poverty eradication and equity.  These drivers and other underlying drivers of malnutrition are affected by climate change which undermines current efforts to reduce undernutrition and the capacity to adapt.   

These drivers should be indentified in the section of "Multiple threats of malnutrition are a major challenge to global development" paragraphs 1-3 and then considered in the analysis and reflected in the commitments.

2.      Do you have any comments on the background and analysis provided in the political declaration (paragraphs 4-20 of the zero draft)?   

The document needs to address critical issues such as health, gender, equity, poverty reduction and human rights across the background, analysis and vision for global action to end all forms of malnutrition provided in the political declaration (paragraphs 4-20 of the zero draft).

The co-benefits to health, nutrition and environment of sustainable food production,  sustainable food consumption and food waste reduction should be outlined in the analysis and reflected in the commitments for action.

When reaffirming the need for improved governance for more effective concerted actions by various key stakeholders across sectors (para 18) it is necessary to stress the urgent need for policy coherence between the agriculture, health and climate agendas. 

The group supports and reinforce the need for accountability in relation para 19:  "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".  We  suggest to incorporate the rights angle taken by the UN Special Rapporteur on the right to food – see http://www.srfood.org/en/official-reports.  In his recent final report the rapporteur includes a sector-by-sector list of recommendations which addresses key issues to be considered in the "Rome accord".  The conclusions of his report stress the urgency of the matter and argue that “business as usual” will not do.

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)?

When committing for action the document needs to address critical drivers of malnutrition related to health systems and access, water and sanitation, environmental health,  maternal and child care and feeding practices, education, social protection, equity etc. (paragraph 21).

Making our food systems provide safe and nutritious food in a sustainable and resilient way is critical but complex and requires additional specific commitments for action to climate resilient and sustainable food systems including  sustainability aspects of dietary patterns . 

The issues addressed in two final paragraphs (22-23) are very relevant and the document will benefit from elaborating more on the Decade of Action on Nutrition and the inclusion of targets, accountability framework and mechanisms. 

To implement a framework through which accountability and progress with achieving the targets and implementing these commitments can be monitored, consideration should be given to the need mechanism for sharing resources, expertise, and data in middle income and low income countries that lack surveillance systems, indicators and metrics.

1.      Do you have any general comments on the draft political declaration and its vision (paragraphs 1-3 of the zero draft)?  

Given the synergies between neglected tropical diseases (specifically soil transmitted helminths (STH) and schistosomiasis) and malnutrition, we encourage inclusion of the following points under paragraph 2:

·         undernutrition is often aggravated, in a vicious cycle, by neglected tropical diseases, foodborne infections and ingestion of chemical contaminants due to unsafe food supplies;”

·         malnutrition is exacerbated by  neglected tropical diseases,  increasing the risk of stunting and vitamin A deficiency in children and exposing pregnant women to increased risk of anemia and low birth weight.

Supporting references for the insertion of the above text;

·         NTDs are significant causes of poor pregnancy outcomes resulting in low birth weight and high maternal mortality[i].

·         Several large scale studies have demonstrated that deworming and iron supplementation reduced anemia among pregnant women and have led to positive birth outcomes[ii].

·         Because of the interconnectedness of NTDs on MCH and nutritional deficiencies, co-morbidities lead to reduced maternal hemoglobin, birth weight, and child survival[iii].

·         Many of the NTDs, and especially hookworm and schistosomiasis, exacerbate anemia co-infection with malaria[iv],[v].

o   An estimated 7.5 million pregnant women (approximately one third) living in sub-Saharan Africa are infected with hookworm[vi].

o   Hemoglobin concentrations were found to be 4.2 grams per liter lower among children. harboring hookworm and malaria co-infections than in children with just hookworm[vii]. 

• NTDs, particularly STH and schistosomiasis, are important cofactors in causing and often leading to chronic malnutrition and hunger[viii] .  STH also suppress the appetite intensifying malnutrition[ix].
• Intestinal worms are a leading contributor to malnutrition among the nearly 200 million preschool children who are stunted[x].
• Studies in 31 STH endemic countries in the Americas showed that deworming can prevent 82% of stunting and that it is responsible for 35% of weight gain in malnourished children.[xi]

·         Vitamin A is critical to a child’s growth and development, but worm infections can deplete a child of vitamin A within as few as two years[xii]. 

2.      Do you have any comments on the background and analysis provided in the political declaration (paragraphs 4-20 of the zero draft)?   

After paragraph 5 which mentions healthcare, the Global Network recommends adding the following new paragraph;

6.  Recognize the impact neglected tropical diseases have on the nutritional status of populations, specifically children and pregnant women, and the value of integrating disease control and water and sanitation interventions to reduce malnutrition.  

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:         

21.

Commitment I: aligning our food systems (systems for food production, storage and distribution) to people’s health needs;    

No comment.

Commitment II: making our food systems equitable, enabling all to access nutritious foods.     

 No comment.

Commitment III: making our food systems provide safe and nutritious food in a sustainable and resilient way;              

 No comment.

Commitment IV: ensuring that nutritious food is accessible, affordable and acceptable through the coherent implementation of public policies throughout food value chains.            

 No comment.

The Global Network recommends adding a new commitment here, stating:

V. Ensuring food systems and nutrition efforts are not undermined by infectious diseases, in particular neglected tropical diseases contributing to women and children’s health.

Commitment V: establishing governments’ leadership for shaping food systems.          

No comment.

Commitment VI: encouraging contributions from all actors in society;              

 No comment.

Commitment VII: implementing a framework through which our progress with achieving the targets and implementing these commitments can be monitored, and through which we will be held accountable.             

 No comment.

22. Commit to launch a Decade of Action on Nutrition guided by a Framework for Action and to report biennially on its implementation to FAO, WHO and ECOSOC.     

 No comment.

23. Commit to integrate the objectives and directions of the Ten Year Framework for Action into the post-2015 global development efforts.   

 No comment.

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:         

21.

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

Thank you very much  for you invitation to this open  discussion.

I am a PhD student  from  Institute of Tropical Medicine and  Hygiene  and I have been  working  in malnutrition and environmental enteropathy in infants from São Tomé -Africa (STP). I  want to share two comments to the first question:

About  undernutrition,  despite of  the overall picture  has improved , there is still a high percentage of children in mild forms of undernutrition ( -2Priya Bhagowalia, in Economics and Human Biology 9 (2011) 66–77).

In a  previous study in preschool children from STP, the proportion of children  with mild forms was  almost twice over moderate and severe forms for underweight and  stunting. ( Abstract in: Special Issue: Abstracts of the8th European Congresso n Tropical Medicine and International Health. Tropical Medicine and International  Health. Volume 8 , Isusue supplemnet s1.  pages 1-250).

 onlinelibrary.wiley.com/doi/10.1111/tmi.2013.18.issue-s1/issuetoc.

For these reasons , I think that mild forms of undernutrition should be included as an important  part of the  picture, that deserve a careful approach.

Another comment  is  to consider  the "environmental enteropathy " into the vicious cycle of malnutrition, taking account that this pathology is the result of  poor environmental sanitation with ingestion of  water and food contaminated , multiple  enteric infections  which lead to inflammatory changes and  disarrangement of intestinal barrier and malabsorption. Thus, the sanitation authorities should be an important part of this framework.

Best regards,

Marisol Garzon.

PhD student

Instituto de Higiene e Medicina Tropical-Lisboa.(IHTM)

Dear sir/madam,

My Director General, Shenggen Fan (IFPRI), asked me to provide some comments on ICN2 zero draft political outcome document. I have only three comments. First, much mention is made of the commitments on nutrition made in 1992, but there are no obvious details of what those commitments were. Second, on item 7, there is discussion of exclusive breastfeeding as a goal, but not of appropriate complementary feeding. This is at least as important a constraint as breastfeeding, and relevant to food systems. Third, there is discussion of relevant sectors, such as health, education, agriculture, etc, but no mention of sanitation, water, family planning and other infrastructure. These sectors are potentially significant contributors and should not be excluded.

Best regards

Derek

Derek Headey, PhD

Research Fellow.

Poverty, Health & Nutrition Division

The International Food Policy Research Institute (IFPRI), Washington DC

202.627.4363; [email protected]

The monitoring and accountability framework should apply to all stakeholders. Civil society actors in particular have a recognised important role in monitoring and holding stakeholders to account.

22. Commit to launch a Decade of Action on Nutrition guided by a Framework for Action and to report biennially on its implementation to FAO, WHO and ECOSOC.

Agree, this is important.

23. Commit to integrate the objectives and directions of the Ten Year Framework for Action into the post-2015 global development efforts.

Agree, this is important. It should be further supported and enabled by the inclusion of a food and nutrition security goal, targets and indicators within the post-2015 development framework.

WHAT IS MISSING?  ATTENTION TO DETAILED EXPLICIT MECHANISMS GUIDES ACTION AND IMPLEMENTATION OF COMMITMENTS TOWARDS ACCOUNTABILITY

REPLY TO QUESTION 3  

References to paragraph 21, Commitment VII   ‘Monitoring and accountability’, action also under paragraphs 22. and 23.

The current draft political declaration fails to set out explicit mechanisms to correct the imbalance between indicators for economic growth and those that reveal progress in addressing childunder nutrition.  This imbalance operates at two levels.  Progress will not come about without better attention to accountability for childunder nutrition in ODA macroeconomic indicators.   Progress will not come about without elevating to national policy discourse indicators for child under nutrition and co-variates that reflect inequities at subnational levels. 

While MDG1 includes reducing child underweight, in policy fora, addressing chronic childunder nutrition   with structured cross-sectoral action still receives little attention. The OECD Paris Declaration remarkably failed   to   include stunting prevalence as an indicator with which to monitor progress.   International policy discourse is still fixed in tradition to consider material living standards  (head-count poverty ratios), not living standards jointly with reduction of (ill) health with intergenerational transmission of poverty (Ref. Angus Deaton, ‘‘The Great Escape: Health, Wealth, and the Origins of Inequality”, 2013).   Little surprise that the positive impact on future economic growth - by preventing impaired   early age human capabilities (-9-24 months) – receives little attention in dominant policy discourse also in   countries burdened with high stunting prevalence.  Progress will remain limited without political alignments to reduce divergence between nutrition status and economic goals.

At global level, OECD DAC indicators neglect to monitor progress in reducing prevalence of stunting. Priorities in ODA traditionally emphasize addressing material poverty relative to health (child under nutrition, stunting). This has meant neglect of the pathway for longer-term inclusive growth operating via reduced stunting prevalence associated; neurocognitive impairment raises risk of intergenerational transmission of poverty. 

Priorities in development aid promoted by the World Bank and OECD countries remain driven by focus on monetary poverty.   These priorities influence those of national development plans; they thwart public discourse for a broader agenda.   Across powerful Ministries of Finance this is associated with less attention to address child under nutrition, and co-variates, to less attention to  cross-sectoral action supported by diagnosis of determinants.

At national level, district level indicators for under nutrition and determinants are either scarce or missing.   Goals other than improved nutrition that  are pursued by strong economic and political interests in the agricultural sector, the postharvest value  chain, and extractive industry  may  adversely impact livelihoods. Economic agents in food systems aim to make money subject to reasonable levels of risk; governments pursue policies that are compatible with the interests of politically powerful stakeholder groups.   “Malnourished populations are rarely among these interests” (Pinstrup –Andersen, The Lancet 2013) 

Can political momentum be created to foster policy interventions to “remedy problems that could have been avoided”?

Nutrition indicators, that may include food diversity - routinely collected at district level - is a necessary, while not sufficient condition, to raise accountability for negative outcomes of missing food and health system policy interventions. When  food-system policies and the private sector promote inexpensive calories and expensive nutrients, results extend beyond inferior nutrition and adverse population health.  The current discussion in India about dominance of starch based diets over pulses, neglected in food support policies, is one reminder. There is so far little attention to that  burden  to respond shift  to underfunded Ministries of health and social protection agencies; by default they seek to provide  a costly  range of interventions that include food and micronutrient supplementation:   to “remedy problems that could have been avoided”.  

A shift, long overdue, is use of frequent district level indicators for nutrition status, by wealth quintile, for nutritional status in high burden countries. Relevant    co-variates to explore in local context include sectoral determinants for rising  stunting and rising mortality trend, up to age five, after weaning from exclusive breastfeeding.   Most sectoral development programmes continue being funded ‘semi-automatically’, supported by scarce evaluations with uncertain or little impact on policy. The uncertain external validity of RCTs reflects the bewildering extent of   unrecognized information disconnects at subnational level. Heavy reliance on RCTs as the only pathway to scaling-up is a barrier with  opportunity costs. Health and nutrition effects resulting from agricultural and other foodsystem policies and programmes are difficult to assess with RCTs; treatments cannot be randomized and the effect pathways are long. “Yet, the most promising opportunities for improvement of health and nutrition are undoubtedly found in such policies, and not in home gardens and other minor projects which are amenable to study within the framework  of  randomised trials” (Per Pinstrup-Andersen, Lancet, 2013).

Focus on plausibility pathways for nutrition improvements  in food systems, with district data, in combination with human rights orientation, need more prominence in scaling-up for more than one reason.     This means building capacity at district level in high burden regions for monitoring trends, establish covariates and plausible determinants and barriers (compare with proposal Victora et al., for ‘District Evaluation Panels’, Lancet 2010 -2011 and comments (Eklund)).  This information is rarely available. If   available it is not well disseminated, and   explained to civil society, local populations and women groups! With more resources,   rigorous evaluations with attention to counterfactual may follow to explore   determinants, particularly when/where   outliers emerge in these trends.

Such institutional capacity development   has potential   of vast improvement over dominant economic growth agendas.  The latter reflect power asymmetry combined with ignorance in policy discourse about regional inequities, co-variates   and determinants. Triangulation of anthropometry with qualitative data sources and information, e.g. re undersupply of local public goods for hygiene, sanitation, and eventual discrimination in services, raise precision in identifying determinants reorienting cross-sectoral interventions.

Information feed back from the field to media, to national policy makers and voters, may educate the public about mutual benefits between growth and development (reference Jean Dreze and Amartya Sen, 2013).   Such information, when impacting political processes, raises   probability of   more balanced development priorities, incorporating child stunting,  an indicator of adverse prospects for future inclusive growth.  

Per A. Eklund

Fr. Sr. Evaluation Officer, IFAD