Through this email I would like to respond to the invitation to an open discussion on the draft ICN2 Framework for Action to implement the Rome Declaration on Nutrition.
1. Do you have any general comments on the draft Framework for Action?
In 2010 the 63rd WHA adopted the Birth Defects resolution “to redress the limited focus to date on preventing and managing birth defects, especially in low- and middle-income countries. ... The resolution calls on Member States to prevent birth defects wherever possible...”
http://www.who.int/maternal_child_adolescent/news_events/news/2010/17_5_10/en/
http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R17-en.pdf
The Framework for Action currently lacks any reference to the prevention of birth defects, such as neural tube defects. While their incidence may not be as high as non-communicable diseases such as obesity or diabetes, birth defects do contribute considerably to stillbirths, neonatal deaths and under-five mortality. Those born with Spina Bifida, one of the most severe neural tube defects, also have long-term healthcare needs.
· Do you have any comments on chapter 1-2
Adding the reduction of neural tube defects to the list of commitments in chapter 1 would seem in line with the WHO Birth Defects resolution. A nutritious diet, with foods that contain folates, and folic acid supplements are essential to lower the risk of neural tube defects such as Spina Bifida developing during the first weeks of pregnancy. Women of childbearing age need adequate folate/folic acid levels before becoming pregnant (the “1000 days” should start before conception).
Strategies should indeed address people’s dietary choices, and the context in which these choices are made (chapter 2, element 1). However, up until now public health campaigns to improve the uptake of folate rich foods and use of folic acid supplements seem to have a limited effect and only changes the choices of women of high(er) social economic status.
Fortification of (a) staple food(s) with folic acid reaches all women of childbearing age, yet this is not enough to reach adequate folate/folic acid levels. A nutritious diet and folic acid supplementation remains essential too. Strategies should reach all women of childbearing age, regardless of education or income.
Do you have any comments on chapter 3?
3.1 Food systems
In addition to the availability of highly processed foods of minimal nutritional value, they are often also the most affordable. This adds to the malnutrition due to micronutrient deficiencies. The fact that it also leads to obesity and diabets is another increased risk for neural tube defects such as Spina Bifida. The cooperation of the private sector is desperately needed to help change people’s dietary choices. As long as cheap “junk food” is easily available, it will remain a challenge to get people to buy healthier foods, such as fruits and (green) vegetables and meat. Even when there is income growth, it is not evident that this money will be spent on nutritious food products. “Popular nutrition education” might make a difference, but the risk remains that only women of high(er) social economic status will be reached. It remains important to take cultural differences into account and involve local authority figures and/or elderly family members to create change in people’s dietary choices.
The list of “Priority actions” only mentions “Encouraging bio-fortification”. It would seem logical to add “Encouraging food fortification”, which is far less controversial and is already being used in many countries to reduce micronutrient undernutrition.
In “Priority actions to address stunting” it says “Improve micronutrient intake through food fortification, including complementary foods, and use of supplements when and where needed”. As neural tube defects also begin “in utero”, fortification with folic acid and folic acid supplementation is of great importance. It would be excellent opportunity “to redress the limited focus to date on preventing birth defects” to include food fortification with folic acid to prevent neural tube defects.
3.2 Social Protection
Indeed “Special attention needs to be given to the ‘first 1000 days’ when vulnerability to nutritional deficiencies is greatest”. However, it needs to be made clear that these ‘first 1000 days’ start before conception, with regard to the prevention of neural tube defects (birth defects). Women of childbearing age need proper folate/folic acid levels before becoming pregnant.
3.3 Health
Health systems also have to deal with the long-term health needs of those born with a neural tube defect such as Spina Bifida. Again this is an opportunity to include the prevention of birth defects in the Framework for Action. Overweight, obesity and non-communicable diseases aren’t the only health consequences of malnutrition. Their incidence may be higher, and they may even increase the risk of birth defects, but malnutrition, and specifically folate/folic acid deficiency, by itself also contributes to a higher incidence of neural tube defects.
3.3.1 Delivery of effective nutrition interventions
On page 16 is the first and only mention of “improving maternal nutritional status before and during pregnancy”. This is an issue which deserves far greater attention in the Framework, more explicit then the referral to ‘the first 1000 days’, especially with regard to the prevention of neural tube defects. Especially when the website www.thousanddays.org refers to the 1000 days as “ the 1,000 days between a woman’s pregnancy and her child’s 2nd birthday”. It is essential for women of childbearing age to have adequate folate/folic acid levels before they conceive.
It should be included that folate/folic acid deficiencies increase the risk of “neonatal adversities”, similarly to Anaemia. Likewise, folate/folic acid deficiency should be added to “Priority actions to address anaemia in women of reproductive age”. The same actions will help reduce the risk of neural tube defects. (Again this would be in line with the WHO Birth Defects resolution and increase the focus on preventing birth defects.)
3.3.2 Delivery of health interventions with an impact on nutrition
Priority actions on reproductive health and family planning
“Enable services such as family planning to become more nutrition-sensitive” is a good start, but in low- and middle-income countries these type of services will possibly not exist or not be accessible to all. Yet it is of the utmost importance that women of childbearing age learn about the importance of a healthy diet and folic acid supplementation before becoming pregnant. “Pre-pregancy advice” by local authority figures and/or elderly family members could be more feasible.
3.3.4 Nutrition education for behaviour change
Governments, international organizations, the private sector and civil society are indeed all responsible for helping consumers make healthier decisions with regard to their diet. However, it will remain a challenge to “lead by example” when we allow the production, distribution and sale of “junk food”, which has little to no nutritional value.
The “social determinants of health” also determine people’s dietary choices. To change the “consumer’s choice” from cheap, highly processed foods to more nutritious but often more expensive food products will require more than nutrition education. The food industry, the “food system”, will need to be changed too.
With kind regards,
Renée Jopp
Renée Jopp - Information officer
International Federation for Spina Bifida and Hydrocephalus
Cellebroersstraat 16 - 1000 Brussels - Belgium
Ms. Renée Jopp