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«Jomo Kwame Sundaram Vikas Rawal Michael T. Clark Tulika Books Published by Food and Agriculture Organization of the United Nations (FAO) Viale delle ...»

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world leaders engaged in all aspects of nutrition work. Statements and declarations issued by individuals and groups at the plenary sessions, round tables, side events as well as at the four pre-conference events – the ScalingUp Nutrition (SUN) Movement Global Gathering, as well as gatherings for parliamentarians, civil society and the private sector – further enriched the conference deliberations.

Some specific debts must be acknowledged. The entire ICN2 process could not have taken place without the crucial support of the DirectorGeneral of FAO, Jose Graziano da Silva, his counterpart Margaret Chan, Director-General of WHO, Oleg Chestnov, Jomo’s WHO counterpart, as well as Fernanda Guerrieri, then FAO Directeur de Cabinet, and Coumba Sow from her office. Anna Lartey, FAO’s Director of Nutrition, and Francesco Branca, her counterpart at WHO, have been patient, generous, and reliable guides through the demanding intellectual, technical, policy, and political journey to build global consensus on nutrition issues. Vital insight was offered at critical moments by Per Pinstrup-Anderson, David Nabarro, Flavio Valente, and others who helped set both the scope and tone for ICN2, and thereby influenced important judgments presented in this book. Virtually the entire FAO Nutrition Division, including Brian Thompson, Ali Mekouar, and Leslie Amoroso, made important contributions to the ICN2 process and outcomes, and thus to the views expressed herein. Dan Gustafson, Anna Lartey, and Dipa Sinha offered important comments, while Terri Raney, Andre Croppenstedt, and the SOFA editorial team who produced SOFA 2013 provided an important foundation for the perspective offered here.

The authors wish to express their thanks to FAO’s Nutrition Division, and it’s Director, Anna Lartey, for their strong support in all aspects of the preparation of this book. The production of this book benefited from the institutional support of FAO’s Office of Corporate Communications, especially Jessica Mathewson, and the Society for Social and Economic Research in Delhi, and from the work of research assistants Mampi Bose, Bhawna Mangla, and Vaishali Bansal. Shad Naved’s careful copy-editing of the manuscript is gratefully acknowledged. In addition, for all the statistical work and writing, the authors relied on R (www.r-project.org), org (www.orgmode.org), and LTEX. All three are open source projects, freely A made available by very vibrant communities of developers. During the course of the work, we often drew on support from these communities.

Finally, special thanks are owed to Tulika Books, and in particular, Indu Chandrasekhar, for approaching the publication in a spirit of true partnership that we hope will make the work accessible to a wider audience than would normally be the case.

While wishing to recognize the many sources of evidence and insight, criticism and encouragement that we have received in the preparation of this work, the authors take sole responsibility for the views expressed.

Uneven Progress in Reducing Hunger and Malnutrition At the First International Conference on Nutrition in 1992, world leaders made clear in the World Declaration on Nutrition that, “Hunger and malnutrition are unacceptable in a world that has both the knowledge and resources to end this form of catastrophe.” Over two decades later, the world continues to face several nutrition-related challenges.

In November 2014, the Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) co-organized the Second International Conference on Nutrition (ICN2), which brought together international organizations, national policy makers, practitioners and experts, to lay out a road map for coordinated action to ensure that no one in the world is left hungry and suffering from malnutrition.

How serious is the problem of malnutrition? Which regions face the various forms of malnutrition the most? Who are the most affected and vulnerable? What are the implications of malnutrition for the malnourished and for the world at large? What are the pros and cons of different policy instruments available to tackle malnutrition? What is the role of food systems in the strategy to end malnutrition? How useful are other means to provide nutrients? What are the means to improve absorption of nutrients?

These are some of the questions addressed in this book. It is argued here that ending malnutrition in all its forms – caloric undernourishment, micronutrient deficiencies, and diet-related non-communicable diseases often associated with obesity – requires a combination of appropriate interventions in food systems, public health, provision of safe water and sanitation, education, and social protection to guarantee the availability of and access to diverse diets; to reduce the susceptibility to disease; to improve the absorption of nutrients; and to increase consumer awareness of the importance of good nutrition. With widespread deprivation, un


2 Ending Malnutrition

employment, underemployment, growing inequalities as well as a slow and skewed economic recovery, a basic universal social protection floor will be crucial to guarantee access to nutritious food. While the use of nutritional supplements may be important in the short run, and in dealing with nutritional deficiencies faced by pregnant women and young children, in the medium and long term, a sustainable reduction in malnutrition requires a balanced diet. Access to safe water, improved sanitation, hygienic living conditions and basic health care are crucial for better retention and absorption of nutrients consumed by people. Sustained commitment to filling large gaps in these areas is imperative for dealing with malnutrition.

The ICN2 adopted two outcome documents: the Rome Declaration on Nutrition (Appendix A) and the ICN2 Framework for Action (Appendix B). The Rome Declaration on Nutrition, signed by representatives of over 170 countries that participated in the ICN2, gave a call for global action to end all forms of malnutrition. It identified focus areas for coordinated action. The ICN2 Framework for Action provides crucial policy guidance for governments to work towards meeting these objectives.

Hunger and malnutrition in the world today The latest Food and Agriculture Organization estimate of the Prevalence of Undernourishment shows that, despite abundant food supplies and considerable progress in reducing hunger in some regions, more than 795 million people had chronically inadequate levels of dietary energy intake during 2014–16 (FAO, 2015).

“Hidden hunger”, or micronutrient deficiencies, is much more widespread than hunger, which only refers to inadequate dietary energy intake. Although there is a paucity of regular and time-series data on micronutrient deficiencies, there is no doubt that the number of people who suffer one or more forms of micronutrient deficiency is staggering and much more than the number of people who chronically experience inadequate dietary energy.¹ According to the latest data available from the World Health Organization’s Vitamin and Mineral Nutrition Information System, about 1.6 billion people globally are anaemic.² Iron deficiency, the primary cause of anaemia, is only one micronutrient among many – vitamin A, zinc, and iodine, to name a few – missing from or insufficiently included in the diets of many around the world. According to data from the WHO’s Global

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Database on Iodine Deficiency, in 2003, about 2 billion people of all ages and about 285 million school-age children globally suffered from iodine deficiency (De Benoist et al., 2004). Estimates for 1995–2005 show that 190 million pre-school children and 19.1 million pregnant women globally had vitamin A deficiency, while about 5.2 million pre-school children and

9.8 million pregnant women consequently suffered night blindness (WHO, 2009). Meanwhile, more than 1.5 billion people are overweight with half a billion obese, exposing them to greater risk of cardiovascular problems and other diet-related, non-communicable diseases.

Reducing caloric undernourishment At the 1996 World Food Summit (WFS), heads of government and the world community committed to halving the number of hungry people in the world recorded in 1990 by 2015. Five years later, the Millennium Development Goals (MDGs) lowered the target to reducing the proportion of hungry people in the world by half. Considerable efforts have been made in many countries to reach these targets. Twenty-nine developing countries have made impressive progress, achieving the more ambitious WFS target, while 72 developing countries have achieved the MDG target of halving the proportion of hungry people (FAO, 2015).

Undernourishment is conventionally measured in terms of adequacy of energy in the diet. FAO’s Prevalence of Undernourishment (PoU) is an internationally comparable, statistically validated, and widely accepted measure of the chronic inadequacy of dietary energy. Given serious data limitations, a methodologically consistent estimate of the prevalence of hunger can only be made for a relatively low benchmark of dietary energy requirement. The estimates of the number of hungry people in the world are also probably compromised by data and methodological limitations.³ Globally, the estimate of the proportion of people unable to consume minimum levels of dietary energy fell from 18.6 percent in 1990–92 to 10.9 percent in 2014–16. Over the same period, the proportion in developing countries fell from 23.3 percent to 12.9 percent (Table 1.1). While this is significant progress, it falls short – by 116 million persons – of meeting ³ While the PoU is crucial for estimating hunger, it needs to be complemented by other measures to capture the complexity of food security in its multiple dimensions as this headline number for world hunger only tells part of the story of undernutrition. For this reason, FAO has developed a suite of indicators to measure different dimensions of food security, including availability, access to, stability, and utilization (nutrition). Information thus generated can shed light on specific problems to be addressed, and point the way to appropriate policy actions. FAO has also developed the Food Insecurity Experience Scale (FIES) as a tool to fill a crucial gap in global food security monitoring, particularly for assessing access to food at individual and household levels. The FIES directly measures the severity of food insecurity, defined as the extent of difficulty in obtaining food.

4 Ending Malnutrition Table 1.1 Prevalence of undernourishment and number of undernourished persons, by region, 1990–92 and 2014–16

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the less ambitious MDG Target 1c of halving the share of chronically undernourished people. Unfortunately, the recent slowdown in progress is not encouraging (FAO, 2015).

The 2012 State of Food Insecurity Report provided additional measures of prevalence of inadequacy of dietary energy, using different benchmarks of minimum dietary energy requirement (FAO, 2012). The report showed that, in comparison with the methodologically most consistent PoU estimate of

14.9 percent in 2010–12, the estimate of the proportion of persons facing dietary inadequacy turned out to be 26.5 percent, if the dietary energy requirement benchmark was assumed to correspond to the minimum dietary energy needs associated with normal levels of physical activity. As per this indicator, referred to as Prevalence of Food Inadequacy (2), in 2010– 12, 1.5 billion people globally faced dietary energy inadequacy.⁴ ⁴ Another indicator, Prevalence of Food Inadequacy(3), which uses a dietary energy requirement benchmark corresponding to minimum dietary energy needs associated with intense level of physical activity, showed an even higher number of persons, 2.6 billion, to be facing dietary inadequacy. For further details, see FAO (2012), Annex 2.

Uneven Progress Figure 1.1 Prevalence of Undernourishment, by country, 2014–16 Note: Map plotted using Gall-Peters projection.

Source: Based on data from FAO (2015).

Figure 1.2 Success in meeting the World Food Summit Target and the Millennium Development Goals Target 1c, by country, 2014–16

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Whether or not the MDG Target is achieved, the overall progress has been highly uneven. About 795 million people – one in ten people worldwide – remain chronically hungry even by the conservative definition used in estimating the Prevalence of Undernourishment. Of these, only about 14 million of the world’s hungry live in developed countries. Some countries and regions have seen only modest progress in reducing hunger. In several countries, the number of hungry people has increased. Meanwhile, there have been significant reductions in the prevalence of undernourishment in most countries of Southeast Asia, Latin America, East Asia, Central Asia, and the Caribbean where the target of halving the hunger rate has been reached, or nearly reached (Table 1.1).

Progress in Sub-Saharan Africa has been limited, and the region has the highest prevalence of undernourishment by far, with almost one in four chronically hungry. Meanwhile, the more populous South Asia still has many more undernourished people. Progress in South Asia and Oceania has not been sufficient to meet the MDG hunger target by 2015, while West Asia and North Africa have had a rising Prevalence of Undernourishment (Table 1.1). Figure 1.1 shows the country-level variation in Prevalence of Undernourishment. Figure 1.2 shows that countries in South Asia and SubSaharan Africa have not been able to make it to the finishing line for the WFS and the MDG targets on hunger.

Slow and uneven progress in reducing malnutrition Progress in reducing malnutrition has been slower and more uneven.

Globally, about 15 percent of all children under 5 years of age continue to be underweight. Between 1990 and 2012, the number of underweight children aged less than 5 years declined by about 38 percent, from about 160 million to about 99 million, well short of the MDG Target 1c (Table 1.2).

In 2012, the World Health Assembly agreed to the following six global


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• Reduce and maintain childhood wasting to less than 5 percent.

The recent Global Nutrition Report shows that at the current pace of change, the world is not on course to meet any of these targets (IFPRI, 2014).

The report includes a detailed study of progress on four of these targets:

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