Executive summary

The global burden of malnutrition

Today, one in every nine people in the world is hungry, and one in every three is overweight or obese. More and more countries experience the double burden of malnutrition, where undernutrition coexists with overweight, obesity and other diet-related non-communicable diseases (NCDs).

The trend is clear: progress is too slow to meet the global targets. Not one country is on course to meet all ten of the 2025 global nutrition targets and just 8 of 194 countries are on track to meet four targets. Almost a quarter of all children under 5 years of age are stunted. At the same time, overweight and obesity are increasing rapidly in nearly every country in the world, with no signs of slowing.

Progress on malnutrition is not just too slow, it is also deeply unfair. New analysis shows that global and national patterns mask significant inequalities within countries and populations, with the most vulnerable groups being most affected. Nutrition outcomes also vary substantially across countries. Underweight is a persisting issue for the poorest countries and can be ten times higher than in wealthier countries. Overweight and obesity prevail in wealthier countries at rates of up to five times higher than in poorer countries.

Within every country in the world, we see striking inequalities according to location, age, sex, education and wealth – while conflict and other forms of fragility compound the problem. This report finds a strong urban–rural divide, and even larger differences across communities. In children under 5 years of age, wasting can be up to nine times higher in certain communities within countries, four times higher for stunting and three times higher for overweight and obesity.

There is a clear link between infant and young child feeding practices and household characteristics. Continued breastfeeding up to 1 or 2 years of age is less common for children in wealthier households, urban areas or with a more educated mother. In contrast, rates of solid food introduction and minimum diet diversity are substantially lower for children in the poorest households, in rural areas or with a less educated mother. Although more granular high-quality nutrition data is needed, we have enough to act.

Tackling injustices in food and health systems

Poor diets and resulting malnutrition are among the greatest current societal challenges, causing vast health, economic and environmental burdens. To fix the global nutrition crisis equitably, we must shift our approach dramatically in two ways: focusing on food and health.

First, we must address inequities in food systems, from production to consumption. Current food systems do not enable people to make healthy food choices. The vast majority of people today simply cannot access or afford a healthy diet. The reasons for this are complex. Existing agriculture systems are largely focused on an overabundance of staple grains like rice, wheat and maize, rather than producing a broader range of more diverse and healthier foods, like fruits, nuts and vegetables. Meanwhile, highly processed foods are available, cheap and intensively marketed; their sales are still high in high-income countries and growing fast in upper-middle- and lower-middle-income countries.

The climate emergency makes it critical to rethink food systems. And this presents an opportunity to shift to approaches ensuring that healthy and sustainably produced food is the most accessible, affordable and desirable choice for all. These approaches must amplify the voices of marginalised groups and address the true cost of food to the environment, as well as to human health. Likewise, they must work both within specific contexts and across sectors to address all elements of the food system.

Second, we must address nutrition inequities in health systems. Malnutrition in all its forms has become the leading cause of ill health and death, and the rapid rise of diet-related NCDs is putting an intolerable strain on health systems. Yet, most people cannot access or afford quality nutrition care for prevention or treatment. Worldwide, only about one-quarter of the 16.6 million children under 5 years of age with severe acute malnutrition received treatment in 2017, highlighting the urgent need to address this unacceptable burden. Nutrition actions represent only a tiny portion of national health budgets, although they can be highly cost-effective and can reduce healthcare spending in the long term. These are largely focused on undernutrition and are rarely delivered by skilled nutrition professionals. At the same time, health records and checks are not optimised to screen, monitor and treat malnutrition, such as through assessments of diet quality and food security.

Global commitment to universal health coverage is an opportunity to integrate nutrition care fully into health systems. Essential nutrition services – preventive and curative – should be universally available to all, with a focus on those who need it most. Strong governance and coordination across sectors is key to building functional and resilient health systems. Mainstreaming and scaling up nutrition care within health systems would save lives and reduce staggering healthcare spending.

Only by tackling injustices in food and health systems will we achieve the transformations needed to end malnutrition in all its forms.

Investments to improve nutrition outcomes

The intensified drive needed to meet global targets and end malnutrition is the collective responsibility of all sectors and countries. Domestic funding by country governments is crucial to ensure sustained improvements. At the same time, the international donor community has a duty to step up where governments lack the resources to respond effectively.

So far, investments have focused on addressing undernutrition. We have seen some success here, as rates of stunting are gradually decreasing over time. In contrast, overweight and obesity are rapidly increasing. The funding gap to address overweight, obesity and other diet-related NCDs is growing too. Countries have to be equipped to fight both sides of malnutrition at the same time.

We need to examine investments in nutrition through an equity lens. Investments must respond to need, and volumes of financing should be proportionate to the burden. We should proactively develop new financing mechanisms that can complement existing sources. Nutrition inequalities exist across countries as well as within communities. Therefore, decisions on resource allocation by need should be informed by granular data at the subnational level, through evidence-based and cost-effective solutions. Coordination is essential to prioritise equitable nutrition investments. Directing resources and programmes to communities and people most affected would enable faster, more equitable progress towards ending malnutrition.

Critical actions to achieve nutrition equity

Food is an important global issue – crucial to health, equity, sustainability, economies and livelihoods. Increased global recognition that governments, businesses and civil society are accountable for healthier and more equitable food and health systems provides an opportunity for us to invest in nutrition to preserve our future. Over the next two years, there are key opportunities to prioritise nutrition in policy agendas and to rethink our food and health systems. These include the Tokyo Nutrition for Growth Summit (N4G), the 2020 UN Climate Change Conference (to be held in 2021) and the 2021 Food Systems Summit.

We urge leaders to prioritise action to ensure that all people, particularly those most affected by malnutrition, have unhindered access to healthy and affordable food, and to quality nutrition care. Governments must work with stakeholders across sectors to overcome the inequities holding back progress to end malnutrition. To drive the transformative change needed to achieve nutrition equity, and end malnutrition in all its forms, we must focus on three key areas: food systems, health systems and financing. The Global Nutrition Report proposes the following specific actions.

Food systems

To ensure that healthy and sustainably produced food is the most accessible, affordable and desirable choice for all, sectors must work together to mainstream nutrition into all elements of the food system.

• Implement strong regulatory and policy frameworks to support healthier diets for all at country and community level and across sectors, from production to consumption.
• Optimise agricultural subsidies and increase public investment for producing a broader range of more diverse and healthier foods.
• Provide support for public transport schemes and shorter supply chains for fresh-food delivery products, particularly to the most nutritionally disadvantaged or harder-to-reach groups.
• Implement, monitor and evaluate evidence-based food policies to support healthy, sustainable and equitable diets, such as fiscal, reformulation, school- and worksite-based, labelling and marketing policies.
• Hold the food industry accountable for producing and marketing healthier and more sustainable food products through strengthened mechanisms.
• Strengthen and increase research spending to address major nutrition questions, identify cost-effective solutions and stimulate innovation.

Health systems

To save lives and cut healthcare costs, sectors must work in collaboration to mainstream nutrition as a basic health service through leveraging existing infrastructure and introducing new technologies.

• Roll out nutrition services within health services by developing costed nutrition care plans, that should be scaled up and sustained to cover all forms of malnutrition, including overweight, obesity and other diet-related NCDs.
• Invest in human resources to increase the number of qualified nutrition professionals and level-out access to quality nutrition care.
• Use a variety of health professionals and workers to alleviate inequities in access, and enhance their performance through educational and development opportunities.
• Include nutrition-related health products like therapeutic foods and innovative technological solutions like digital nutrition counselling, where appropriate – especially when working with more remote and harder-to-reach communities.
• Optimise health records and checks for nutrition care, to deliver preventive and curative nutrition services and identify those in greatest need.
• Commit to routine and systematic collection of equity-sensitive nutrition data at the community level, disaggregated by key population characteristics to strengthen the evidence base and inform targeted priority-setting.

Nutrition coordination, financing and accountability

Sectors must work in partnership to develop complementary funding and accountability mechanisms focused on directing resources and programmes to the communities and people most affected by malnutrition.

• Increase domestic financing to respond to the needs of communities most affected by malnutrition – including undernutrition, as well as overweight, obesity and other diet-related NCDs.
• Invest in data management systems to strengthen data on financial flows, enabling alignment with national nutrition priorities.
• Increase international nutrition financing and coordination, targeting populations most in need – especially in fragile and conflict-affected countries and in those with limited possibility for domestic resource mobilisation.
• Establish an international system of governance and accountability to address power imbalances in the food and health system and hold to account those responsible for creating inequities in food and health systems.
• Establish support spaces for dialogue on coordinated action to achieve nutrition equity and sensitise the policy space through lobbying for community involvement – from design to evaluation.
• Undertake situational assessments to identify bottlenecks in food, health, education and social protection, to remove barriers to improving nutrition outcomes.

We need to act now. We need to be well resourced, strongly coordinated and accountable. Meeting the global nutrition targets would enable healthier, happier lives for all. With an extra push at the N4G summit, this success is within reach.

Photo: Paula Bronstein/Getty Images/Images of Empowerment