Ensuring equitable nutrition: a collective responsibility

Systematic tracking by the Global Nutrition Report over the last six years shows improvements in key nutrition outcomes, but progress remains too slow to achieve the 2025 global nutrition targets. Around 149 million children under five years of age are stunted, 49.5 million are wasted, and 40.1 million are overweight, while 677.6 million adults are obese. Our world has substantially changed over the past four decades into one where far more people are overweight or obese than underweight, except in parts of sub-Saharan Africa and Asia. The unacceptably high burden of malnutrition can be attributed mainly to the hugely insufficient deployment of resources, the inadequate implementation of policies, programmes and interventions, and the lack of coherence and coordination across multiple sectors. Crop failures, reduced food production and extreme weather events that produce droughts and flooding are adding to increasing food insecurity and undernutrition among vulnerable populations.

More positively, there is increasing global recognition that malnutrition needs to be addressed comprehensively, going beyond the traditional focus on undernutrition. Several recent reports have highlighted actions to address the challenges of nutrition, food and health. The EAT–Lancet Commission’s report on healthy diets from sustainable food systems links nutrition targets with environmental sustainability, climate change and a substantial shift towards healthy dietary patterns; it recommends widespread multisector, multi-level action.^[1] The 2019 State of food insecurity (SOFI) report underscores the critical need for multisectoral policies focused on tackling inequalities at all levels.^[2] The issues of food and nutrition affecting children (against a backdrop of rapid change, and the need for food systems to deliver nutritious, safe, affordable and sustainable diets) is the central theme of UNICEF’s 2019 The state of the world’s children report.^[3] The Global Panel for Agriculture and Food Systems for Nutrition (GLOPAN) will also be releasing a report linking healthy diets to environmental sustainability ahead of the Tokyo Nutrition for Growth Summit.^[4] Recently The Lancet published a series of papers on the double burden of malnutrition to explore the coexistence of all forms of malnutrition.^[5] The Global Nutrition Report supports these efforts and aims to add to these perspectives to broaden the narrative – linking human potential, economic growth and environmental sustainability with equitable nutrition and health.

This report examines data disaggregated by key sociodemographic characteristics and evidence beyond national averages to reveal that progress over recent decades has been not only slow but also unequally distributed, resulting in widely differential outcomes. Many factors can contribute to these inequalities, including location, demography, sex, age, wealth and ethnicity. Variations exist across countries and within countries, across socioeconomic groups and within households. Recognising and promoting equity, therefore, needs to be a fundamental component of nutrition policy design, implementation, monitoring and evaluation.

The 2020 Global Nutrition Report calls for a pro-equity agenda to design and deliver nutrition actions through healthcare, to enable food environments that support and provide healthy diets, to expand and target financing, and to prioritise systematic and continuous disaggregated data collection for informed policy setting. Building on the findings of recent reports, this publication highlights the need to address inequities embedded within the delivery of nutrition interventions and identifies demonstrable and evidence-based actions that can address nutrition inequities. It emphasises the need to integrate nutrition actions within health and food systems and a range of other sectors. These actions need to be supported by equity-sensitive environments and governance, and by resource allocation that targets those who are often missed.

The world can achieve the 2025 global nutrition targets and Sustainable Development Goals (SDGs) only through a comprehensive and multifaceted approach that applies an equity lens to interventions, ensuring they reach those most in need. Such an approach should span multiple sectors supported by expanded resources and targeting, based on the following guiding principles.

A multisectoral and equitable nutrition approach

Nutrition is central to the SDGs, with 12 of the 17 SDGs containing indicators relevant to nutrition. Ending malnutrition in all its forms will catalyse improved outcomes and have powerful multiplier effects across the SDGs. Likewise, progress across the SDGs is essential to address the causes and consequences of malnutrition. Proactive consideration and inclusion of nutrition actions, goals and indicators across the SDGs will ensure that nutrition becomes a cross-cutting priority on the global development agenda and will promote engagement at all levels. In addition to the vast health and economic consequences, the global malnutrition burden has environmental impacts affecting the entire planet. Climate change and food systems are interrelated; we need to understand both the environmental consequences of poor diets and the impacts of climate change on agriculture. Future policy recommendations for optimal nutrition should include equity considerations, and be given in the context of potential environmental effects to address these issues simultaneously. This requires a more robust governance structure for nutrition – including high-level central coordination and subnational governance mechanisms. This can ensure greater participation and accountability for all key sectors, including health, education, water and sanitation, as well as food, economics, finance and planning.

Nutrition care should be an integral part of universal health coverage to address nutrition inequities reliably

At the United Nations General Assembly 2019, world leaders signed a landmark declaration on universal health coverage (UHC), which recognised that food security and food safety, adequate nutrition and sustainable, resilient and diverse nutrition-sensitive food systems are essential elements for healthier populations.^[6] They stressed the need for sustained political commitment, leadership and good governance combined with capacity-building to mainstream nutrition within the health system and facilitate coordination and cooperation across multiple sectors and levels to reach those in most need.

Mainstreaming nutrition within UHC will also help to ensure equitable access to a standard package of universally available nutrition services that improve diets and reduce illness – resulting in better health outcomes for all. Specific interventions would include optimisation of electronic health records for nutritional screening and assessment, micronutrient supplementation, infant and young child feeding promotion, and counselling or treatment of acute malnutrition, where prevention fails.

An equity-sensitive approach to food systems is key to ensuring healthy, accessible and affordable food for all

An equity-sensitive approach to food systems would seek to reduce inequity in producing and delivering healthy diets through food policies – from agriculture to food assistance and fiscal policies – to help make healthy, sustainably produced foods the most accessible, affordable and convenient choice for everyone. Population-based interventions, which reach broader segments of society and require less individual effort, should benefit everyone, particularly those of lower socioeconomic status. Such ‘upstream’ strategies appear more effective in reducing inequalities, with the most significant impacts seen for multi-component interventions.

Governments can and should regulate to avoid inequities in the delivery of nutrition interventions. They can also offer financial and non-financial incentives to the private sector to ensure that their populations have access to healthy foods, and sufficient information and education to make informed choices. For example, fiscal policies could include taxes on sugar-sweetened beverages and ultra-processed foods, plus subsidies for healthy foods, food assistance programmes, front-of-package nutrition labels, mass media campaigns, marketing restrictions, and food reformulation to support healthier diets and hold the food industry accountable.

Resources should be expanded and preferentially targeted to where the need is greatest

Current financing of high-impact nutrition interventions is well below the level needed to achieve global nutrition targets. There is additionally a growing funding gap for addressing malnutrition related to overweight, obesity and non-communicable diseases (NCDs). It is critical to increase nutrition investments significantly, through a mix of domestic allocations from country governments combined with official development assistance and other financing mechanisms, with a focus on equity by targeting countries and populations most in need. Governments need to address the priorities and needs of the most vulnerable and marginalised groups by investing in information systems that provide disaggregated data at the subnational level and targeting funding flows at that level based on need.

In 2020, the Government of Japan was due to host the Tokyo Nutrition for Growth Summit^[7] to highlight nutrition as an essential driver for sustainable development and to secure policy and financial commitments from governments, donors, the private sector and other agencies to address malnutrition in all its forms. The Summit has been postponed due to the outbreak of Covid-19, but when the event can be held, it will offer a tremendous opportunity for action on addressing inequity and securing new investments and commitments to overcome malnutrition. As part of the commitment-setting at the Tokyo Summit, it will be crucial to ensure a focus on equity by targeting countries with a higher burden of malnutrition and those with less ability to mobilise domestic resources for programmes. This includes fragile states where mobilisation of significant domestic revenues is very limited or impossible. Countries can optimise programme impact with the resources available to them by prioritising cost-effective interventions and targeting populations most in need.

Investment in data and information systems at disaggregated levels is critical

Understanding drivers of unequal diets and related health outcomes through increased investments in data and information systems at disaggregated levels is essential for informed priority setting and policy design. Public health monitoring and surveillance systems for nutrition should be established for ongoing and systematic assessment of a range of nutrition indicators at the granular level to underpin policies and prevention initiatives.

Given that the various forms of malnutrition are intertwined throughout the life cycle and between generations, it is not possible to address the persisting high levels of undernutrition coupled with the worldwide increase of obesity and other diet-related NCDs through reliance on one system. Tackling malnutrition in all its forms requires active engagement within and across a range of sectors and systems to result in better outcomes at all levels and simultaneously support the achievement of sectoral goals.

Health: The health system can provide a platform to deliver nutrition actions to promote healthier eating and prevent and treat malnutrition – from maternal and child health outcomes to diet-related NCDs. Ensuring that high-quality nutrition services are part of the standard package of universally available health services can reliably address nutrition inequities. Increased capacity of the nutrition workforce is crucial in ensuring the delivery of equitable and quality nutrition care. Implementing effective and cost-effective nutrition interventions within our health systems would improve diets, save lives and reduce healthcare spending.

Food: An equity-sensitive approach to food systems that delivers healthy diets would seek to reduce inequities, as well as directly addressing food availability, accessibility and price in local food environments. The application of a range of different strategies and interventions is necessary to shift to healthier, environmentally sustainable and more equitable diets for all. Interventions targeting food environments should be included, along with agricultural and food-supply approaches. Moreover, stakeholders – including governments, industry, consumers and civil society – can act through different entry points of the food system.

Education and information: Better nutrition brings enormous improvements in the cognitive ability and physical performance of children, contributing to their ability to do well in school. Improved school meal programmes can reduce undernutrition, ensure that children are not unduly exposed to foods that increase their risk of obesity, provide income to farmers, and encourage children to stay in school and learn better. Schools can also educate children on the importance of healthy diets, physical activity and improved hygiene practices to help them make healthier lifestyle choices. Improving access to continued education also has long-term implications for the nutrition status of future generations. Other initiatives, such as mass media campaigns and marketing restrictions, also play an essential role in informing and educating communities.

The private sector: Given that no single action can address the complexities of the food system, all stakeholders should work in coordination through complementary and synergistic approaches to ensure that it delivers healthy and nutritious foods. Undeniably the food industry – managed mostly by the private sector – is an essential player in the food supply chain. On the one hand, there are instances where the private sector has opposed healthy food policies. Because of its scale and political power, such opposition can have a significant negative impact and must be checked. On the other hand, its strengths in innovation, problem-solving and marketing can potentially be applied to develop, produce and market healthy foods in sustainable and equitable ways. The impetus for this must come from consumer demand for such foods as well as from strong government regulation. In addition to holding the food industry accountable through strengthened mechanisms and regulatory frameworks free from conflicts of interests, governments should endorse healthy and nutritious eating practices through public messaging and campaigns, and by ensuring healthier food environments.

Governments, the private sector and civil society should work to recognise connections across the SDGs to enhance the impact of investments, commitments and actions by each sector. There is a need for greater legitimacy, space and support for civil society; for an accountable private sector; for greater transparency in the political processes led by governments towards healthier food environments; and for people across society to act on public interests and reinvest in collective action.

The Tokyo Nutrition for Growth Summit is an opportunity to streamline accountability in nutrition and pool the resources of existing initiatives for a joint output with the engagement of governments, civil society organisations and the private sector. It should highlight the trends and barriers to financing for nutrition and ensure that pledges are targeted judiciously, remaining relevant to the areas and populations in greatest need. An accountability strategy developed ahead of Tokyo should ensure that nutrition stakeholders make nutrition commitments that are ambitious and SMART (specific, measurable, achievable, relevant and timely)^[8] and that stakeholders are effectively held accountable to those commitments.

The year 2020 marks the midpoint of the UN Decade of Action on Nutrition to eradicate hunger and prevent all forms of malnutrition worldwide. There are only five years left to achieve the global nutrition targets and just a decade remaining to realise the 2030 Agenda for Sustainable Development. Accelerating progress towards the 2025 global nutrition targets depends on:

• Improving the granularity of data, with a concerted effort to define and target specific inequities in contexts where the malnutrition burden is high
• Strengthening global nutrition governance and improving integration across players
• Holistically integrating nutrition into UHC
• Reforming food systems.

All of this must be supported by expanded funding.

World leaders must make bold nutrition commitments so that all people can survive and thrive. These commitments can be best realised through action on four key components to ensure that no one is left behind: collection, analysis and reporting of equity-sensitive nutrition data; broader equity evidence; enabling equity-sensitive environments, services and interventions to address the social determinants of malnutrition; and equity-sensitive governance and financing. Malnutrition is everyone’s problem: it affects every country in one form or another. It is one of the most significant global challenges we face. But, with the combined efforts of all, it is one challenge we can overcome.