Chapter 01

Introduction: towards global nutrition equity

Chapter 1 of 6
Contents
1.1 Share section

Inequalities in all forms of malnutrition

Poor diet is the leading cause of mortality and morbidity worldwide, exceeding the burdens attributable to many other major global health challenges.[1] The resulting global malnutrition crisis includes hunger and undernutrition – mainly stunting, wasting, underweight and micronutrient deficiencies – and diet-related non-communicable diseases (NCDs) – mainly overweight, obesity, diabetes, cardiovascular disease and cancer. This double burden of malnutrition – two sides of one crisis – has vast health, economic and environmental implications, affecting every country of the world in some form. Yet, there are marked differences in nutrition outcomes, or nutrition inequalities, by key sociodemographic characteristics, such as geographic location, age, gender, ethnicity, education and wealth. The 2020 Global Nutrition Report provides high-quality data and in-depth analyses to shed light on the global burden of malnutrition. Our aim is to help disentangle the patterns and causes of nutrition inequalities to drive action and ensure that no one is left behind.

Currently, 1 in 9 people – 820 million worldwide – are hungry or undernourished, with numbers rising since 2015, especially in Africa, West Asia and Latin America.[2] Around 113 million people across 53 countries experience acute hunger, as a result of conflict and food insecurity, climate shocks and economic turbulence.[3] At the same time, more than one-third of the world’s adult population is overweight or obese, with increasing trends over the past two decades.[4]

Latest data reveals some progress towards select 2025 global nutrition targets, including maternal, infant and young child nutrition (MIYCN) targets,[5] and diet-related NCD targets.[6] Childhood stunting has dropped globally from 165.8 million in 2012 to 149 million in 2018, representing a 10% relative decrease. No country worldwide has managed to reverse the rising overweight and obesity trend. Overall, progress towards global nutrition targets is far too slow or non-existent (see Chapter 2).[7] Malnutrition is persisting at unacceptably high levels, with marked differences between countries, within countries and by population characteristics.

Global leaders affirmed a vision for a world that 'leaves no-one behind' by committing to the Sustainable Development Goals (SDGs).[8] This vision includes a world free from malnutrition in all its forms.[9] Immediately following the SDGs, the United Nations (UN) Decade of Action on Nutrition 2016–2025[10] articulated the goal of eliminating all forms of malnutrition by 2025, a goal underpinned by the principle of universality and achieving food and nutrition security for all.[11] The principle of universality refers to an inclusive approach ensuring that everyone has fair access to the resources and services they need to achieve optimal nutritional health. Equity adds an ethical dimension and focuses on opportunities rather than outcomes. Unequal nutrition outcomes are rooted in deeper inequities that arise from unjust systems and processes that structure everyday living conditions. These systems and processes shape opportunities and barriers to attaining healthy diets, healthy environments, adequate healthcare and healthy lives. Considerable progress has been made in measuring nutrition inequalities, but we have been less clear on understanding and confronting inequity. Recognising this gap, this year’s Global Nutrition Report focuses on nutrition equity.

Inequity affects people throughout the social hierarchy and is grounded in the marginalisation, stigmatisation or relative disempowerment of different individuals and groups. As the voices and ideas of marginalised people are unheard or ignored, their health and nutrition needs are not addressed. While a focus on inequality is about understanding the differences in nutrition outcomes, such as diets and disease patterns, among different population groups, looking at inequity shifts the focus to the underlying systems and processes that generate unequal distributions of outcomes.[12] If inequalities in nutrition outcomes are avoidable through human intervention – and evidence suggests they are – then these inequalities are by definition inequitable.[13] We need a pro-equity policy agenda to inform priority-setting, target resources according to needs, and ensure that no one is left behind. To achieve the SDGs and related global nutrition targets for all, it is critical to explain the reasons for inequalities in nutrition outcomes through understanding nutrition inequities and their determinants.

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FIGURE 1.1 Nutrition equity framework

FIGURE 1.1 Nutrition equity framework

Nutrition equity framework

Source: Adapted from the World Health Organization (WHO) Commission on the Social Determinants of Health[14] and broadly aligned with the United Nations Children’s Fund (UNICEF) framework.[15]

1.2 Share section

Nutrition inequities and their determinants

This Global Nutrition Report proposes a conceptual framework (Figure 1.1) to help understand and address nutrition inequities through their determinants. The framework is adapted from the World Health Organization (WHO) Commission on the Social Determinants of Health[16] and broadly aligned with the United Nations Children’s Fund (UNICEF) framework.[17] Unequal and avoidable outcomes are caused by inequitable processes, which are the focus of an equity analysis. This nutrition equity framework drills deeper through determinants at basic and underlying levels (in alignment with structural and intermediary WHO levels, both of which map roughly to, but expand on, similar UNICEF levels).

At the underlying level, nutrition inequity is caused by the way that people’s everyday social, psychological/behavioural and material circumstances interact with their wider environments. These environments include: access to adequate and quality food; provision for infant care; healthcare environments; and wider living environments (including sanitation and opportunities for physical activity). There may be multiple interactions at this level. For example, a family caring for a child weakened by poor diet and malnutrition, resulting partly from inadequate sanitation and immunisation status, may find themselves unable to afford or access adequate health services, including advice and support for prevention. In time, this may lead to further deterioration of material or psychosocial circumstances, due to, for example, missed earning opportunities and diversion of family caring resources.

People’s everyday circumstances and exposure to food, healthcare and living environments are ultimately determined by factors described at the basic level, which can produce unequal exposure or access to the underlying determinants. The basic level of the nutrition equity framework describes how nutrition inequity originates in inequalities in social position, human capital and potential, which are shaped by or differ according to socioeconomic and political contexts. These contexts vary in stability, particularly in countries or regions affected by conflict or other forms of fragility (including economic, environmental, political, security and societal forms as set out in the Organisation for Economic Co-operation and Development (OECD) Fragility Framework[18]).

The basic level of the framework is particularly useful for highlighting how someone’s social position can significantly affect their human capital and potential. Social position is influenced not only by wealth but also by sociocultural perceptions of age, gender, ethnicity, education or disability. Human capital or potential includes education and employment opportunities, and access to social networks, all of which in turn affect everyday circumstances and environments. For example, poorer people may have less money to access food, health services or education, or they and others (including wealthier people) may find this access also restricted by other forms of social discrimination.

Processes of unfairness, injustice and social exclusion (Box 1.1) start at the basic level and extend to the underlying level. For example, particular groups are excluded from political processes, or are stigmatised and receive fewer opportunities to build their human capital. Food systems are affected by a range of powerful commercial determinants, such as marketing, advertising and the influence of companies on government policy (such as through lobbying), which can in turn affect both people’s behaviours and their immediate food environment.[19] Both basic and underlying factors encompass social, political and commercial determinants. From now on, we will refer to these collectively as social determinants (adapting the WHO’s terminology on the social determinants of health).

BOX 1.1 What causes inequity?

Injustice:

Social injustice occurs due to discrimination against individuals or groups because of social norms and cultural values, leading to them being treated as unequal, unwanted or stigmatised. Often, these forms of discrimination intersect[20] and policy failure to recognise this discrimination perpetuates the inequities.[21] The resulting social position – ‘a disabled boy’ or ‘a low-caste woman’ – becomes a source of repeated unfairness throughout lives and generations, affecting access to education, health and nutrition.[22]

Unfairness:

Multiple points of unfairness throughout the life course stem from basic social injustices. Suboptimal access to life chances (such as education)[23] result in suboptimal knowledge, services and physical environments.[24] Some social groups may find that they are further discriminated against, by health workers[25] for example. The same ‘disabled boy’ or ‘low-caste woman’ may find themselves unable to access adequate healthcare because services are neither designed for their needs nor available in their communities, or because they lack the knowledge to seek help. Similar factors may bar access to food markets, or adequate sanitation, collectively contributing to poorer nutrition outcomes.

Political exclusion and imbalances in power:

Those in marginalised social positions are less likely to be represented in institutions that allocate educational or economic opportunities[26] and frame policies and programmes that address the underlying causes of nutrition inequities. This lack of power works at multiple levels, from assumptions that dictate what happens within a family (such as whether a girl goes to school), through barriers in setting public health standards,[27] to the relative voices of different countries within trade or other global agreements[28] and powerful food manufacturers lobbying behind closed doors against public health measures or undermining scientific research.[29]

The causes of inequity are complex, driven by the multiple ways in which social determinants interact at the basic and underlying levels, and influence, collectively, the social, institutional, policy and commercial contexts within which people live. Everyday circumstances, environment, social position, human capital, and social context all jointly determine a person’s likelihood of becoming malnourished. Poor food environments that affect everyone may arise from poor policy choices, weak governance, state fragility or conflict. But even these society-wide effects are differential, usually disproportionally affecting poorer, more vulnerable or more excluded groups.[30] It is no coincidence therefore that many forms of malnutrition affect the most socially and politically powerless groups: women, children, ethnic minorities and those less educated or living in poverty. Exposure to these inequity determinants and their impact on people’s wellbeing is often long term and cumulative, rather than episodic.

1.3 Share section

Nutrition equity through action on social determinants

Global leaders reaffirmed their commitment to bringing justice, equality and human rights into efforts to tackle global problems through the Sustainable Development Goals, set in 2015. SDG 10 (Box 1.2) is directly relevant to tackling the global malnutrition epidemic and recognises the importance of acting on social determinants as the root causes of nutrition inequities.

BOX 1.2 Equity and the focus on justice, vulnerability and non-discrimination

Sustainable Development Goal 10: Reduce inequality within and among countries

SDG 10 recognises that equality and the pursuit of equity are inextricably linked in the imperative to ‘leave no one behind’:

“We envisage a world of universal respect for human rights and human dignity, the rule of law, justice, equality and non-discrimination; of respect for race, ethnicity and cultural diversity; and of equal opportunity permitting the full realisation of human potential and contributing to shared prosperity. A world which invests in its children and in which every child grows up free from violence and exploitation. A world in which every woman and girl enjoys full gender equality and all legal, social and economic barriers to their empowerment have been removed. A just, equitable, tolerant, open and socially inclusive world in which the needs of the most vulnerable are met.”[31]

Source: Transforming our world: the 2030 Agenda for Sustainable Development.[32]

1.4 Share section

Pro-equity policy agenda to deliver nutrition actions

Nutrition actions need to become more ‘equity-sensitive’ to comprehensively address malnutrition. This requires linking more closely to the overarching SDG vision of ‘leaving no one behind’. Within the international development community, stakeholders have already begun to embrace the approach to ‘reach the furthest behind first’.[33] With a renewed focus on data that helps pinpoint nutrition inequalities, it is imperative to translate this overarching vision into actionable, equity-sensitive nutrition policies.

Governments and policymakers should consider how broader social policies, covering housing, labour, urban planning, transport, gender, education and social protection, are impacting nutrition outcomes, and integrate these into nutrition strategies. Such broader pro-equity actions are now increasingly being incorporated into municipal food strategies through consideration of the food and health linkages from an equitable and systemic perspective.[34] For example, the Brighton and Hove Food Partnership (UK), between the local health and municipal authorities and civil society organisations, has resulted in a food strategy action plan that lists “employment, social benefits, and housing and fuel costs” as part of its “preventative approach to tackle food poverty”.[35]

A pro-equity nutrition policy agenda should also consider potential environmental links and implications. There is a growing and urgent need to improve our understanding of links between our food and our planet that go beyond waste production and water pollution. Our food affects our climate, and in turn our climate affects our food. We need to optimise the diets of all people and achieve a sustainable food system worldwide. A recent Lancet Commission recognises the importance of these links and recommends connecting “the silos of thinking and action between undernutrition, overweight and obesity and climate change to work collaboratively on common systemic drivers” in systems of food and agriculture, transportation, urban design and land use.[36] Now is the time to make healthy, sustainably produced foods the most accessible, desirable, affordable and convenient choices for all.

1.5 Share section

Governance to address nutrition inequities

Strengthened governance, coordination, political commitment and accountability is crucial to address nutrition inequities, as further emphasised by the WHO Commission on the Social Determinants of Health (CSDH):

"In order to address health inequities, and inequitable conditions of daily living, it is necessary to address inequities – such as those between men and women – in the way society is organized... To achieve that requires more than strengthened government – it requires strengthened governance: legitimacy, space, and support for civil society, for an accountable private sector, and for people across society to agree public interests and reinvest in the value of collective action."[37]

At global and national levels, it will be necessary to prioritise policies and financing to address the broader social determinants of nutrition inequities. The ability of different groups and individuals to access healthy, nutritious diets is ultimately related to “the inequitable distribution of power, money and resources” highlighted by the WHO Commission.[38] Addressing these inequities through greater political commitment, leadership and governance, combined with capacity-building, training and earmarked financial and human resources, is required to achieve equality in nutrition outcomes. This calls for action by key stakeholders, including national governments, the UN system, civil society organisations and businesses. Action must also take place at subnational levels, to address inequities within countries.

This requires a renewed focus on inclusive governance, human rights and accountability. Such ‘thinking and working politically’ is being embraced by international development actors,[39] and has catalysed multiple studies of nutrition governance.[40] Previous Global Nutrition Reports have highlighted efforts to build and sustain political commitment to nutrition through renewed emphasis on governance and accountability. This includes forms of social accountability involving people participating and auditing the decisions and services that affect them most.[41] Examples of a rights-based approach to nutrition, in terms of national programmes, legislation and constitutional guarantees, are Brazil’s Right to Food movement[42] and India’s Transformation of Aspirational Districts initiative[43] (see Spotlight 3.1 in Chapter 3).

Better government structure and coordination has a direct bearing on mitigating nutrition inequalities. A study of 116 countries, over a 15-year period, compared changes in childhood stunting against basic governance attributes (bureaucratic effectiveness, law and order, political stability, restraint of corruption and democratic accountability), concluding that “better quality of governance in countries serves to reduce child undernutrition, independent of income”.[44]

Under conditions of political and economic instability, or other forms of fragility, governance is often compromised, leading to aggravation of nutrition inequities and resulting nutrition inequalities. Fragility and conflict can undermine basic services and infrastructure, raise food prices, devalue currencies and introduce damaging coping mechanisms (such as missing meals or withdrawing children from school) that can have longer-term consequences. This calls for specific actions to bridge the humanitarian–development divide and address multiple drivers and manifestations of nutrition inequities in fragile states.

1.6 Share section

Measuring and understanding nutrition data with an equity lens

Accountability on global nutrition is necessary to identify and understand the drivers of unequal nutrition outcomes and facilitate the right action for impact. Current accountability mechanisms – including the Global Nutrition Report – need to take a more equity-sensitive approach to their assessments, analysis and reporting. This year’s report reveals strong evidence for the presence of nutrition inequities in health systems, food systems and financing, and inequalities in all forms of malnutrition. It also highlights the significant information gaps which need to be filled by “simultaneous disaggregation of data by multiple dimensions, including income, sex, age, race, ethnicity, migration status, disability, geographic location and other characteristics relevant to national contexts”, as well as “qualitative work to understand root causes”.[45] The latter dimension is critical to bring forward the voices of those affected by malnutrition, and of those who play vital roles in the provision of food and care.[46]

Since inequities are pervasive across all areas of society, equity actions cannot happen in isolation or be limited to one sector alone. Box 1.3 illustrates how an equity lens can be applied to nutrition action through a set of straightforward questions when designing or implementing a new nutrition policy or programme. It may not be feasible or acceptable to track all of these indicators in all situations, and the local context and appropriate use of data should always be considered. Box 1.4 summarises priority actions aligned with an equity focus on data, environments and governance towards equitable nutrition outcomes.

BOX 1.3 Designing equitable nutrition actions

Situation analysis

  • Are nutrition outcomes distributed fairly? How do they differ when disaggregated by a range of potential forms of social discrimination and marginalisation – not only by wealth (e.g. income), but also by gender, ethnicity, sexuality, disability, migration status, geography and broader determinants of social position such as entitlements and social and cultural capital?
  • Is coverage of programmes that can influence nutrition outcomes – particularly those concerned with health, food and living environments – extending to those identified as most in need (interpreted through disaggregated data analysis)?
  • Which aspects of people’s daily living conditions – including housing, sanitation and basic income levels – may be contributing to their differential exposure to these different environments?
  • Are there particular assumptions about forms of social identity (e.g. gender, ethnicity, disability) that are contributing to the marginalisation of some groups from decision-making structures?

Designing action

  • What kind of governance arrangements, policy and programming actions would tackle the basic and systemic drivers of these inequities, among those most at risk of exclusion, marginalisation or discrimination?
  • Is refocusing with a more specific equity lens likely to improve their effectiveness at preventing unequal nutrition outcomes?
  • How does this apply to more macro-level policies such as trade or labour policy, agricultural subsidies or social protection?
  • How do we give more power to those most at risk of exclusion, marginalisation or discrimination?
  • How do we better harness and improve existing systems of democracy, governance, accountability and rights-based approaches, with nutrition objectives in mind?
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FIGURE 1.2 How stakeholders can address nutrition inequities

FIGURE 1.2 How stakeholders can address nutrition inequities

How stakeholders can address nutrition inequities

Source: WHO-EU 2014 – Obesity and inequities.

BOX 1.4 Priority actions for nutrition equity

Priorities for an equity agenda and equity-sensitive nutrition actions

Data

Measure and understand nutrition data from an equity perspective:

  • Leverage and analyse existing nutrition data with a strengthened equity lens.
  • Enhance the collection of new disaggregated health and nutrition data, for example incorporating determinants such as age, sex, ethnicity, education, wealth, disability, migration status, geographic location data into demographic, health or nutrition surveys.
  • Collect and analyse qualitative accounts of inequities at the community level to increase understanding of the root causes of inequities.

Nutrition sector environments

Universally address the broader social determinants of nutrition:

  • Ensure universal access to and coverage of nutrition services, such as community-based support for infant and young child feeding, treatment of acute malnutrition and maternal health services.[47]
  • Ensure universal access to services relating to the social determinants of nutrition, including primary healthcare, immunisation, agricultural extension, nutrition education, sanitation and safe drinking water.[48]
  • Provide additional funding and resources for those most nutritionally disadvantaged, including young children, expectant and nursing mothers, adolescents and older people, in line with commitments to universal health coverage.
  • Provide financial and other resources for civil society organisations and community groups reaching and including nutritionally vulnerable communities.
  • Invest in health/nutrition workforces, increasing nutrition and equity awareness and knowledge across sectors, and develop clear processes for ensuring that specific groups do not experience exclusion or discrimination at the point of service.[49]

Multisectoral environments

Universally target the broader social determinants of nutrition:

  • Tackle inequities in resource distribution via, for example, systems of social protection, support for stable employment, agrarian and land reform.[50]
  • Adopt government-wide approaches to policy and regulation to target multiple drivers of nutrition inequity simultaneously – including housing, education, planning, food systems, transport and finance.

Governance

Leverage SDG 10 on inequality to address the broader social determinants of nutrition:

  • Incorporate nutrition-equity considerations into decisions on macro-economic policies in trade, investment, debt/finance and taxation.
  • Address power imbalances in food systems, via a strengthened system of international governance and accountability, rights-based approaches to food and nutrition policy development and programming, responsible business models and civil society action.[51]
  • As part of this, establish and support new spaces for dialogue, participation and coordinated action, whether globally (e.g. UN Committee on World Food Security,[52] the Scaling Up Nutrition (SUN) movement[53]) and within climate change forums (e.g. Conference of the Parties[54]) or nationally (e.g. SUN networks[55] or food policy councils).
  • Include alternative voices in thinking and action to sensitise policy spaces and systems that affect nutrition – in particular, ensure community involvement in the design, provision, monitoring, evaluation or audit of services.
  • Work across the humanitarian–development divide to address multiple drivers and manifestations of nutrition inequity in fragile states.

1.7 Share section

The 2020 Global Nutrition Report

Since 2014, the Global Nutrition Report has provided high-quality, comprehensive and credible data for tracking progress, guiding action, inspiring commitment and mobilising financing to end malnutrition in all its forms. It is a key mechanism to hold all stakeholders (public and private, from all relevant sectors) accountable to the commitments made by global leaders.

The 2020 Global Nutrition Report presents the latest data and evidence on the state of global nutrition.[56] There is now an increased global recognition that poor diet and consequent malnutrition are among the greatest health and societal challenges of our time. This year’s report applies an equity lens to analyse and interpret global nutrition data, elucidate how nutrition can be integrated into the health system, understand the role of food systems in shaping healthier diets and environments, and highlight nutrition financing needs and accountability. The presence of nutrition inequities in health systems, food systems and financing, and inequalities in all forms of malnutrition all highlight the need for multifaceted equitable nutrition action. This is crucial to achieving the 2025 global nutrition targets.

Chapter 2 presents and analyses the latest available data on the global burden of malnutrition and progress towards meeting the 2025 global nutrition targets (on MIYCN and NCDs). It goes deeper to characterise inequalities in nutrition indicators across countries and within countries with a focus on location, and further by key population characteristics, such as age, sex, wealth and education. It highlights key data gaps and the need for granular, systematically collected nutrition data for informed priority-setting and resource targeting according to needs.

Chapter 3 recognises the centrality of nutrition to a healthy life and emphasises the need to integrate and mainstream nutrition within our health systems. It identifies inequities and challenges in such integration and proposes actions across each of the WHO’s six health system building blocks to ensure universally covered, equitable, effective and sustained access to high-quality nutrition care. Implementing effective and cost-effective nutrition actions would improve diets, save lives and reduce health spending.

Chapter 4 examines the crucial role food systems can play in supporting healthier, equitable and sustainable diets. Addressing inequities in food systems (from production to consumption) through equity-sensitive food policies – such as agricultural, labelling, fiscal, reformulation, school procurement and marketing policies – could ensure that healthy, sustainably produced foods are the most accessible, desirable, affordable and convenient choices for all. Everyone needs to be part of the solution, with appropriate mechanisms in place to track effectiveness, financing and accountability.

Chapter 5 presents and analyses the current state of global nutrition financing, primarily from domestic and donor resources. The analysis reveals that nutrition financing remains particularly low, with differences noted by sector, malnutrition form, and population covered, and that more granular data is needed for equitable resource prioritisation. A renewed and increased focus on equitable nutrition financing, leveraging both existing and innovative funding mechanisms, is critical to universally achieving the 2025 global nutrition targets.

Chapter 6 highlights that equitable nutrition is a collective responsibility and calls for all stakeholders to engage and act. This year marks the midpoint of the UN Decade of Action on Nutrition, and the upcoming Tokyo Nutrition for Growth Summit will offer a unique opportunity for world leaders to make bold nutrition commitments that support a pro-equity agenda, so that all people can survive and thrive.

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Footnotes

  1. Afshin et al, 2019. Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet, 393(10184), pp. 1,958–72.

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  2. FAO, 2019. The state of food security and nutrition in the world. Available at: www.fao.org/state-of-food-security-nutrition/en

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  3. Food Security Information Network, 2019. Global report on food crisis. Available at: https://reliefweb.int/report/world/global-report-food-crises-2019

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  4. Ng M., Fleming T., Robinson M. et al., 2014. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet 384(9945), available at: www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60460-8/fulltext

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  5. Global nutrition targets to improve maternal, infant and young child nutrition. Available at: www.who.int/nutrition/global-target-2025/en/

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  6. Global voluntary targets on four major NCDs. Available at: www.who.int/beat-ncds/take-action/targets/en/

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  7. Global Nutrition Report – Country Nutrition Profiles. Available at https://globalnutritionreport.org/resources/nutrition-profiles/

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  9. UN Resolution adopted by the General Assembly on 25 September 2015. 70/1. Transforming our world: the 2030 Agenda for Sustainable Development.

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  10. UN Decade of Action on Nutrition. See www.un.org/nutrition/un-decade-action-nutrition-2016-2025

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  11. Development Initiatives, 2017. Global Nutrition Report 2017: nourishing the SDGs. Available at: www.globalnutritionreport.org

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  12. Norheim O.F. and Asada Y., 2009. The ideal of equal health revisited: definitions and measures of inequity in health should be better integrated with theories of distributive justice. International Journal for Equity in Health 8:40, available at: www.ncbi.nlm.nih.gov/pubmed/19922612; UNSCN, 2018. Advancing equity, equality and non-discrimination in food systems: pathways to reform. UNSCN News 43, available at: www.unscn.org/en/Unscn-news?idnews=1838

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  13. World Health Organization Commission, 2008. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social determinants of Health. Available at: www.who.int/social_determinants/thecommission/finalreport/en/

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  14. World Health Organization Commission, 2008. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social determinants of Health. Available at: www.who.int/social_determinants/thecommission/finalreport/en/

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  15. For an updated version, see: State of the world’s children, 2019. New York: UNICEF, p. 97.

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  16. World Health Organization Commission, 2008. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social determinants of Health. Available at: www.who.int/social_determinants/thecommission/finalreport/en/

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  17. For an updated version, see: State of the world’s children, 2019. New York: UNICEF, p. 97.

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  18. “The OECD characterises fragility as the combination of exposure to risk and insufficient coping capacity of the state, system and/or communities to manage, absorb or mitigate those risks. Fragility can lead to negative outcomes including violence, the breakdown of institutions, displacement, humanitarian crises or other emergencies.”

    Fragility can also be viewed in terms of multidimensional interactions between different forms of fragility, including, in the OECD Fragility Framework: economic, environmental, political, security and societal fragility (OECD, 2016, States of fragility 2016: understanding violence. Available at: http://dx.doi.org/10.1787/9789264267213-en).

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  19. World Health Organization Commission, 2008. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social determinants of Health. Available at: www.who.int/social_determinants/thecommission/finalreport/en/; Baker Phillip, Hawkes Corinna, Wingrove Kate et al, 2018. What drives political commitment for nutrition? A review and framework synthesis to inform the United Nations Decade of Action on Nutrition. BMJ Global Health 3(1): e000485.

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  20. Phumzile Mlambo-Ngcuka, 2018. Opening remarks by UN Women Executive Director at the 62nd session of the UN Commission on the Status of Women.

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  21. UNDP, 2018. What does it mean to leave no one behind? A UNDP discussion paper and framework for implementation. New York: United Nations Development Programme. Available at: www.undp.org/content/undp/en/home/librarypage/poverty-reduction/what-does-it-mean-to-leave-no-one-behind-.html

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  22. World Health Organization Commission, 2008. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social determinants of Health. Available at: www.who.int/social_determinants/thecommission/finalreport/en/, pp. 50–59.

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  23. UNDP, 2018. What does it mean to leave no one behind? A UNDP discussion paper and framework for implementation. New York: United Nations Development Programme. Available at: www.undp.org/content/undp/en/home/librarypage/poverty-reduction/what-does-it-mean-to-leave-no-one-behind-.html

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  24. World Health Organization Commission, 2008. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social determinants of Health. Available at: www.who.int/social_determinants/thecommission/finalreport/en/, pp. 50–59; Barros F.C., Victora C.G., Scherpbier R. et al, 2010. Socioeconomic inequities in the health and nutrition of children in low/middle income countries. Revista de Saúde Pública 44(1): pp. 1–16.

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  25. Cambell J., Hirnschall G. and Magar V., 2017. Ending discrimination in healthcare settings. Commentary. Geneva: the World Health Organization. Available at: www.who.int/news-room/commentaries/detail/ending-discrimination-in-health-care-settings

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  26. UNDP, 2018. What does it mean to leave no one behind? A UNDP discussion paper and framework for implementation. New York: United Nations Development Programme. Available at: www.undp.org/content/undp/en/home/librarypage/poverty-reduction/what-does-it-mean-to-leave-no-one-behind-.html, pp. 13–14.

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  27. UNDP, 2018. What does it mean to leave no one behind? A UNDP discussion paper and framework for implementation. New York: United Nations Development Programme. Available at: www.undp.org/content/undp/en/home/librarypage/poverty-reduction/what-does-it-mean-to-leave-no-one-behind-.html, p. 14.

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  28. Thow A.M. and Nisbett N., 2019. Trade, nutrition, and sustainable food systems. The Lancet 394(10200): pp. 716–18.

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  29. Hagenaars L.L., Jeurissen P.P.T. and Klazinga N.S., 2017. The taxation of unhealthy energy-dense foods (EDFs) and sugar-sweetened beverages (SSBs): an overview of patterns observed in the policy content and policy context of 13 case studies. Health Policy 121(8): pp. 887–94. (doi:10.1016/j.healthpol.2017.06.011); Swinburn B.A., Kraak V.I., Allender S. et al, 2019. The global syndemic of obesity, undernutrition, and climate change: The Lancet Commission report. The Lancet 393(10173): pp. 791–846.

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  30. Barros F.C., Victora C.G., Scherpbier R. et al, 2010. Socioeconomic inequities in the health and nutrition of children in low/middle income countries. Revista de Saúde Pública 44(1): pp. 1–16; World Health Organization Commission, 2008. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social determinants of Health. Available at: www.who.int/social_determinants/thecommission/finalreport/en.

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  32. Transforming our world: the 2030 Agenda for Sustainable Development Adopted at the United Nations Sustainable Development Summit on 25 September 2015. Available at: https://sustainabledevelopment.un.org/post2015/transformingourworld

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  36. Swinburn B.A., Kraak V.I., Allender S. et al, 2019. The global syndemic of obesity, undernutrition, and climate change: The Lancet Commission report. The Lancet 393(10173), pp. 791–846.

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  37. World Health Organization Commission, 2008. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social determinants of Health. Available at: www.who.int/social_determinants/thecommission/finalreport/en/, p. 2.

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  38. World Health Organization Commission, 2008. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social determinants of Health. Available at: www.who.int/social_determinants/thecommission/finalreport/en/

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  40. Summarised in Gillespie et al, 2014. The politics of reducing malnutrition: building commitment and accelerating progress. The Lancet 382(9891), pp. 552–69; Nisbett et al, 2015. What drives and constrains effective leadership in tackling child undernutrition? Findings from Bangladesh, Ethiopia, India and Kenya. Food Policy, 53, May, pp. 33–45; and Baker et al, 2018. Addressing trade policy as a macro-structural determinant of health: The role of institutions and ideas. Global Social Policy 18(1), pp: 94–101.

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  44. Smith L.C. and Haddad L., 2015. Reducing child undernutrition: past drivers and priorities for the post-MDG era. World Development 68: pp. 180–204. The authors used the International Country Risk Guide (ICRG) indicators published by the Political Risk Services Group in 2013. A similar set of indicators is available via the Worldwide Governance Indicators project of the World Bank (https://info.worldbank.org/governance/wgi/).

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  45. UN Women, Women Count and United Nations Department of Economic and Social Affairs, 2019. Progress on the Sustainable Development Goals. The Gender Snapshot 2019. Available at: www.unwomen.org/en/digital-library/publications/2019/09/progress-on-the-sustainable-development-goals-the-gender-snapshot-2019

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  46. UN Women, Women Count and United Nations Department of Economic and Social Affairs, 2019. Progress on the Sustainable Development Goals. The Gender Snapshot 2019. Available at: www.unwomen.org/en/digital-library/publications/2019/09/progress-on-the-sustainable-development-goals-the-gender-snapshot-201947

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  49. World Health Organization Commission, 2008. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social determinants of Health. Available at: www.who.int/social_determinants/thecommission/finalreport/en/.

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  50. World Health Organization Commission, 2008. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social determinants of Health. Available at: www.who.int/social_determinants/thecommission/finalreport/en/.

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  51. Swinburn B.A., Kraak V.I., Allender S. et al., 2019. The global syndemic of obesity, undernutrition, and climate change: The Lancet Commission report. The Lancet 393(10173), pp. 791–846.

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  52. Committee on World Food Security, http://www.fao.org/cfs

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  53. Scaling Up Nutrition Movement, https://scalingupnutrition.org/

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  54. UN Climate Change, COP, https://unfccc.int/

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  56. This edition of the Global Nutrition Report uses the latest available data at the time the analysis was performed.

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