Chapter 04

From promise to action: Progress towards the 2013 and 2017 Nutrition for Growth commitments

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Contents
4.1 Share section

Key points

  • By 2020, while slightly over 40% of donors and civil society organisations had reached their financial commitment goals on Nutrition for Growth, there was limited progress towards country financial and impact commitment goals.
  • Only 36% of all the Nutrition for Growth commitment goals were aligned with the six global targets on maternal, infant and young child nutrition. No commitment goals aligned with the diet-related targets on non-communicable diseases.
  • The Covid-19 pandemic severely affected 43% of country commitment goals. Progress was hindered due to a lack of funding or diversion of national revenue and resources towards Covid-19 mitigation.
4.2 Share section

Introduction

Nutrition for Growth (N4G) is a global effort that brings together all stakeholders, including country governments, donors, businesses, and civil society organisations (CSOs) to accelerate progress on tackling poor diets and malnutrition in all its forms.[1] During the 2013 N4G Summit, stakeholders came together to scale up political commitments, increase financial investments and take urgent action[2] that led to 110 stakeholders making 357 commitments. The 2017 N4G Summit led to an additional 34 commitments from 16 stakeholders. Between 2013 and 2017, the N4G effort raised US$7.4 billion[3] in nutrition-specific and US$19 billion in nutrition-sensitive investments.[4]

The Global Nutrition Report (GNR) was a key commitment of the N4G Summit in 2013 to monitor nutrition commitments and assess translation to impact, to accelerate progress in tackling poor diets and malnutrition in all its forms worldwide (Chapter 1). In 2021, to support the registration and reporting of new and SMART[5] nutrition commitments made in the Nutrition for Growth Year of Action and beyond, the GNR has set up the Nutrition Accountability Framework (NAF). The role of the GNR and its stewardship in monitoring the state of the world’s nutrition is more critical than ever, given the toll of the Covid-19 pandemic on food systems, nutrition and food security, and consequences for maternal and child undernutrition,[6][7][8] as well as the powerful intersections between diet-related non-communicable diseases (NCDs) and Covid-19 outcomes (Chapter 1 Box 1.1 and Box 1.2).

In this chapter, we assess progress on N4G 2013 and the Global Nutrition Summit 2017 commitment goals in 2020, followed by preliminary analysis of the ongoing 2021 assessment, and examine the alignment of these N4G commitments with the global nutrition targets. We also assess the impact of the Covid-19 pandemic on stakeholders’ ability to achieve their ongoing commitment goals (Box 4.1).

4.3 Share section

The N4G commitments

The GNR has implemented the N4G tracker survey annually since 2014, to assess progress towards commitments made by stakeholders at the 2013 and the 2017 Summits (Figure 4.1).[9][10] Progress is assessed using a comprehensive methodology available online: Global Nutrition Report | N4G Commitment Tracker methodology. With no "a priori" classification system established, the past N4G commitments were categorised into specific categories by stakeholder type.[11] Country commitments were grouped into policy, programme, financial and impact commitments; business commitments into workforce and non-workforce commitments; commitments from UN, and other groups into general commitments; while commitments from donors and civil society organizations (CSOs) into financial and non-financial commitments.[12] Details on progress for each stakeholder can be found on the Nutrition for Growth Commitment Tracker webpage of the Global Nutrition Report.

Commitments, as reported by stakeholders, could have one or multiple measurable goals. A measurable goal is what the stakeholder has committed to achieve and is used to track and assess progress made towards the commitment. Given the lack of initial classification on how formulated commitments were to be tracked (ensuring SMART-ness and comparability across stakeholders),[13] we standardised commitments by disaggregating them into ‘commitment goals’. Thus, if a stakeholder had made one commitment with two distinct measurable goals, progress was assessed for each of the two commitment goals separately.

We refer to these measurable goals as commitment goals.[14] Of 391 commitments, we enumerated 456 commitment goals, 416 made during the 2013 Summit and 40 during the 2017 Summit.

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Figure 4.1 Countries have the highest number of commitment goals, most made in the N4G 2013 Summit

Number of commitment goals by stakeholder type

Figure 4.1 Countries have the highest number of commitment goals, most made in the N4G 2013 Summit

Stacked bar chart showing number of commitment goals by stakeholder type

Source: Authors and collaborators based on Global Nutrition Report (2020) Nutrition for Growth Commitment Tracker. Bristol, UK: Development Initiatives

Notes: The total number of commitment goals is 456 (of 391 commitments). The ‘other’ category includes research agencies and institutes such as the Consultative Group for International Agricultural Research. Values reflect the absolute number of commitment goals by stakeholder type made at past N4G summits (2013 and 2017 combined).

4.4 Share section

Progress in 2020, on achieving the 2013 and 2017 N4G commitments

Progress reporting in 2020 had a response rate of 61% (69% for the 2013 commitment goals and 48% for the 2017 commitment goals). The highest response rate was recorded among donors (79%) and CSOs (80%) and the lowest response rate among businesses (33%) and the ‘other’ category (28%).[15] This represents a substantial decline in the response rate compared to 2014 (90%), but an increase since the lowest response rate recorded in 2017 (51%).[16] Irrespective of summit year, the 2020 progress assessment revealed that 38% of commitment goals were on course while 16% of commitment goals had been reached by 2020. Of those commitment goals made in 2013 (n=343), 17% (n=58) had been reached by 2020 and 39% (n=135) were on course. Of those made in 2017 (n=40), only 5% (n=2) had been reached and 30% were on course (n=12).

By stakeholder type, goals made in the 2013 Summit that had been reached were: 39% of donor goals (12 of 31 commitment goals), 13% country (20 of 150), 29% civil society (8 of 28), 29% other (2 of 7), 14% UN (4 of 28) and 12% business (12 of 125). The 2013 goals on course to be met were: 86% of UN (24 of 28 commitment goals), 26% donor (8 of 31), 46% country (69 of 150), 46% civil society (13 of 28) and 21% business (21 of 99). Of commitment goals set at the 2017 summit, 18% of donor goals had been reached (2 of 11), while there was progress ‘on course’ for 50% of civil society commitment goals (1 of 2), 25% country (5 of 20) and 55% donor (6 of 11).[17] No business commitment goal made in 2017 had been reached or were on course.

Figure 4.2 shows progress in 2020 by stakeholder and type of commitment goal, combined for both summits (n=383 goals).[18] As of 2020, over 40% of financial commitment goals made by donors (8 of 18 goals) and civil society (4 of 9 goals) had been reached, but 23% of country (6 of 26 goals), 22% of civil society (2 of 9 goals) and 11% of the financial commitment goals made by donors (2 of 18 goals) were off course. Between 40% and 55% of country impact, programme and policy commitment goals and civil society non-financial commitment goals were on course, as were 86% of UN commitment goals. For the 2013 Summit specifically, 18% of country financial, 14% of civil society and 9% of donor financial commitment goals were off course. Commitment goals made in the 2017 Global Nutrition Summit were fewer and response rate was low.

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Figure 4.2 Just over half of all commitment goals made at past N4G summits were either reached (16%) or on course (38%) by 2020

Reported progress in 2020 towards commitments made in the 2013 and 2017 N4G Summits

Figure 4.2 Just over half of all commitment goals made at past N4G summits were either reached (16%) or on course (38%) by 2020

Stacked bar chart showing reported progress in 2020 towards commitments made in the 2013 and 2017 N4G Summits

Source: Authors and collaborators based on Global Nutrition Report (2020) Nutrition for Growth Commitment Tracker. Bristol, UK: Development Initiatives.

Notes: This figure shows percentages of all unique commitment goals (n=383) made at past N4G summits (2013, 2017) and excludes those classified as not applicable (n=73).

4.5 Share section

Progress on achieving the 2013 and 2017 commitment goals in 2021: Preliminary findings

The 2021 N4G tracker survey was deployed in June 2021; by August 2021, 54 stakeholders had reported on their progress.[19] While there is substantial progress across stakeholders, about 20% of country-level financial and impact commitment goals are still off course (Figure 4.3). A complete picture of progress will be available on completion of the survey (November 2021) on the N4G tracker website.[20] The N4G tracker also included questions to assess the impact of Covid-19 on progress in achieving goals (Box 4.1).

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Figure 4.3 Donors and civil society made the best progress between 2020 and 2021 towards meeting financial commitment goals

Progress achieved by commitment goal and stakeholder type, 2021

Figure 4.3 Donors and civil society made the best progress between 2020 and 2021 towards meeting financial commitment goals

Stacked bar chart showing progress achieved by commitment goal and stakeholder type, 2021

Source: Authors and collaborators based on the 2020 and 2021 Global Nutrition Report Nutrition for Growth Commitment Trackers. Bristol, UK: Development Initiatives.

Notes: The total number of unique commitment goals followed up on was 456. The substantially reduced unique commitment goals are due to exclusion of business stakeholders (n=132) and those classified as not applicable (n=46). Thus, a total of 278 unique commitment goals are assessed in this figure and include those that reached commitment in 2020 (n=48), reached commitment in 2021 (n=7), on course (n=134), off course (n=26), non-assessable (1) and no response (62) as of August 2021.

4.6 Share section

Alignment of N4G commitment goals with the global nutrition targets

We assessed the alignment of N4G commitment goals (2013 and 2017) with the global nutrition targets by conducting an in-depth review of all commitment goals and coding each goal based on the language of the commitment. The global nutrition targets include the six maternal, infant and young child nutrition (MIYCN) targets and the three diet-related non-communicable disease (NCD) targets. To assess alignment, we coded each commitment goal as aligning with a global nutrition target if the goal made any reference to that global nutrition target. For example, with respect to the stunting target, a commitment goal was considered aligned if it addressed stunting whether it specified the exact target or had a different one (e.g., 50% reduction instead of 40% reduction in stunting). Similarly, if a goal outlined actions to support a target (e.g., a social behaviour change campaign to promote breastfeeding or a maternal workforce nutrition policy), it was considered to align with the exclusive breastfeeding target.

Of the 383 commitment goals, 136 commitment goals (36%) aligned to at least one of the six MIYCN global nutrition targets. These were 71 country, 9 UN agency, 9 civil society, 10 donor and 37 business commitment goals. There were no commitment goals aligned with the three-diet related NCD targets. Most aligned country commitment goals focused on MIYCN improvements, and reduction in stunting and wasting. In absolute numbers: 31 goals were aligned with reduction of stunting (8.1%), 8 with reducing anaemia (2.1%), 2 with preventing low birth weight (0.5%), 4 with prevention of overweight in children under 5 years of age (1.0%), 73 on improving maternal health, breastfeeding, infant and young child feeding (19.1%) and 18 on reduction of wasting (4.7%). There were 247 goals not aligned with any of the nine targets (64.5%) (Figure 4.4).

We separately examined all the commitment goals and found few that referred to improvements in diets. Only 17 commitment goals focused on improving food production/ quality and emphasised nutrition-sensitive agriculture which may indirectly support improved diets. While committing to diet-related goals or other diet-related targets was not part of the commitment-making process in either the 2013 or 2017 Summits, healthy diets are critical in preventing all forms of malnutrition. This deficiency is being addressed with the Tokyo N4G 2021 Summit calling for action on prioritising nutrition across health and food systems, advocating for instance for a ‘Whole of Government Food System Action Plan’ and forming a multisectoral response to promote healthy and sustainable diets and reduce diet-related diseases.[21]

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Figure 4.4 Commitment goals aligned to the global nutrition targets primarily focused on reducing stunting and improving MIYCN

Distribution of commitment goals by alignment to the global nutrition targets

Figure 4.4 Commitment goals aligned to the global nutrition targets primarily focused on reducing stunting and improving MIYCN

Stacked bar chart showing distribution of commitment goals by alignment to the global nutrition targets

Source: Authors and collaborators based on Global Nutrition Report (2020) Nutrition for Growth Commitment Tracker. Bristol, UK: Development Initiatives

Notes: The total number of commitment goals aligned were 383, of which 247 were general commitment goals, 136 aligned with six MIYCN targets. No goals aligned with the three diet-related targets.

4.7 Share section

Challenges in measuring progress

The GNR established a systematic and standardised approach in tracking the N4G commitments, yet there were several challenges that affected assessment.[22] First, commitments as formulated at the time did not meet the SMART (Specific, Measurable, Achievable, Relevant and Time-bound) criteria. An assessment made in 2015 and 2016 found that only 29% of the N4G commitments met the SMART criteria. While impact and financial commitments were more likely to be SMART, progress towards these was also least likely to be on course.[23]

The need for trackable SMART nutrition commitments has been long emphasised as critical, and essential for accountability. An independent accountability framework for nutrition was advocated and called for by a joint statement of the N4G Summit on Nutrition and the UN Food Systems Summit.[24] The Nutrition Accountability Framework (NAF) is the world’s first independent and comprehensive global accountability framework for nutrition, designed to drive stronger nutrition action and accelerate progress in tackling poor diets and malnutrition in all its forms. The NAF has established SMART criteria for assessing commitments, with commitments made during the Nutrition for Growth Year of Action being the first to be assessed.[25]

Second, progress toward these commitments is self-reported by stakeholders, there is potential for incomplete or biased reporting that threatens the validity of the reporting.[26] Information bias can be generated by either poor or incorrect recall or the need for social desirability or approval. Validating data-collection tools can help to overcome such biases, as addressed by the NAF.

Third, the lack of initial guidance and a classification system for commitment goals led stakeholders to use different approaches in formulating and recording their commitments. While some stakeholders bundled multiple goals within one commitment, others submitted individual goals or actions as commitments. This made comparison over time and across stakeholder groups difficult. In this chapter, we disaggregate commitments into individual ‘unique’ commitment goals to make them comparable. This also allows us to assess alignment with the global nutrition targets, as well as to compare progress more accurately across and within stakeholder groups. The NAF also uses this approach during the commitment registration process.[27]

Fourth, the response rate across stakeholders has declined considerably over time, indicating reporting fatigue. Coordination and collaboration across different mechanisms of measuring accountability and tracking progress is critical to relieve reporting burden, a major consideration being addressed through the NAF.[28]

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Box 4.1 The Covid-19 pandemic has affected progress in country commitment goals

Shibani Ghosh and Mariachiara Di Cesare

The impacts of the Covid-19 pandemic on maternal and child undernutrition and child mortality and food security have been highlighted by the global community (Chapter 1).[29][30][31][32] The impacts of overweight and obesity, type 2 diabetes and hypertension on worsening complications of Covid-19 are also well documented.[33][34] The GNR, as part of its annual N4G tracking, has expanded the 2021 survey to assess how the Covid-19 pandemic has affected progress in achieving commitment goals. In this ongoing survey, of the 230 commitment goals that have been reported on, 28 were reported to have been severely-to-highly impacted by the pandemic, 32 moderately and 23 with little or low-to-no impact. Twenty-six country commitment goals were severely to highly impacted (43% of all country commitment goals), with 18 moderately impacted and 15 with low/little-to-no impact by Covid-19 (Figure 4.5). The most common stated reasons were a general lack of funding for achieving the nutrition commitment, due to either a lack of revenue at the national level because of economic disruptions or diversion of resources (both national and donor aid) for Covid-19 interventions.

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Figure 4.5 Covid-19 has primarily affected commitment goals made by countries

Reported impact of the Covid-19 pandemic by stakeholder type, 2021

Figure 4.5 Covid-19 has primarily affected commitment goals made by countries

Stacked bar chart showing reported impact of the Covid-19 pandemic by stakeholder type, 2021

Source: Global Nutrition Report (2021) Nutrition for Growth Commitment Tracker. Bristol, UK: Development Initiatives.

Notes: This figure includes stakeholders that had not reached their commitment goals by 2020 and responded to the Covid-19 questions in the 2021 survey (n=96 out of 230 unique commitment goals).

4.8 Share section

Conclusion

The need to tackle poor diets and malnutrition in all its forms is well established. Malnutrition in all its forms has shared causes, and tackling these necessitates integrated action and surveillance.[35][36] While progress has been made, stunting and wasting remain significant issues in low-income countries, as does prevalence of anaemia in women while the burden of death and disability due to poor-quality and unhealthy diets continues to escalate (Chapter 1 and Chapter 2).[37][38] While there is progress, countries are not on course to meet their financial and impact commitment goals. Only 36% of commitments made in past N4G summits aligned with MIYCN targets while none aligned with the diet related NCD targets. The likely reason for this is the lack of focus on diet-related conditions in the first N4G summit. However, there is renewed attention and focus on addressing malnutrition in all its forms, including emphasis on building food systems that promote sustainable and healthy diets.[39]

There have been significant challenges in measuring progress, which have been long recognised by the nutrition community. The GNR has launched the Nutrition Accountability Framework, which addresses many of these challenges. Finally, the Covid-19 pandemic has had severe impacts on financial resources at the country level, which is likely to decelerate progress. Despite the ongoing pandemic, the global community is galvanising, during the Nutrition for Growth Year of Action, the UN Food Systems Summit and the Tokyo N4G 2021 Summit, to take strong nutrition action to win the fight against poor diets and malnutrition in all its forms.

4.9 Share section

Key recommendations

To achieve the global nutrition targets, country stakeholders must intensify and accelerate efforts to reach their commitment goals, particularly financial and impact goals.

There has been progress by donor and civil society groups on reaching their commitment goals in 2020, yet there is far less progress by countries towards financial and impact commitment goals. While most country impact commitment goals appear to be ‘on course’, very few ‘reached commitment’.

We advocate for stakeholders of the Tokyo N4G Summit to make SMART commitments targeting undernutrition, anaemia, micronutrient inadequacy, overweight, obesity, NCD mortality and disability. Special attention is needed to ensure equitable, sustainable and healthy diets for all.

Only 36% of all the N4G commitment goals were aligned with the six MIYCN targets and most do not meet the SMART criteria. None of commitment goals specifically targeted improving diets. While diet-related goals were not explicitly targeted in either the 2013 or 2017 Summits, there is urgent need for action on diet-related commitments and goals.

Following revenue and economic disruptions due to the Covid-19 pandemic, which have hampered achievement of country commitment goals, we recommend urgent assessment of the impact of the pandemic and of additional financing needs to ensure that past progress is not lost.

Of all country goals, 43% were severely or highly affected due to financial constraints. Diversion of revenue and resources towards the Covid-19 pandemic were reported. We must act to ensure that we do not lose progress made so far in improving nutrition worldwide.

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Footnotes

  1. Nutrition For Growth (https://nutritionforgrowth.org). Accessed 19 August 2021.

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  2. International Food Policy Research Institute. Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030. Washington DC: IFPRI, 2016 (www.globalnutritionreport.org/reports/2016-global-nutrition-report/).

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  3. US$4 billion raised in 2013 and US$3.4 billion in the 2017 Summit.

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  4. Nutrition-sensitive actions are interventions, programmes or policies in sectors other than nutrition that address the underlying determinants of fetal and child nutrition and development, and incorporate specific nutrition goals and actions. Sectors include agriculture, health, social protection, early child development, education, and water and sanitation. Nutrition-specific actions are interventions, programmes or policies intended to have a direct impact on immediate determinants of nutrition. Nutrition-specific actions can include: promotion of adequate food and nutrient intake; feeding, caregiving and parenting practices; and prevention of infectious diseases. Examples are breastfeeding promotion, disease management and treatment of acute malnutrition in emergencies.

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  5. SMART goals are: Specific, Measurable, Achievable, Relevant and Time-bound.

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  6. Osendarp S, Akuoku JK, Black RE et al. The COVID-19 crisis will exacerbate maternal and child undernutrition and child mortality in low- and middle-income countries. Nat Food 2 2021; 476–84 (doi.org/10.1038/s43016-021-00319-4).

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  7. Heidkamp R, Piwoz E, Gillespie S, et al. Mobilising evidence, data, and resources to achieve global maternal and child undernutrition targets and the Sustainable Development Goals: an agenda for action. Lancet 2021; 397(10282):1400–18 (https://doi.org/10.1016/S0140-6736(21)00568-7).

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  8. World Bank. Food Security and COVID-19. 23 August 2021 (www.worldbank.org/en/topic/agriculture/brief/food-security-and-covid-19).

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  9. Nutrition for Growth Tracker methodology (https://globalnutritionreport.org/resources/nutrition-growth-commitment-tracking/methodology/). Accessed 15 July 2021.

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  10. While a summit was held in Rio De Janeiro in 2016, there were no commitments made. In addition, this analysis does not consider non-summit commitments (made in years outside the summit year).

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  11. No a priori classification system was established; while the original N4G compact focuses on four types of commitments, subsequent data processing led to separate categories by stakeholder type.

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  12. Commitments at the country level range from regulatory and cross-sectoral policies for nutrition to specific actions targeting maternal, infant and young child nutrition, and increasing domestic support. At the business level, these include workforce policies to support maternal health and wellness and non-workforce commitments to improve nutrition delivered through the food system. Commitments also include mobilisation and alignment of international resources, empowering country-led coordination and facilitating mutual learning by donors, mobilising private sector resources to support scaling up nutrition programmes, and, at the UN and donor level, jointly setting targets for nutrition with relevant Sustainable Development Goal indicators by the United Nations and UN member states.

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  13. The SMART approach has since been implemented for new commitments: Global Nutrition Report. The SMARTness of nutrition commitments. Available at: www.globalnutritionreport.org/resources/naf/smart-commitments/.

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  14. Return to source text
  15. These estimates are based on 383 of 456 commitment goals. Of these, 343 are 2013 Summit commitments while 40 are 2017 Summit commitments; 73 goals are excluded because they are coded as not applicable. Further details are available in the online methodology (www.globalnutritionreport.org/resources/nutrition-growth-commitment-tracking/methodology/).

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  16. Development Initiatives, 2017. Global Nutrition Report 2017: Nourishing the SDGs. Bristol, UK: Development Initiatives. Available at: https://globalnutritionreport.org/reports/2017-global-nutrition-report/.

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  17. No UN commitments were made in the 2017 Summit.

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  18. There are 73 commitments not tracked and coded as not applicable. Some of these are commitments listed under businesses not required to make commitments, while some are country and donor commitments that are endorsements and not active commitments that can be tracked.

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  19. The total number followed up was 456. The substantially reduced unique commitment goals are due to exclusion of business stakeholders (n=132), those classified as not applicable (n=46) and those that reached commitment in 2020 (n=48). Thus, a total of 230 unique commitment goals are being assessed.

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  20. The Nutrition for Growth Commitment Tracker is available at: www.globalnutritionreport.org/resources/nutrition-growth-commitment-tracking/.

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  21. Return to source text
  22. Nutrition for Growth Tracker methodology (https://globalnutritionreport.org/resources/nutrition-growth-commitment-tracking/methodology/). Accessed 15 July 2021.

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  23. International Food Policy Research Institute 2016. Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030. Washington DC (https://globalnutritionreport.org/reports/2016-global-nutrition-report/).

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  24. The Nutrition Accountability Framework: About the Nutrition Accountability Framework (Chapter 1) (www.globalnutritionreport.org/resources/naf/about/).

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  25. Global Nutrition Report - The SMARTness of nutrition commitments. Available at: https://globalnutritionreport.org/resources/naf/smart-commitments/.

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  26. Althubaiti A. Information bias in health research: definition, pitfalls, and adjustment methods. J Multidiscip Healthc 2016; 9: 211–17 (doi:10.2147/JMDH.S104807).

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  27. Nutrition Accountability Framework. A guide to the NAF Platform's Commitment Registration Form - Global Nutrition Report (www.globalnutritionreport.org/resources/naf/platform-guide/).

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  28. Global Nutrition Report - About the Nutrition Accountability Framework - Global Nutrition Report). Available at: https://globalnutritionreport.org/resources/naf/about/

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  29. Osendarp S, Akuoku JK, Black RE et al. The COVID-19 crisis will exacerbate maternal and child undernutrition and child mortality in low- and middle-income countries. Nat Food 2 2021; 476–84 (doi.org/10.1038/s43016-021-00319-4).

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  30. Fore HH, Dongyu Q, Beasley BM, Ghebreyesus TA. Child malnutrition and COVID-19: the time to act is now. Lancet 2020; 396(10250): 517–18 (doi.org/10.1016/S0140-6736(20)31648-2).

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  31. Headey D, Heidkamp R, Osendarp S, et al. Impacts of COVID-19 on childhood malnutrition and nutrition-related mortality. Lancet 2020; 396(10250): 519–21 (doi.org/10.1016/S0140-6736(20)31647-0).

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  32. Robertson T, Carter ED, Chou VB, et al. Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. Lancet Global Health 2020; 8(7): e901–e908.

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  33. Soeroto AR, Soetedjo NN, Purwiga A, et al. Effect of increased BMI and obesity on the outcome of COVID-19 adult patients: a systematic review and meta-analysis. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 2020; 14(6): 1897–1904 (doi.org/10.1016/j.dsx.2020.09.029).

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  34. Kuehn BM. More severe obesity leads to more severe COVID-19 in study. JAMA 2021; 325(16): 1603 (doi:10.1001/jama.2021.4853).

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  35. WHO. The double burden of malnutrition. Policy brief. Geneva: World Health Organization, 2017.

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  36. Development Initiatives, 2017. Global Nutrition Report 2017: Nourishing the SDGs. Bristol, UK: Development Initiatives. Available at: https://globalnutritionreport.org/reports/2017-global-nutrition-report/.

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  37. Victora CG, Christian P, Vidaletti LP, et al. Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda. Lancet 2021; 397(10282): 1388–99 (doi.org/10.1016/S0140-6736(21)00394-9).

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  38. GBD 2017 Diet Collaborators. Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study, 2017. Lancet 2019; 393(10184): 1958–72 (doi: 10.1016/S0140-6736(19)30041-8).

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  39. Return to source text