Governments: Tackling poor diets and malnutrition domestically

1. Governments have boosted efforts to tackle poor diets and malnutrition in all its forms; 65 registered almost half of all goals made during the Nutrition Year of Action. These 470 goals focused on enabling (196, 42%) and impact (183, 39%) actions rather than policy (91, 19%), with limited focus on food systems.
2. Impact goals focused on tackling maternal, infant and young child nutrition outcomes such as stunting, wasting, anaemia and exclusive breastfeeding. Clear effort to address the overweight epidemics is emerging. Commitments to tackle non-communicable diseases and their risk factors remains limited.
3. Most (90%) of the goals submitted by governments during the Nutrition Year of Action were from low- and lower-middle-income countries. High-burden countries committed to a range of nutrition actions to enhance leadership, governance and finance nutrition actions, and low-burden countries focused on policy nutrition actions.

If you would like to know more about any of the terms used in this chapter, you can visit the report glossary.

Domestic commitments from governments^[1] are critical to achieve the shared vision of a world free from malnutrition in all its forms. Local and national governments must provide their population with access to healthy foods, ensure food security, and deliver high-quality healthcare.^[2] Governments must be fully committed to the Sustainable Development Goals and implement actions, programmes and policies addressing both the underlying and immediate causes of malnutrition.^[3]

During the Nutrition Year of Action, 65 governments (across 78 government organisations)^[4] over four continents submitted 223 commitments with 470 goals.^[5] Looking at the 17 goals (out of 43) for which financial information was available, they committed US$13.3 billion in the effort to end malnutrition. Yet this is an underestimation, given that information on the total amount of the contribution is not available consistently. The US and Denmark submitted commitments with both domestic and international remits.^[6] Of the 223 commitments, 220 (99%) were submitted during the Tokyo Nutrition for Growth (N4G) Summit 2021 and the remaining were submitted during the Nutrition Year of Action but outside the summit. This is a major step forward from the 2013 N4G Summit when only 27 governments committed to reducing malnutrition, increasing domestic nutrition budgets, and scaling up national nutrition plans.^[7] Most commitments (153, 69%) submitted by the governments were joint and made on behalf of multiple commitment-making entities (i.e. United Nations agencies, other governments, and other donor organisations). Of the 470 goals put forward by the governments, 128 (27%) were developed in response to the impact of the Covid-19 pandemic.

Of the 65 governments that engaged with the Nutrition Year of Action, 52 (80%) were from low- and lower-middle-income countries^[8] and 55 (85%) belonged to the Scaling Up Nutrition (SUN) Movement.

Of the 470 goals submitted by governments, 196 (42%) focused on establishing an enabling environment for effective nutrition action across all sectors (i.e. categorised as enabling) and 183 (39%) on directly improving poor diets and reducing malnutrition in all its forms (impact actions). Only 91 (19%) focused on strategies, policies, interventions or programmes that aimed to improve nutrition outcomes both directly and indirectly (policy actions).

The approach used by governments to tackle poor diet and malnutrition in all its forms considers mostly actions targeting the national geographic area (91%) compared with subnational or community-level areas. In terms of target population, 226 (48%) goals made by governments focused on a specific group of people, mostly specific age groups. For example, 210 (45%) goals targeted children and women of reproductive age, and 33 (7%) targeted only girls and women.

A third of goals submitted by governments (151, 32%) were lower moderate in SMARTness, followed by low (122, 26%), high (116, 25%) and upper moderate (81, 17%). Overall, 260 (55%) goals were not trackable requiring minimal (138, 29%) or extensive (122, 26%) clarifications. Goals submitted by the governments can be substantially improved by quantifying the estimated costs associated with the delivery of the goals in general.

Finally, the average duration of a goal differed across the three nutrition action categories: 6.0 years for the enabling goals, 6.5 years for policy and 7.3 years for impact. Within the nutrition action sub-categories, ‘food and nutrition security’, ‘undernutrition’ and ‘obesity and diet-related non-communicable diseases (NCDs)’ goals (all under the impact category) were set to be achieved in the longest timescale (over 7 years); ‘leadership and governance’, ‘operational’, ‘food supply chain’, and ‘food environment’ (enabling and policy actions) were those with the shortest timescale (below 6 years).

Commitments (223) were mostly focused on maternal, infant and young child nutrition global targets – stunting (145, 65%), wasting (131, 59%), anaemia (107,48%), low-birth weight (108, 48%), child overweight (106, 48%) and exclusive breastfeeding (103, 46%). They were less focused on the NCD targets – obesity (81, 36%), diabetes (65, 29%), raised blood pressure and salt (56, 25%) (commitments may focus on multiple targets, so percentages total over 100%).

In this chapter, we provide initial analysis of commitments submitted during the Nutrition Year of Action by governments. We focus on understanding the remit of impact actions and the differences in action categories based on the country income group and burden of malnutrition profile. We provide a preliminary characterisation of the commitments and goals submitted and their association with the economic and nutritional burden experienced by countries.^[9]

In the Nutrition Year of Action, governments mostly registered enabling (196, 42%) and impact (183, 39%) goals (Figure 3.1). For enabling nutrition actions, they embraced the need for: bold political leadership and good governance in delivering effective nutrition policies, interventions and programmes (87, 44%); secure financial resources and investments for nutrition-specific and/or nutrition-sensitive actions (43, 22%); and reliable and up-to-date nutrition information (40, 20%). For impact actions, most goals (107, 58%) were directly aimed at reducing undernutrition with a focus on maternal, infant and young child nutrition outcomes. Policy goals remained limited (91, 19%), focusing on integrating and enhancing nutrition services and interventions (43, 47%), and with ‘food environment’, ‘food supply chain’, and improving ‘consumer knowledge’ comprising 44 (48%) of all policy goals (Figure 3.1). For both SUN and non-SUN governments, 180 (39%) goals were specific to impact. SUN governments submitted a larger proportion of enabling goals (180, 43%) and a lower proportion of policy goals (76, 18%) than non-SUN countries (respectively 16, 31%, and 15, 29%).

All commitments submitted by governments during the Tokyo N4G Summit (467) met the N4G criteria.^[10]

They covered all N4G thematic areas with the largest being ‘health’ (145, 31%) followed by ‘food’ (122, 26%), ‘resilience’ (98, 21%), ‘data’ (70, 15%) and ‘financing’ (69, 15%) (commitments may focus on multiple thematic areas, so percentages total over 100%).

Out of 43 financial goals submitted by governments, 17 included a committed amount for a total of over US$13.3 billion (yet this is an underestimation given information on the total amount of the contribution is not available consistently). The majority (30, 70%) of all financial goals were specific to budget allocation to nutrition, and the remaining included mobilisation of financial resources for national plans (4, 9%), mobilisation of financial resources for nutrition mechanisms (3, 7%), costing for plans (2, 5%), creation of a budget line specific to nutrition (2, 5%), investment in nutrition programmes (1, 2%), and mobilisation of financial resources for ready-to-use therapeutic food (1, 2%). Ten of the 43 ‘financial’ goals included some level of reporting mechanism (i.e. international organisations, government).

Governments’ impact goals show their willingness to commit to improving poor diets and reducing malnutrition, particularly by addressing food insecurity and undernutrition and also partly by tackling obesity and diet-related NCDs. Figure 3.2 shows the number of impact goals submitted by governments. Governments committed to all four impact sub-categories of ‘diet’ (45, 25%), ‘undernutrition’ (107, 58%), ‘obesity and diet-related NCDs’ (21, 11%), and ‘food and nutrition security’ (9, 4.9%). Two-thirds (31, 57%) of government goals were in at least two of these areas. Some notable examples show that it is possible to develop goals in all four areas, as the case of Bangladesh (8 goals) and Philippines (15 goals). Ethiopia, Guinea, Honduras, Kenya, Mongolia, Nepal, Tanzania and Zambia submitted ‘diet’, ‘undernutrition’, and ‘obesity and diet-related NCDs’ goals, but not ‘food and nutrition security’. Philippines and Nepal submitted the largest number of impact goals (15 and 10, respectively) followed by Pakistan (8), Bangladesh (8) and Kenya (7).

Governments mostly designed their impact goals through population-targeted actions with the majority (138, 75%) aimed at specific age groups such as infants, children in a specific age group, women/men in specific age groups and/or focusing only on girls and women. When the impact goals that were ‘diet’, ‘undernutrition’, and ‘obesity and diet-related NCDs’ are explored for specific patterns, we find that the majority of governments focus on maternal, infant and young child nutrition with stunting, wasting, anaemia (mostly focused on women), and exclusive breastfeeding. A smaller number of impact goals were ‘obesity and dieted-related NCDs’, the majority of which were aimed at overweight and obesity reduction, with very limited focus on tackling raised blood pressure, diabetes and other NCDs.

To better understand the level of effort committed by governments, the average percentage change was calculated for the 172 impact goals when at least two goals specific to the same target were submitted (i.e. reduction in the prevalence of stunting) and for which relevant information (e.g. baseline and target levels) was available. Across all the goals the average percentage changes were a reduction of 42.6% in the prevalence of anaemia (43% for children, 32% for adolescents and 44% for women); 14% in the prevalence of overweight (8% for children, 20% for adults); 30% in the prevalence of stunting; 45% in the prevalence of wasting; 40% in the prevalence of low birth weight; 70% in the prevalence of childhood underweight; and 48% in the prevalence of severe and moderate food insecurity (at populations or household level). In addition, specific goals included an average percentage increase of 46% in the prevalence of exclusive breastfeeding; 61% in the proportion of people receiving minimum dietary diversity (66% for children, 56% for women); and an increase of 127% in the proportion of individuals (mostly children) receiving a minimal acceptable diet. In absolute terms prevalence of anaemia (−17%), prevalence of exclusive breastfeeding (17%), proportion of people receiving minimum dietary diversity (17%), prevalence of severe and moderate food insecurity (−17%), and proportion of people receiving a minimal acceptable diet (19%) were those requiring on average the largest change.

Of the 65 governments that engaged with the Nutrition Year of Action with domestic commitments, 52 (80%) are from low- and lower-middle-income countries,^[11] submitting 200 (90%) commitments and 424 (90%) goals. The 11 upper-middle-income countries submitted 20 (9%) commitments and 41 (9%) goals. The two high-income countries, US and Denmark, submitted respectively two and one commitments and four and one goals domestically (i.e. in a non-donor role).

In low- and lower-middle-income countries, ‘undernutrition’ was the main focus of action followed by ‘leadership and governance’, and there was some evidence of government investment in ‘research, monitoring and data’, ‘nutrition care services’ and ‘diet’ (Figure 3.3). While the number of commitments and goals made by governments in upper-middle-income countries was small compared with the low- and lower-middle-income governments, their focus was on policy goals (11, 27%, compared with 22, 16%, in low-income countries and 55, 19%, in lower-middle-income countries), and on ‘leadership and governance’ in nutrition and tackling ‘undernutrition’. High-income countries submitted five goals that focused on improving the ‘food environment’ and ‘consumer knowledge’ (policy goals), and ‘diet’ (impact goals).

Figure 3.4 presents the types of goals made by governments when grouped based on the country's burden of malnutrition.^[12] Almost all (466, 99%) of goals were made by governments experiencing at least one form of malnutrition (48, 10%) with the majority having two (201, 43%), three (180, 38%) or more (37, 8%). The strategic approach to tackle malnutrition and poor diet used by countries with multiple forms of malnutrition shows a shift in focus from enabling to impact to policy actions across the high (three or more burdens), medium (two burdens) and low (one burden) burdens. Around half (102, 47%) of the goals submitted by governments with three or more burdens of malnutrition focused on enabling actions, specifically investing in ‘leadership and governance’ (50 goals, 23%) and ‘financial’ goals (25, 12%). Countries experiencing a smaller burden of malnutrition switched their focus from enabling nutrition actions (those with only one burden categorised 29% of goals as enabling) to impact nutrition actions (40% and 46%, respectively, for countries with one burden and two burdens of malnutrition). Among countries with one burden of malnutrition 31% of goals were categorised as policy nutrition actions with most of the goals falling into the ‘nutrition care services’ sub-category (10, 2.1% of total goals and 11% of policy goals). Governments with two malnutrition burdens had the largest proportion of impact goals, with the larger proportion focusing on ‘undernutrition’ (54, 27%).

More specifically in countries experiencing three or more forms of malnutrition, ‘financial’ goals (24) focused on specifying/increasing budget allocation to nutrition (15, 63%), six (25%) on mobilisation of resources, two (8%) on implementing national survey/interventions and one (4%) on providing cash transfers. In high-burden countries (three or more malnutrition burdens) the recurrent areas of focus for the 50 goals specific to ‘leadership and governance’ were related to creating or maintaining partnerships and facilitating meetings between countries (8, 16%), developing governmental policies, laws or acts (16, 32%), creating nutrition action plans or equivalent (9, 18%), relating to a national coordination mechanism (9, 18%), or developing regulatory bodies for nutrition (4, 8%). The focus of countries experiencing a smaller burden of malnutrition was on policy nutrition actions, with most of the goals being ‘nutrition care services’ (10, 21%), and with half (5, 50%) of goals related to dietary supplementation programmes. Governments with two malnutrition burdens had the largest proportion of impact goals, with the larger proportion focusing on ‘undernutrition’ (57, 28%), with a specific focus on stunting (21, 37%), anaemia (16, 28%), wasting (11, 19%), low-birth weight (4, 7%), or a combination of these (4, 7%).

During the Nutrition Year of Action, governments, mostly in low- and lower-middle-income groups, showed an outstanding level of commitment to tackle poor diet and malnutrition. They represented the largest stakeholder group as well as the group submitting the largest number of commitments and goals. This group also committed US$13.3 billion to tackle poor diet and malnutrition.

The complexity of response needed to tackle poor diet and malnutrition is reflected in the number and variety of goals submitted by governments domestically (i.e. in a non-donor role). The goals spanned all three nutrition action areas – enabling, policy and impact – requiring a high level of subnational, national and international coordination and integration across sectors, a characteristic unique to non-donor governments. Impact actions show a very high level of commitment to tackling maternal, infant and young child nutrition, with increasing evidence of national efforts to tackle the overweight epidemic.

Investment in political leadership and good governance is crucial to ensure positive nutrition-related outcomes and, while this requires coordination across stakeholders, governments are actively leading domestic actions.

1. While effort has been made to ensure commitments across the enabling, policy and impact nutrition actions, governments should commit to bolder actions to transform and establish equitable food systems, increase food security, reduce obesity and diet-related NCDs, and ensure sustainable financial resources. Action to protect and improve the food system and to ensure nutrition security is worryingly absent and should be prioritised in the future.
2. National and subnational actions to tackle obesity and diet-related NCDs are urgently needed. Governments have shown a long-term and high level of commitment to tackle maternal, infant, and young child nutrition. It is now urgent to increase recognition of obesity and diet-related NCDs as a priority and that governments commit to increased action to ensure progress to prevent diet-related NCDs, while maintaining maternal, infant, and young child nutrition at the top of their agenda. In addition, adolescent nutrition is equally important and needs urgent long-term action to ensure better health outcomes for future generations. Progress towards maternal, infant, and young child nutrition, adolescent nutrition, and obesity and diet-related NCDs can be achieved through increased focus on safe and sustainable healthy food systems.
3. While coordination across areas of actions tends to be aligned to the level of socio-economic development and burden of malnutrition, emerging needs should be recognised to ensure a prompt response. Intersectoral effort is needed to support countries to enhance their enabling, policy and impact actions and to ensure a coordinated response to current and future priorities. Governments need to keep building on the momentum and ensure the achievement of commitments submitted during the Nutrition Year of Action.