Shining a light to spur action on nutrition
Malnutrition is a universal issue holding back development with unacceptable human consequences. Yet the opportunity to end malnutrition has never been greater. The UN Decade of Action on Nutrition 2016–2025 and the Sustainable Development Goals (SDGs) provide global and national impetus to address malnutrition and expedite progress.
The burden of malnutrition across the world remains unacceptably high, and progress unacceptably slow. Malnutrition is responsible for more ill health than any other cause. Children under five years of age face multiple burdens: 150.8 million are stunted, 50.5 million are wasted and 38.3 million are overweight. Meanwhile 20 million babies are born of low birth weight each year. Overweight and obesity among adults are at record levels with 38.9% of adults overweight or obese, stretching from Africa to North America, and increasing among adolescents. Women have a higher burden than men when it comes to certain forms of malnutrition: one third of all women of reproductive age have anaemia and women have a higher prevalence of obesity than men. Millions of women are still underweight.
Yet significant steps are being made to address malnutrition. Globally, stunting among children has declined and there has been a slight decrease in underweight women. Many countries are set to achieve at least one of the targets set by the global community to track progress on nutritional status to 2025. The level of knowledge on what it takes to deliver results has never been greater. The global community and national stakeholders have never been better placed to deliver results, with more governance, policies, actions, plans and targets. Advances in data are enabling us to progress our understanding of the nature of the burden of malnutrition in all its forms and its causes – and therefore guide and inspire action and improve our ability to track progress.
It is vital we urgently seize this window of opportunity to get on track towards the SDG target of ending malnutrition in all its forms by 2030. The 2018 Global Nutrition Report provides a data update to shine a light on steps needed to do so. For if we are to end malnutrition in all its forms, we must understand the nature of the problem we are dealing with. The report collates existing data, presents new innovations in data and conducts novel data analysis, focusing on five areas: the burden of malnutrition, emerging areas in need of focus, diets as a common cause of malnutrition in all its forms, financing of nutrition action, and global commitments. Throughout the report, examples of actions being taken to address malnutrition are highlighted and explored.
Through this analysis, the 2018 Global Nutrition Report casts a light on where there has been progress and identifies where major problems still lie – and thus where actions are needed to consolidate progress and fill major gaps.
There has been some progress in reducing malnutrition, but it has been too slow and not spread across all forms of malnutrition
- Stunting in children under five years of age is declining at a global level but numbers in Africa are increasing, and there are significant disparities in progress at the subnational level. Stunting declined from 32.6% of all the world’s children under 5 years of age in 2000 to 22.2% in 2017. In numbers this is a decline from 198.4 million to 150.8 million. Stunting among children in Asia has declined from 38.1% to 23.2% since 2000 and in Latin America and the Caribbean from 16.9% to 9.6%. Stunting among children in Africa has decreased in percentage terms from 38.3% to 30.3% over the same period, yet due to population growth, the actual number of stunted children has risen. The use of geospatial data shows that trends in stunting vary significantly within countries, with some areas experiencing increases and other areas declines.
- At global level, progress in addressing underweight and anaemia among women has been extremely slow while overweight and obesity among adults is getting worse, with higher rates of obesity among women than men. Underweight among women has declined slightly since 2000 though not significantly – 9.7% of women (aged 20–49) and 5.7% of adolescent girls (aged 15–19) are still underweight. Anaemia has risen slightly to 32.8%. Globally, overweight (body mass index (BMI) ≥25) and obesity (BMI ≥30) have been increasing year on year since 2000. Women have a higher prevalence of obesity than men, at 15.1% compared with 11.1%.
- Several countries are on course to meet at least one of the globally adopted nutrition targets set for 2025, but most are off-track and none are making progress on the full suite of targets. Our 2018 assessment of progress against nine targets, which includes new data points from 32 countries, reveals that 94 of the 194 countries included are on track for at least one nutrition target, with 44 of these on track to meet one target and 35 on track to meet two. Of the countries on target, 24 are on track for the stunting target, 37 for wasting and 18 for stunting and wasting. This leaves most of the countries with data off-track. No country is on track to achieve the adult obesity target, nor to reach the anaemia target. Just five countries are on track to meet four targets – the maximum number of targets any country is on track for.
- Different forms of malnutrition continue to compound one another – with new analysis further confirming this reality. New analysis of the multiple burdens of malnutrition within nations is providing novel insights into the degree to which countries and people experience more than one form of malnutrition. Of the 141 countries with consistent data on three forms of malnutrition – childhood stunting, anaemia in women of reproductive age and overweight among women – 88% (124 countries) experience a high level of at least two types of malnutrition, with 29% (41 countries) experiencing high levels of all three. Most of these 41 countries (30) are in Africa. Coexisting burdens bear down on millions of children, with 15.95 million children affected by wasting and stunting, which increases the risk of child mortality, and 8.23 million children affected by stunting and overweight.
- Crises around the world are increasingly protracted and significantly hamper tackling all forms of malnutrition. In situations of crises arising from conflict, fragility, violence and environmental change there is an urgent need to treat and prevent multiple burdens of malnutrition while also building nutrition resilience to what are often protracted crises. An estimated 86% of international humanitarian assistance goes to countries affected by long and medium-term crisis, yet it is mostly in the form of short-term programming. Recognition of the high burden of multiple forms of malnutrition in these protracted crises is growing and the humanitarian community is beginning to change its approaches to consider longer-term and context-specific action. Yet building lasting nutrition resilience will require the humanitarian and development communities to work together more closely to tackle the full extent of malnutrition in these most vulnerable and challenging contexts.
Increasing commitment to addressing malnutrition but a long way to go to finance the agenda
- There has been an increase in the number and breadth of national nutrition policies and nutrition targets, with the outstanding challenge being the financing and action to deliver them. More countries are committing to nutrition by establishing national nutrition policies and action plans: 164 now have such plans, 61% of which are multisectoral. Countries also have more nutrition targets – and a greater breadth of targets to cover different forms of malnutrition: 189 countries have at least one nutrition target and 81% of countries have three or more nutrition targets. The share of countries with overweight targets has increased to 84%. There are fewer targets on micronutrient deficiencies: 41% of countries with high rates of anaemia have no anaemia target. A key outstanding challenge is ensuring that the plans to deliver on these targets are costed, funded and implemented.
- Donors have met the funding commitment made at the Nutrition for Growth (N4G) Summit in 2013, but globally there is still a significant financing gap. In 2018, 10 N4G donors had disbursed a total of US$21.8 billion, thus exceeding their target of US$19.6 billion two years before it was due to be achieved. At the Global Nutrition Summit 2017 in Milan, three of the largest original donors combined with four new ones pledged an additional US$640 million to nutrition. All financial commitments were SMART (specific, measurable, achievable, reliable and timely). Looking across all official development assistance (ODA), a modest step has been taken in spending on obesity and diet-related NCDs, with spending increasing to US$32.5 million in 2016. Yet donor assistance falls far short of what is needed, with ‘nutrition-specific’ spending being particularly low.
- Early indications suggest that governments in low and middle-income countries are committing more domestic expenditure to nutrition. Data from 25 countries highlights that the increase in spending on nutrition is driven by increases of 24.4% in nutrition-sensitive and 8.9% in nutrition-specific allocations. Countries are spending most of their financing on nutrition-sensitive investments. More governments are taking steps to monitor the levels of spending and some are assessing the degree of subnational spending. Yet there is significant variation between countries, indicating significantly more progress is needed to increase domestic spending and measure it.
Attention urgently needed to improve diets to end malnutrition in all its forms
- More and better data is enabling us to more fully understand what people are eating and why it matters – but shows that diets in all countries and wealth groups pose a significant threat to achieving nutrition targets. There has been a surge in efforts to collect, collate and analyse data on diets, so improving our understanding of what the world eats. But the data shows that the world is eating badly. The latest data on infants’ diets shows the proportion of babies who are exclusively breastfed (up to 6 months of age) has increased but only to 41% (from 37% in 2012), and sales of infant formula are growing rapidly. Fewer than one in five children (16%) aged 6 to 23 months eat a minimally acceptable diet while only half (51%) of children aged 6 to 23 months get the recommended minimum number of meals. While there are differences between countries, rural and urban settings and wealth groups, poor feeding practices of infants and young children are a problem everywhere. Regardless of wealth, school-age children, adolescents and adults are eating too many refined grains and sugary foods and drinks, and not enough foods that promote health such as fruits, vegetables, legumes and whole grains. About a third (30.3%) of school-aged children do not eat any fruit daily, yet 43.7% consume soda every day. New analysis of over 23,000 packaged food products shows 69% are of relatively poor nutrient quality, with the proportion higher in low and middle-income than high-income countries.
- Healthy diet policies and programmes are proving effective in countries, cities and communities but overall there is inadequate delivery of a holistic package of actions. The World Health Organization Global database on the Implementation of Nutrition Action (GINA) includes more than 1,000 national policies in 191 countries in support of healthy diets. For example, many countries have adopted sugar-sweetened beverage taxes in recent years, and these are proving effective, as are product reformulation policies. Large-scale food fortification is another area where there has been progress – but also exemplifies that there remain many barriers to change. A growing number of community and city-level initiatives are being implemented to improve diets and nutrition. New evidence is showing that intensive multi-level action can improve infant diets and reduce childhood obesity. Lessons could be scaled up from city to national level and shared through newly emerging international city networks. To date, however, few countries have implemented the comprehensive package of actions needed to significantly improve diets at the population level.
- The world is paying more attention to the importance of improving nutrition among adolescents, but their diets warrant greater focus. Adolescent girls remain particularly vulnerable to malnutrition during this stage of the lifecycle due to higher iron needs, early marriages which can lead to early pregnancies, and increased susceptibility to obesity. Nutrient needs increase in adolescence to meet the demands of pubertal growth and brain maturation. A growing body of international evidence shows that addressing nutrition problems and adopting healthy dietary habits during adolescence can be important for potential ‘catch up’ growth, improved cognition and reduced risk of non-communicable diseases (NCDs) later in life. New calls to actions and research, programmes and policies show promise in advancing our understanding of how to intervene in adolescence, especially through improved diets. Many of these programmes are bringing in the voices of young people who experience the problems as a means of identifying more effective solutions.
Data is ever improving but with some basic gaps remaining and further investment needed to help drive more effective action
- Data is ever improving – equipping us with vital information for tackling malnutrition across the board, but there is a severe data gap on micronutrient deficiencies. Analysis of geospatial data is transforming our understanding of how the burdens of malnutrition and rates of progress vary between and within countries. This type of data is providing new insights into the substantial subnational variations of malnutrition within countries right down to district level. An increasing number of databases and initiatives are collecting, collating, analysing and disaggregating diet data, which provides a growing body of evidence that needs to be acted on. Data is also shining a light on the importance of tackling malnutrition during adolescence. New ways of tracking financing show promise in helping us better understand how the funding for nutrition action is being spent. Yet some basic gaps remain. Many countries do not yet collect the necessary data to fully understand the nature of the burden of malnutrition, diet or indicators of progress. There is also a significant gap around micronutrients. We do not know the full profile of micronutrient deficiencies across populations, globally. Individual deficiencies rarely occur in isolation. There is limited knowledge on the overlaps with other forms of malnutrition, and the consequences for health and disease.
Five critical steps needed to speed up progress
Now steps have been made in addressing and understanding malnutrition in all its forms, the uncomfortable question is not so much why are things so bad, but why are things not better when we know so much more than before? The findings of the 2018 Global Nutrition Report indicate that meeting the 2030 target of ending malnutrition in all its forms will require five critical steps in the way we think and act. These are not new ideas but common sense based on the evidence presented, and worth repeating year after year as the data continues to show just how important they are if we are to truly make things better.
1: Break down silos between malnutrition in all its forms
The data shows that different forms of malnutrition coexist but are being tackled at different rates, vary between populations, and overlap with each other in various ways. Therefore they require integrated approaches and cohesive work to address them. Different communities – the humanitarian, obesity, NCD and micronutrient communities for example – must work together to ensure the different burdens are tackled efficiently and effectively. Tackling one form of malnutrition should be an opportunity for tackling another: governments, the humanitarian community and the nutrition community should assess if existing actions targeted at one form of malnutrition could be extended or redesigned to address other relevant forms. For example, intervening in undernutrition in early life to address obesity and NCDs in later life. Pooling often-scarce resources, varied expertise and innovative, and diverse tools and approaches could be transformative in ensuring nutrition actions work ‘double duty’ for different forms of malnutrition.
2: Prioritise and invest in the data needed and capacity to use it
Designing actions that result in impact is impossible without adequate knowledge of who is affected by malnutrition and why. The progress made in recent years in gathering, collating and analysing data presented in the 2018 Global Nutrition Report shows how investing in data can help inform the nutrition response. Governments, international organisations, research organisations and academic institutions must continue this ongoing data revolution in nutrition. Geospatial data on who is affected by what form of malnutrition, where and why offers promise to support all decision-makers in designing actions for impact. Data on nutritionally vulnerable populations – such as people in poverty, women, adolescent girls, young children and people who are marginalised and geographically isolated – is vital. The efforts made to improve the collection and analysis of diet data must continue, and the shocking gap in micronutrient data filled as a matter of urgency. But data collection and analysis is not enough: all stakeholders need the capacity to use it to make evidence-based decisions. The data community must make the data easy to interpret by policymakers, businesses and NGOs who are making decisions about what to invest in, and where to intervene.
3: Scale up financing for nutrition – diversify and innovate to build on past progress
Every year the Global Nutrition Report calls for more financing for nutrition: ultimately, without adequate and appropriate funds invested towards all forms of malnutrition, we cannot make progress. The data in this year’s report shows patchy progress. Building on this progress, domestic investments must continue to grow and international aid donors must keep investing through ODA. The use of the new policy markers and the improved DAC Creditor Reporting System (CRS) code should be taken up so funding streams are transparent and traceable. Funding needs to be focused on ensuring nutrition plans are delivered in practice. Yet different and innovative forms of financing will also be needed to make progress. Those who control resource flows – governments, multilateral organisations, philanthropic foundations and wealthy investors – need to find innovative ways to finance nutrition action and provide the institutional and human capacity necessary to do so.
4: Galvanise action on healthy diets – engage across countries to address this universal problem
The data presented in the 2018 Global Nutrition Report shows that poor quality diets among infants, young children, adolescents and adults is unacceptable. Suboptimal diets are a major risk factor of malnutrition, disease, disability and death globally. And they are a problem everywhere: no country or population group is immune. Governments and business need to implement a holistic package of actions to ensure food systems and food environments are delivering healthy diets that are affordable, accessible and desirable for all. The lead taken by communities, cities and city networks must be scaled up. Lessons must be learned from successes everywhere and barriers broken down.
5: Make and deliver better commitments to end malnutrition in all its forms – an ambitious, transformative approach will be required to meet global nutrition targets
Only SMART commitments designed for impact that signatories consistently report on and deliver will be fit for purpose to end malnutrition in all its forms. The N4G 2020 summit in Tokyo, Japan offers an opportunity to respond to the challenges and opportunities presented by the data in this year’s report and for the global community – donors, national governments and business – to renew commitments, hold ourselves accountable, and expedite the critical steps needed to end malnutrition in all its forms.
Photo credit: Axel Fassio/CIFOR
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