The Nutrition Action Classification System

Authors

Renata Micha (Lead author), Dimitra Karageorgu, Jason Wu

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Introduction

As part of the Nutrition Accountability Framework (NAF), the Global Nutrition Report (GNR) has developed a novel nutrition action classification system – effectively, a taxonomy to name, define and classify nutrition actions based on common principles and shared characteristics. This classification system groups nutrition actions into three major action categories, each further divided into four action sub-categories, as detailed in the next sections (12 action categories in a hierarchical fashion). The classification system captures a comprehensive list of nutrition actions.

The classification system was released in September 2021 in time to inform the identification of relevant nutrition actions by stakeholders making commitments in the Nutrition Year of Action (YoA). After reviewing the nutrition actions registered through the NAF during the YoA, the classification system was updated. It will be further expanded, refined and developed to account for the evolving nature of nutrition actions.

This webpage provides the rationale and the methods used to develop the current iteration of the classification system and describes how we use it to classify the nutrition commitments registered through the NAF. The classification of commitments is publicly shared through the NAF Commitment Tracker.

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Nutrition Action Classification System

The aim of the classification system is to help stakeholders identify and commit to taking transformational nutrition actions, which are defined as strategies, policies, interventions, programmes and investments intended to tackle poor diets and malnutrition in all its forms. The GNR, in the current iteration of the classification system, does not provide guidance to stakeholders as to which actions to select and prioritise. Over time, the intention is for the classification system to evolve and provide evidence-based recommendations for nutrition action. When considering which nutrition action to commit to, stakeholders (definitions of the different stakeholders are provided in the Glossary) should also take into account priorities that are relevant to their own context and, where feasible, respond to the nutrition situation and current state of the food and health systems of the country in which they operate.[1]

The classification system originally included a comprehensive list of potential nutrition actions that were identified based on: 1) mapping of nutrition outcomes that are agreed priorities of the global nutrition and public health communities (e.g., World Health Assembly (WHA) global nutrition targets on maternal, infant and young child nutrition and diet-related non-communicable diseases (NCDs),[2] nutrition-related Sustainable Development Goals (SDGs)),[3] and should be the focus of nutrition commitments; 2) review of the 2013 and 2017 Nutrition for Growth (N4G) commitments, as N4G has been one the largest global fora over the past decade for making nutrition commitments; and 3) nutrition actions across diverse domains (e.g. governance, financing and policy) and settings (low-, middle- and high-income countries), with an emphasis on those that are supported by evidence to improve nutrition outcomes. The list of nutrition actions was expanded after reviewing the nutrition commitments registered through the NAF.

The classification system also provides the basis for efficient tracking and reporting of nutrition commitments across different action categories, thereby enabling analysis of where actions are being focused and where more commitments might be needed. Over time, the classification system will allow us to identify gaps in action, determine the most impactful actions and inform actions and priorities for improving nutrition.

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The Nutrition Action Classification System: Naming, defining and classifying nutrition actions

The Nutrition Action Classification System: Naming, defining and classifying nutrition actions

Graphic answers questions relating to the Nutrition Action Classification System, a classification system developed by the GNR to map nutrition action. It identifies the type of nutrition action in a consistent and standardised manner by classifying nutrition actions into three categories (enabling, policy, impact). Each is further divided into four sub-categories. It clearly defines nutrition action types and allows for consistent reporting, enabling informed priority setting.

Nutrition action categories and sub-categories

The GNR nutrition action classification stems from the theory of change model[4] that defines final intended impacts and then maps these backwards to identify necessary preconditions. Intended impacts are tackling poor diets and malnutrition in all its forms across geographies and sectors, which can be achieved by ensuring that those that have the power to act take necessary action. The classification system thus defines, classifies and groups nutrition actions into three broad and mutually exclusive nutrition action categories based on the common principles of the theory of change, further informed by commitments registered to date: enabling, policy and impact (see ‘Detailed examples of nutrition actions by action category and sub-category’).

Stakeholders can commit to establishing an enabling environment for nutrition through direct and indirect nutrition measures,[5] such as increased nutrition-specific and nutrition-sensitive financing (enabling actions); or commit to actions such as strategies, policies, interventions or programmes designed to directly and indirectly improve nutrition outcomes, such as improved nutrient profiles of packaged products, implementation of nutrient supplementation programmes and promoting consumer awareness of a healthy diet (policy actions); or commit to directly targeting and improving population nutrition outcomes such as reduced prevalence of stunting, anaemia or obesity (impact actions).[6]

The term ‘action’ is further aligned with the UN Decade of Action on Nutrition definition of a ‘commitment’: “the will to act and keep on acting until the job is done”, including both the intention to act and sustained actions over time to reduce and eliminate the causes and manifestations of malnutrition.[7]

Each of those broad action categories are further divided into nutrition action sub-categories based on shared characteristics, as shown below, and described in detail further on this page.

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Nutrition Action Classification System: Classifying nutrition actions into standardised categories and sub-categories

Nutrition Action Classification System: Classifying nutrition actions into standardised categories and sub-categories

• Stakeholders register their commitment(s) • Each commitment may have one or more goals • The GNR categorises each goal into one of three action categories, and then into an action sub-category o Enabling actions, which aim to establish an enabling environment for nutrition  Sub-categories: leadership and governance; financial; operational; research, monitoring and data. o Policy actions, which aim to implement nutrition strategies, policies, interventions or programmes  Sub-categories: food supply chain; food environment; consumer knowledge; nutrition care services. o Impact actions, which aim to achieve improved nutrition outcomes in the population  Sub-categories: diet; food and nutrition security; undernutrition; obesity and diet-related NCDs.

These categories and sub-categories build on and expand existing frameworks and classification systems,[8] and were intended to be compatible with the Tokyo N4G summit commitment types and the UN FSS action tracks.[9] Nutrition commitments made in the Nutrition Year of Action were self-classified by stakeholders using the commitment types introduced in the N4G commitment-making guide.[10] They were subsequently re-classified and checked by the GNR against the comprehensive nutrition action classification system introduced herein.

The section ‘Detailed examples of nutrition actions by action category and sub-category’ on this webpage provides a comprehensive (yet non-exhaustive) list of examples of nutrition actions – aligned to the nutrition action categories and sub-categories – to inspire and inform the shaping of nutrition commitments by stakeholders. This list was initially drawn from the literature as well as expert input from the GNR Independent Expert Group and has been updated based on nutrition commitments registered in the NAF. As shown below, one commitment may have multiple goals covering different action categories.

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A Nutrition Action Classification System commitment may have multiple goals spanning multiple categories of action

A Nutrition Action Classification System commitment may have multiple goals spanning multiple categories of action

Example: • A government registers a commitment entitled ‘Improve childhood malnutrition’ • This commitment has three goals o Goal 1: Form a multisectoral body for the regulation of breastmilk substitutes marketing by the end of 2023  Action category: enabling • Action sub-category: financial o Goal 2: Implement legislation on breastmilk substitutes marketing by 2025  Action category: policy • Action sub-category: food environment o Goal 3: Increase exclusive breastfeeding for the first 6 months from 15% in 2022 to 25% in 2030  Action category: impact • Action sub-category: undernutrition

For this current iteration of the classification system, we aligned each category and/or sub-category with the relevant N4G commitment type,[11] the nutrition-related SDGs[12] and the WHA global nutrition targets.[13] Over time, we will further align these with all SDGs[14] as appropriate, as well as with the UN FSS action tracks[15] and the ICN2 actions.[16]

Enabling actions

The enabling action category (see ‘Detailed examples of nutrition actions by action category and sub-category’) captures measures taken to establish an enabling environment for effective nutrition action across all sectors (including multi-sectoral actions). They are designed to improve the contextual – social, economic, political, cultural or environmental – conditions within which effective and sustained action aimed at improving nutrition outcomes is taken (e.g., form a government regulatory body to oversee implementation of policies, strategies, programmes and other investments in nutrition). They reflect the willingness to act on nutrition and ensure readiness for political commitment, capacity and coordination across different administrative levels and among decision-makers in nutrition and all other involved sectors (e.g., health, industry, education, agriculture and water, sanitation and hygiene (WASH)).

Enabling environments for nutrition action – in addition to political will, collaborative engagement and coordination – should have the necessary resources (such as financial, infrastructure and human), accountability (defined roles and responsibilities of all stakeholders) and responses (depending on research, monitoring and surveillance) in place to improve nutrition. They should also address the needs of the marginalised and the most vulnerable and ensure no one is left behind.

These enabling actions are necessary conditions for enabling effective nutrition policy action through the food and health system. Although both the food and health system capture the whole environment, people, inputs, processes, infrastructures, institutions, etc., commitments that are relevant to these systems but constitute enabling measures for action that fall under leadership and governance, financing, operational (infrastructure, workforce) or research, monitoring and data are classified under the relevant sub-categories of enabling actions as described below. As such, this category includes all actions that encompass five of the six building blocks for integrating nutrition into health systems:[17] leadership and governance; health systems financing; health workforce; access to essential medicines; and health information systems. The sixth block, health service delivery, is included under policy actions.

For the purposes of this framework, conditions that cannot be addressed with a nutrition action (e.g., ongoing drought, political instability or conflict, unpredictable precipitation) are not included in the classification system.

There are four sub-categories under enabling actions.

1. Leadership and governance

It is now widely accepted that political leadership and good governance are key foundations for delivering effective nutrition policies, interventions and programmes.[18] These are defined as actions that are relevant to the system by which a country or an organisation (e.g., donor organisation, private business, including food industry and health sector) is governed and operates with regards to advancing the food and nutrition agenda across sectors, as well as the mechanisms for determining food and nutrition policy and by which those in control are held to account.

  • Examples: forming a parliamentary coalition for nutrition; establishing a coordinating body for nutrition legislation; developing inter-sectoral mechanisms for nutrition (between countries and/or within a country); developing a national nutrition plan or strategy; increasing the number of nutrition-specific and/or sensitive projects; and advocating for evidence-based nutrition policies and practices.[19]
  • Alignment: any relevant policy N4G commitment[20] and any commitment that references a specific WHA global nutrition target.[21]

2. Financial

As emphasised in the 2020 Global Nutrition Report,[22] financing for nutrition needs to be scaled up to address the burdens of poor diets and malnutrition in all its forms. These are defined as actions whose aim is to secure, raise or commit financial resources and investments for nutrition-specific and/or nutrition-sensitive actions. Nutrition-specific financing targets immediate determinants of nutrition and as such has a direct focus on nutrition, while nutrition-sensitive financing targets broader, underlying determinants of nutrition, such as food security, access to food, health and WASH.

  • Examples: allocating a specified portion of the national budget for health to nutrition; contributing a specified amount per year to support nutrition-related data and evidence innovations; including a line for nutrition in the health or agricultural budget; securing/raising a specified amount for nutrition-specific and nutrition-sensitive investments.
  • Alignment: any financial N4G commitment[23] and any commitment that references a specific WHA global nutrition target.[24]

3. Operational

Infrastructure and capacity development is generally agreed as essential in enabling nutrition action delivery, with evidence suggesting current significant shortfalls in the quantity, quality, and geographical coverage of such key resources for nutrition.[25] This sub-category includes nutrition actions whose aim is to support and enhance infrastructure and capacity development across different sectors (e.g., food supply chain, health systems), including human resources, facilities, equipment and training.

  • Examples: equipping health/treatment centres with essential quality-assured, nutrition-related health products and/or tools for nutritional assessment; increasing the number of nutrition professionals across the country and/or at different administrative levels; incorporating academic and/or pre-service nutrition training into medical, nursing and health workers’ curricula; designing short term training workshops for those working in nutrition (e.g., frontline workers) at national and subnational levels; training farmers on sustainable agricultural techniques; establishing post-harvest facilities and infrastructure; improving water sanitation services in the community through improved water sources in public facilities.
  • Alignment: any relevant policy N4G commitment[26] and any commitment that references a specific WHA global nutrition target.[27]

4. Research, monitoring and data

Availability and access to reliable and up-to-date nutrition information is essential to all stakeholders for deciding on priorities and informing nutrition action. This sub-category includes nutrition actions whose aim is to improve nutrition research and innovation and nutrition monitoring/surveillance to enable nutrition accountability through better data, monitoring and reporting.

  • Examples: conducting regular national nutrition surveys; regularly collecting specified nutrition indicators for overall or specific population groups of interest; incorporating nutrition assessment and monitoring into health information systems; ensuring monitoring of any nutrition-related policy or action plan; ensuring continuous monitoring and evaluation of nutrition programmes/interventions; developing a tool/score to assess sustainable healthy diets, diet quality, diet diversity or adherence to guidelines; strengthening nutrition resource/finance tracking mechanisms.
  • Alignment: any relevant policy or programmatic N4G commitment[28] and any commitment that references a specific WHA global nutrition target.[29]

Policy actions

The policy action category (see ‘Detailed examples of nutrition actions by action category and sub-category’) includes strategies, policies, interventions or programmes that aim to improve nutrition outcomes both directly and indirectly. Having built an enabling environment for nutrition, this category reflects the scaling up of nutrition efforts through committing to nutrition policy actions. Such actions are generally population-based strategies with a broad reach that are crucial complements to individual-based efforts.[30]

We drew upon established international frameworks[31] for classifying nutrition policy actions that shape the systems – food and health – which drastically affect the nutritional status of the population. This category includes both direct (e.g., food fortification, micronutrient supplementation, food labelling, taxes on unhealthy food products, treatment of severe acute malnutrition and nutrition counselling programme for obesity therapy) and indirect nutrition actions (e.g., agricultural and WASH policies).[32] Many of these actions are evidence based and have been shown to have broad and sustained impact.[33]

For food systems, we included policy actions that are relevant to food supply chains, food environmentalism and consumer behaviour. We slightly adapted the definition of consumer behaviour to ensure that each of those three sub-categories are mutually exclusive. Given that consumer behaviour is largely shaped by the existing food supply chains and food environment[34] and as such by actions already captured in the respective sub-categories, we defined a separate non-overlapping ‘consumer knowledge’ sub-category. This includes only actions that aim to educate the public on adopting healthy and sustainable diets and increasing awareness on nutrition. Nutrition actions that have additionally considered sustainability and environmental outcomes will be classified under the food system sub-categories, as appropriate. We further included a sub-category of policy actions that fall under the health system and, in particular, nutrition care services (the sixth block for integrating nutrition into health systems).[35]

Equity and social protection policies[36] have been incorporated under each of these four sub-categories as appropriate; the current iteration of the classification system only includes social protection policies related to nutrition, such as subsidised school meals for students from low-income families, access to nutrition care services for all. Broader social protection policies without an explicit focus on nutrition, such as those that aim to address income or gender-related inequities, are not currently included.

There are four sub-categories under policy actions.

1. Food supply chain

The food supply chain refers to all the processes,[37] and as such actions, that move raw foods of plant or animal origin from production to consumption and affect the availability, accessibility, quality, diversity, health and environmental impacts of produced food. In particular, the food supply chain includes, among others, nutrition actions that are relevant to food production, such as by agriculture, farming, breeding and fishing (e.g., agribusiness, raising of livestock, fisheries and aquacultures); food storage and distribution (e.g., trade policies, food safety, food quality losses and waste); and food processing (e.g., food industry processing, packaging).[38]

  • Examples: increasing crop diversification; providing incentives to produce nutritious foods and protect local agrobiodiversity; improving trade policies; implementing regulations to improve food safety and reduce food quality losses and waste of perishable foods during food storage and distribution; using short-supply chains for the provision of fruits and vegetables and other nutritious local foods; improving food industry processing techniques to minimise nutrient losses; improving nutrient profile of products through reformulation and/or fortification.
  • Alignment: any relevant policy N4G commitment[39] and any commitment that references a specific WHA global nutrition target.[40]

2. Food environment

Improved food environments allow individuals to access, purchase and consume more nutritious and healthy foods. Food environments refer to the physical, economic, political and sociocultural contexts in which individuals engage with the food system to make their decisions about acquiring, preparing and consuming food.[41] Effectively, they connect supply with demand systems and they impact food supply chains, as well as the choice and quality of individual diets through a variety of factors.[42] In particular, food environment includes, among others, nutrition actions that are relevant to availability of and accessibility to nutritious and healthy foods across different establishments and locations (e.g., worksites, schools, restaurants, ‘food deserts’); nutrition improvement programmes, which might include nutritional status assessments, across different establishments and locations; affordability of healthier diets through regulations and standards on food prices such as taxes and subsidies; and promotion of healthy foods through regulations on labelling, marketing and advertising. This sub-category further includes relevant social protection policies to build resilience with regards to fragile and conflict affected contexts, such as food assistance programmes and subsidised meals.[43]

  • Examples: implementing procurement standards for vending machines in schools (or worksites); subsidising school meals for students with low family income; establishing soup kitchens for vulnerable population groups; providing healthy meals and set standards (e.g., on content of added sugar, salt, saturated fat) in public institutions and other settings (e.g., schools, worksites); increasing food market availability in ‘food deserts’; implementing breastfeeding support policies at workplaces; setting incentives and rules to create a healthy food retail environment such as zoning restrictions on fast food outlets; setting food price ceilings for healthy foods; using economic tools to address food affordability such as targeted subsidies; implementing taxation on sugar-sweetened beverages; implementing nutrition labelling standards (e.g., front-of-pack labels, health warning labels) and regulations on the use of claims on foods; restricting confectionary advertising directed towards children; increasing income to improve access to nutritious food.
  • Alignment: any relevant policy N4G commitment[44] and any commitment that references a specific WHA global nutrition target.[45]

3. Consumer knowledge

Regulation, information and education can orient consumers towards healthier and more sustainable food choices.[46] The theory underlying such policies is that the more informed and educated individuals are, the more likely it is that they make favourable health decisions for themselves and those in their care.[47] Consumer knowledge includes, among others, nutrition actions that are relevant to improving community knowledge (e.g., on healthy nutrition, exclusive breastfeeding, sanitation) through nutrition education, mass media and public awareness campaigns, and dietary guidelines, to enable positive changes to their dietary behaviours.

  • Examples: introducing nutrition education in schools; providing cooking and food production training to young people and other vulnerable groups; implementing mass media and/or social marketing campaigns on the importance of healthy foods; implementing awareness programmes on exclusive breastfeeding; publishing food-based dietary guidelines; implementing workplace nutrition literacy programs.
  • Alignment: any relevant policy N4G commitment[48] and any commitment that references a specific WHA global nutrition target.[49]

4. Nutrition care services

Nutrition is frequently under-prioritised in national healthcare policies.[50] Integrating nutrition into Universal Health Coverage (UHC) and ensuring equitable access to effective nutrition interventions within health systems can play a pivotal role in improving diets, saving lives and reducing healthcare spending, while ensuring that no one is left behind[51]. The World Health Organization (WHO) has highlighted that UHC can only be achieved through the integration of nutrition services as a central part of health systems.[52] The WHO has suggested a set of essential nutrition actions for healthier populations over the life-course.[53] This sub-category includes nutrition policy actions whose aim is to integrate and enhance nutrition services and interventions offered in public or private health systems, and can include nutrition care services within and outside (e.g., community interventions) the health system.[54] This sub-category further includes relevant social protection policies to ensure access to nutrition care services for all, including vulnerable population groups.

  • Examples: integrating lifestyle interventions with a focus on diets and physical activity by multi-disciplinary teams; implementing nutrient supplementation programmes as a treatment for nutrition-related conditions; implementing breastfeeding support policies at maternity and newborn health facilities; offering medically tailored meals to high-risk, food-insecure patients with complex chronic conditions; implementing medical prescriptions of healthy food, such as fruits and vegetables, within large government healthcare programmes; offering nutrition counselling during pregnancy and lactation; offering nutrition counselling for obesity; providing remote (phone or online) nutrition counselling extending nutrition services beyond the facility context to more remote or harder-to-reach communities; establishing cash (or near cash) transfer programmes for accessing nutrition care programmes.
  • Alignment: any relevant policy N4G commitment[55] and any commitment that references a specific WHA global nutrition target.[56]

Impact actions

The impact action category (see ‘Detailed examples of nutrition actions by action category and sub-category’) captures final intended impacts in the theory of change, including commitments designed to directly improve poor diets and reduce malnutrition manifestations, related to both food insecurity and undernutrition as well as obesity and diet-related NCDs.

The nutrition actions falling under this category use as 'tools’ the policies (policy actions) that are already in place in an enabling environment (enabling actions) to improve the population’s nutritional status. The nutrition outcomes that are included in this category are aligned with the WHA global nutrition targets,[57] the nutrition-related SDGs,[58] and the recommendations by the Second International Conference on Nutrition Framework for Action (ICN2).[59]

There are four sub-categories under impact actions.

1. Diet

Poor diets are a leading cause of morbidity and mortality worldwide.[60] They, furthermore, have major impacts on planetary health.[61] Improving the population’s dietary intakes, to reduce diet-related health, economic and environmental burdens, should be a key priority for all stakeholders. We now understand several key dietary priorities for improving diet and health (both for people and the planet), which extend beyond micronutrient deficiencies and hunger or excess weight, that should be highlighted, targeted and tracked in order to tackle all forms of malnutrition. This sub-category includes commitments to improve the nutrition outcomes that are relevant to infant and young child feeding practices, food and nutrient intakes, as well as overall diet quality (including diet diversity).

  • Examples: increasing the prevalence of exclusive breastfeeding in the first six months of life; reducing salt intake; reducing added sugar intake; increasing fruit and vegetable intake; improving diet quality – and dietary diversity – indices, such as the Healthy Eating Index, the Mediterranean Diet Score and the Minimum Dietary Diversity for Women (MDD-W).[62]
  • Alignment: any relevant N4G impact commitment,[63] any commitment that aligns with the WHA global targets of exclusive breastfeeding and salt intake[64] and any commitment that falls under SDG 2.1.[65]

2. Food and nutrition security

Hunger and food insecurity are at high levels globally. Covid-19 and the socio-economic impacts of the pandemic are threatening a lasting impact on adults and children.[66] The pandemic has increased food insecurity through disruptions to food supply chains, loss of income and livelihoods, uneven food prices and disruptions to social protection programmes. As emphasised in the 2020 Global Nutrition Report,[67] healthy, sustainably produced food should be the most accessible, affordable and desirable choice for all. This sub-category includes commitments to improve the nutrition outcomes that are relevant to hunger and food and nutrition security, defined as having consistent access to affordable foods and beverages that promote well-being, while preventing – and, if needed, treating – disease.[68] There is not a single indicator to measure food security, but rather multiple proxy ones;[69] the indicators that are relevant to diet quality are captured in the sub-category of ‘Diet’ above.

  • Examples: reducing the prevalence of undernourishment; reducing the prevalence of critical food poverty; improving the Food Insecurity Experience Scale; increasing household availability of fruits and vegetables; increasing the availability of healthy foods, such as fruits and vegetables, with a focus on low-income populations; reducing the cost of a healthy diet.
  • Alignment: any relevant N4G impact commitment,[70] any commitment that references a specific WHA global nutrition target[71] and any commitment that falls under SDG 2.1.[72]

3. Undernutrition

Undernutrition persists at unacceptably high levels globally.[73] This sub-category includes commitments to improve the nutrition outcomes that are relevant to maternal and child undernutrition, adolescent and adult undernutrition and micronutrient deficiencies. Of note, multiple malnutrition manifestations may co-exist (e.g., stunting and wasting, micronutrient deficiencies and overweight), and the ones related to excess weight and diet-related NCDs are captured in the sub-category of ‘Obesity and diet-related NCDs’ below.

  • Examples: reducing prevalence of stunting; reducing prevalence of wasting; reducing prevalence of anaemia in women of reproductive age; reducing low birthweight; reducing prevalence of individuals with vitamin A deficiency.
  • Alignment: any relevant N4G impact commitment,[74] any commitment that aligns with the WHA global targets on anaemia among women of reproductive age, low birthweight, childhood stunting and childhood wasting and any commitment that falls under SDG 2.2.[75]

4. Obesity and diet-related NCDs

Obesity and diet-related NCDs are also at alarmingly high levels globally.[76] This sub-category includes commitments to improve the nutrition outcomes that are relevant to child, adolescent and adult overweight and obesity and diet-related NCDs and their major risk factors (obesity is both a chronic disease and a risk factor for NCDs).

  • Examples: reducing prevalence of overweight in children and adults; reducing prevalence of obesity in children and adults; reducing prevalence/incidence of diabetes; reducing prevalence of individuals with raised blood pressure; reducing prevalence/incidence of cardiovascular diseases (e.g., coronary heart disease, stroke).
  • Alignment: any relevant N4G impact commitment,[77] any commitment that aligns with the WHA global targets on childhood overweight and adult obesity, diabetes and raised blood pressure and any commitment that falls under SDG 2.2 and 3.4.[78]
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Classification of NAF commitments

All commitments registered through the NAF are reviewed and classified using the specified nutrition action categories and sub-categories. Since commitments can have multiple goals, each of which might have a different areas of focus (as assessed by the categories of action), classification is performed at the commitment-goal level. Two researchers review and independently classify all commitment goals; agreement between researchers ranges between 95% to 100%, and any potential disagreement is resolved through mutual discussion.

To classify each commitment goal, the following data fields from the Commitment Registration Form are reviewed: (1) goal description (Q13); (2) full commitment (Q2); (3) indicator fields (GX.8a–GX.8f); and (4) action plan (GX.2). The classification assessment is primarily based on the goal description. To ensure that this assessment is accurate it is cross-checked against the information provided in fields 2–4 of the form. If the goal description is in alignment with what is described in the other fields, then the original classification is preserved as is; if the goal description is not in alignment with the other fields, then the classification is based on the fields that are more consistent (e.g., if the full commitment and indicator fields agree with each other but not with the goal description, the classification is based on them); if the information across all fields is poor/ inconsistent, the classification is also based on the goal description. During the verification process, the classification of some commitment goals may change based on clarifications that are requested and received; the GNR will track and report on such changes.

Beyond 2022, the classification system is expected to evolve further to include more nutrition actions as these are being registered. It is also expected to expand to include a third classification level that will further refine the nutrition action sub-categories of the second classification level.

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Detailed examples of nutrition actions by action category and sub-category

Enabling

Leadership and governance

Examples of nutrition actions to which stakeholders can commit:

  • Form a parliamentary coalition to design and legislate new nutrition programmes
  • Establish a national food and nutrition governance authority for nutrition legislation (e.g. Department of Nutrition in the Ministry of Health)
  • Establish a coordination body for nutrition legislation and action across different sectors, such as health and agriculture
  • Develop and publish whole-of-government food system nutrition action plans and strategies
  • Develop intersectoral mechanisms for nutrition (between countries and/or within a country)
  • Appoint nutrition focal persons in all relevant ministries and/or other administrative bodies
  • Develop a national nutrition plan or strategy
  • Facilitate, support and advocate for evidence-based nutrition policies and practices
  • Become a member of and support multinational nutrition programmes, such as the Scaling Up Nutrition (SUN) Movement
  • Increase the number of new nutrition-sensitive and/or nutrition-specific projects
  • Support the Committee on World Food Security and governments to integrate the Guiding Principles for Sustainable, Healthy Diets into relevant texts, policies and programmes
  • Facilitate and support the collection, sharing and dissemination of data to inform food systems analysis and policy development for physical and affordable access to sustainable, healthy diets
  • Support partnerships for Gavi and Global Fund funding proposals for assistance to deliver integrated essential nutrition actions in national health plans.
Financial

Examples of nutrition actions to which stakeholders can commit:

  • Allocate and spend a specific proportion of total national and/or health budget on nutrition
  • Allocate and spend a set amount per child per year for nutrition actions supporting national plans
  • Include specific funding lines for nutrition actions in the health and agricultural budgets
  • Develop evidence-based, costed nutrition plans, including data, monitoring and evaluation components
  • Contribute a specified amount to support nutrition-related research, data and evidence innovations
  • Enhance the impact of resources for nutrition by using evidence-based decision tools
  • Allocate resources to deliver integrated essential nutrition actions in national health plans
  • Secure/raise a specified amount of new funding for nutrition-specific and/or nutrition-sensitive interventions
  • Organise a resource-mobilisation event
  • Establish or join an investor coalition with a clear set of expectations around nutrition
  • Strengthen existing innovative financing sources through performance-based financing mechanisms that hold recipients accountable for measurable improvements in coverage of an enhanced set of nutrition-specific interventions, accountability-enabling data and measurement systems
  • Invest funds to leverage existing public and private investment and commitments
  • Contribute a specified amount per year to support existing nutrition action tracking mechanisms, such as at the national level or the Global Alliance for Improved Nutrition and the Global Nutrition Report.
Operational

Examples of nutrition actions to which stakeholders can commit:

  • Incorporate academic and/or pre-service nutrition training, including on the integrated delivery of nutrition interventions across the life-course, into medical, nursing and health workers’ curricula
  • Promote nutrition-relevant massive open online courses (MOOCs)
  • Develop and provide short-term training workshops for those working in nutrition
  • Provide training to farmers on sustainable agricultural techniques
  • Improve the agricultural knowledge and practices of farmers living in extreme poverty (e.g., home gardens)
  • Provide education to farmers on the production techniques and nutritional value of certain foods
  • Establish post-harvest facilities and infrastructure
  • Implement integrated and supportive supervision and mentoring for health workers that builds capacity to deliver nutrition interventions
  • Have a specified minimum number of nutrition professionals per healthcare setting, across the country and at different administrative levels
  • Increase the number of nutrition professionals (e.g., dietitians) working in healthcare systems by achieving specific ‘densities’ (i.e. X nutrition professionals per 100,000 people in the population)
  • Equip healthcare settings with quality-assured nutrition-related health products, such as enteral and parenteral nutrition products
  • Include nutrition-related health products in national essential medicines lists
  • Develop and bring to market low-cost solutions for nutrition-related health products, diagnostics and technologies
  • Equip healthcare settings with quality-assured tools for nutritional assessment, such as digital scales for body weight and composition
  • Develop or use new technology platforms that become integrated into clinical practice
  • Improve water sanitation services in the community through improved water sources in public facilities
  • Ensure access to potable water for consumption and household needs
  • Implement measures to provide and improve adequate sanitation services (waste water management, excretal disposal, solid waste management, drainage, vector control and community-led total sanitation initiatives).
Research, monitoring and data

Examples of nutrition actions to which stakeholders can commit:

  • Develop national dietary guidelines for the general population
  • Develop clinical guidelines for diet-based approaches to treat non-communicable diseases (NCDs), such as cardiovascular disease and diabetes
  • Develop nutrition programmes to enhance the nutritional profile and properties of food products
  • Establish an Alliance on Sustainable and Healthy Diet Food Demand Creators to consolidate efforts to pilot/test evidence-based solutions and create a learning platform to share evidence and ‘what works’
  • Conduct surveys to evaluate public perception and support of specific nutrition actions such as school lunch support programmes
  • Develop a tool/scoring system to assess sustainable and healthy diets, diet quality, diet diversity or adherence to guidelines
  • Design and implement a national or subnational nutrition survey at regular time intervals
  • Regularly collect specified nutrition indicators for overall or specific population groups of interest
  • Design and implement a national or subnational survey related to the prevalence, incidence and cost of treating diet-related outcomes such as stunting, obesity and cardiovascular diseases at regular time intervals
  • Develop tracking mechanisms and indicators for monitoring the coverage and quality of nutrition actions committed in the Nutrition Year of Action
  • Ensure monitoring of any nutrition-related policy or action plan
  • Ensure continuous monitoring and evaluation of nutrition programmes/interventions
  • Strengthen nutrition resource and financing tracking mechanisms using sustainable financial management and data systems
  • Report on all nutrition programming, including both nutrition-specific and nutrition-sensitive investments, using the OECD policy marker on nutrition
  • Incorporate nutrition assessment and monitoring into health information systems
  • Increase the capacity of national health information systems to provide early warning of nutrition emergencies
  • Develop capacity to use national health information for decision-making.

Policy

Food supply chain

Examples of nutrition actions to which stakeholders can commit:

  • Improve international trade policies and investment agreements on food environments and population nutrition
  • Design safeguards on the level of investment of foreign ownership of local food production
  • Implement measures to support increased production of healthy commodities
  • Leverage short supply chains for the provision of fruits and vegetables and other nutritious local foods
  • Provide research and development incentives for agricultural producers
  • Specify a proportion of national budgets in food procurement programmes be spent on food purchased from family farms
  • Increase crop diversification
  • Provide incentives to protect local agrobiodiversity
  • Implement regulations and processing protocols for ensuring foods are manufactured, transported, prepared and stored in ways to best reduce the risk of foodborne illnesses
  • Implement regulations and processing protocols for minimising nutrient losses and waste of perishable foods during processing, storage and distribution
  • Adopt water sanitation regulations for food manufacturing and preparation
  • Implement regulations and practices for minimising pesticide residue in manufactured food products
  • Work with the food industry to improve ingredients supplied in food manufacturing or the informal food sector
  • Provide research and development incentives for food manufacturers
  • Implement a food safety education programme and accreditation standards for food businesses and workers
  • Improve the nutrient profile of products through reformulation and/or fortification
  • Implement or comply with mandatory nutrition compositional limits for components such as salt, saturated fats, trans fats and added sugar in packaged foods, following government recommendations or global best practices
  • Implement mandatory iodisation of salt at national level
  • Fortify staple foods with vitamin A
  • Sign up to a responsible food business pledge that promotes progress in areas such as demand creation, product quality, workforce, supply chain and adherence to the Nutrition for Growth (N4G) Principles of Engagement
  • Sign up to a workforce nutrition pledge that includes elements such as access to affordable nutritious diets, nutrition information, breastfeeding facilities and wellness checks.
Food environment

Examples of nutrition actions to which stakeholders can commit:

  • Implement procurement standards to maximise availability of healthy foods and minimise availability of unhealthy foods at public institutions, schools, worksite cafeterias and catered events
  • Implement food standards (e.g. on added sugars, salt and saturated fats) for healthy meals served at public institutions, schools and worksites
  • Implement interpretive (e.g. color-coded) food labels to provide information related to the relative healthiness of foods available in public institutions, schools, worksite cafeterias and catered events
  • Implement product placement standards to minimise visibility of unhealthy foods and beverages in public institutions, schools and worksites (e.g. remove unhealthy foods from checkout counters)
  • Implement advertising standards to minimise promotion of unhealthy foods and beverages, such as sugary drinks, in public institutions, schools and worksites
  • Ban vending machines from public institutions and schools
  • Implement procurement standards for vending machines
  • Implement interpretive (e.g. color-coded) food labels to provide information related to the relative healthiness of foods available in vending machines
  • Provide school students or worksite employees with fruits and vegetables at no or low cost
  • Install water fountains in schools/worksites for free water provision
  • Implement garden/farm programmes in schools
  • Provide free healthy school meals for students generally or targeted to those from low-income families
  • Subsidise healthy foods and beverages (or meals) that are sold at public institutions, schools and worksites
  • Implement quantitative nutrient (e.g. related to sodium, added sugar content) and/or interpretive (e.g. color-coded) food labels in restaurants – for example on menu boards or online food menus
  • Implement breastfeeding support policies for lactating employees
  • Implement zoning restrictions on fast food outlets in general and/or around schools
  • Implement nutrition improvement programmes (e.g., healthy meals, education), which include nutritional status assessments, at worksites
  • Legislate mandatory display of nutrition information including calories and key nutrients on pre-packaged food products
  • Legislate mandatory display of interpretive front-of-pack nutrition fact panels on pre-packaged food products
  • Introduce regulations on the use of health and nutritional claims on pre-packaged food products
  • Implement product placement standards to minimise visibility of unhealthy foods and beverages in retail stores (e.g. remove unhealthy foods from checkout counters)
  • Incentivise and expand the availability of food markets in food deserts
  • Incentivise and expand the availability of farmers’ markets and mobile produce vendors
  • Implement sugar-content-based levies on sugar-sweetened beverages to encourage industry reformulation
  • Set a fixed price or a price ceiling for healthy food items
  • Develop and implement guidelines that limit in-store, outdoors or online marketing to children of foods and beverages that do not meet nutrition standards
  • Implement programmes of in-kind food transfer for vulnerable population groups (e.g. refugees, homeless people)
  • Provide income-based or other conditional food vouchers
  • Establish community soup kitchens for vulnerable population groups (e.g., refugees, homeless people, unemployed people)
  • Integrate food assistance programmes with healthcare for low-income and other vulnerable groups
  • Increase income to improve access to healthy and nutritious food.
Consumer knowledge

Examples of nutrition actions to which stakeholders can commit:

  • Implement mass media and social media public awareness campaigns on the importance of healthy foods
  • Publish food-based dietary guidelines
  • Incorporate a nutrition subject within the school curriculum
  • Provide free seminars for workers related to nutrition and cooking skills
  • Provide cooking and food production training to young people and vulnerable groups
  • Implement workplace nutrition literacy programmes
  • Implement public awareness programmes on the benefits of exclusive breastfeeding, timing of breastfeeding initiation, frequency of breastfeeding, timely introduction of high-quality complementary foods, minimum meal frequency and minimum acceptable diets
  • Develop a multisectoral breastfeeding policy in line with the International Code of Marketing of Breast-milk Substitutes
  • Establish a support programme for breastfeeding mothers at work.
Nutrition care services

Examples of nutrition actions to which stakeholders can commit:

  • Establish medically tailored meal programmes for high-risk, food-insecure patients with complex chronic conditions
  • Establish produce (fruit and vegetable) prescription programmes for patients
  • Integrate lifestyle interventions with a focus on diets and physical activity by multidisciplinary teams
  • Provide nutrition counselling during pregnancy and early childhood
  • Provide breastfeeding counselling
  • Implement the "Ten Steps for Successful Breastfeeding" at maternity and newborn health facilities
  • Provide nutrition counselling for obesity
  • Provide remote (phone or online) nutrition counselling extending nutrition services beyond the facility context to more remote or harder-to-reach communities
  • Establish a minimum number of antenatal visits
  • Provide pregnant women with iron, folate and/or multiple micronutrient supplements
  • Provide ready-to-use therapeutic foods for emergency feeding of malnourished children
  • Provide ready-to-use therapeutic foods for those suffering from severe acute malnutrition
  • Implement a programme of vitamin A supplementation for treating diarrhoea in children
  • Implement a programme of vitamin A supplementation for preventing mortality in children aged 6–59 months
  • Introduce a nutrient supplementation for older people
  • Integrate World Health Organization (WHO) Essential Nutrition Actions into a package of essential health services as part of national health plans and universal health care (UHC) roadmaps
  • Provide technical assistance to support a country-led, comprehensive approach to UHC and health planning and delivery that integrates essential nutrition actions
  • Provide technical assistance to support Gavi and Global Fund funding proposals for funding to deliver integrated essential nutrition actions in national health plans
  • Develop and update normative guidance and other global public goods to support a comprehensive approach to UHC that integrates essential nutrition actions
  • Support research and evidence generation, surveillance, analysis and use of data capacity to support countries to follow an evidence-based path to taking a comprehensive approach to UHC that integrates essential nutrition actions
  • Ensure that national, multisectoral nutrition plans are aligned with national UHC plans
  • Strengthen cross-agency coordination and coherence through the SDG3+ Global Action Plan to ensure a joined-up approach to supporting a country-led, comprehensive approach to UHC that integrates essential nutrition actions
  • Implement cash transfer programmes (e.g. direct cash-in-hand or cash envelopes, money transfer agents, accounts in financial institutions, mobile banking systems, smart cards, cheques and mobile money transfers) for accessing nutrition care programmes
  • Implement a health insurance scheme that integrates essential nutrition actions
  • Increase the effective coverage of essential nutrition actions through the health system, with a focus on reaching those most left behind
  • Develop quality metrics and reimbursement systems that reward community engagement to address upstream causes of poor health
  • Support community demand-generation for preventive essential nutrition actions as part of health service delivery platforms.

Impact

Diet

Examples of nutrition actions to which stakeholders can commit:

  • Increase prevalence of early initiation of breastfeeding from X% to Y% of infants
  • Increase prevalence of exclusive breastfeeding of infants aged 0–5 months from X% to Y%
  • Increase prevalence of introduction of solid, semi-solid or soft food in infants aged 6–8 months from X% to Y%
  • Increase prevalence of continued breastfeeding from X% to Y% among infants at 1 year of age
  • Increase prevalence of continued breastfeeding from X% to Y% among infants at 2 years of age
  • Increase prevalence of minimum dietary diversity from X% to Y% in children under 2 years of age
  • Increase prevalence of children under 2 years of age that receive at least three meals a day from X% to Y%
  • Increase prevalence of minimum acceptable diet from X% to Y% in children under 2 years of age
  • Increase fruit intake in the population (or specific population groups)
  • Increase non-starchy vegetable intake in the population (or specific population groups)
  • Increase whole-grain intake in the population (or specific population groups)
  • Decrease processed meat intake in the population (or specific population groups)
  • Decrease sugar-sweetened beverage intake in the population (or specific population groups)
  • Increase fibre intake in the population (or specific population groups)
  • Increase seafood omega-3 fatty acid intake in the population (or specific population groups)
  • Decrease trans fat intake in the population (or specific population groups)
  • Decrease added sugar intake in the population (or specific population groups)
  • Increase calcium intake in the population (or specific population groups)
  • Decrease sodium intake in the population (or specific population groups)
  • Improve average dietary diversity score in the population (or specific population groups)
  • Improve average dietary quality score in the population (or specific population groups)
  • Improve minimum dietary diversity score in women.
Food and nutrition security

Examples of nutrition actions to which stakeholders can commit:

  • Decrease prevalence of undernourishment in the population from X% to Y%
  • Decrease prevalence of critical food poverty in the population from X% to Y%
  • Improve Food Insecurity Experience Scale metrics
  • Increase household availability of fruits and vegetables
  • Increase the availability of healthy foods, such as fruits and vegetables, with a focus on low-income populations
  • Reduce the cost of a healthy diet.
Undernutrition

Examples of nutrition actions to which stakeholders can commit:

  • Decrease prevalence of anaemia from X% to Y% in pregnant women
  • Decrease prevalence of anaemia from X% to Y% in non-pregnant women
  • Decrease prevalence of anaemia from X% to Y% in all women of reproductive age
  • Decrease prevalence of anaemia from X% to Y% in children aged 6–59 months
  • Decrease prevalence of anaemia from X% to Y% in adolescents (13–19 years of age)
  • Decrease prevalence of anaemia from X% to Y% in older people
  • Decrease prevalence of low birthweight from X% to Y%
  • Decrease prevalence of stunting from X% to Y% in children under 5 years of age
  • Decrease prevalence of wasting from X% to Y% in children under 5 years of age
  • Decrease prevalence of severe wasting from X% to Y% in children under 5 years of age
  • Decrease prevalence of underweight from X% to Y% in children under 5 years of age
  • Decrease prevalence of underweight from X% to Y% in children aged 5 years and over, and/or in adolescents
  • Decrease prevalence of underweight from X% to Y% in adults overall or in specific population groups (e.g., homeless people)
  • Decrease prevalence of vitamin A deficiency from X% to Y% in the population (or specific population groups)
  • Decrease prevalence of vitamin D deficiency from X% to Y% in the population (or specific population groups)
  • Decrease prevalence of vitamin B1 deficiency from X% to Y% in the population (or specific population groups)
  • Decrease prevalence of vitamin B2 deficiency from X% to Y% in the population (or specific population groups)
  • Decrease prevalence of vitamin B3 deficiency from X% to Y% in the population (or specific population groups)
  • Decrease prevalence of folate deficiency from X% to Y% in the population (or specific population groups)
  • Decrease prevalence of vitamin B12 deficiency from X% to Y% in the population (or specific population groups)
  • Decrease prevalence of calcium deficiency from X% to Y% in the population (or specific population groups)
  • Decrease prevalence of iron deficiency from X% to Y% in the population (or specific population groups)
  • Decrease prevalence of zinc deficiency from X% to Y% in the population (or specific population groups)
  • Decrease prevalence of iodine deficiency from X% to Y% in the population (or specific population groups).
Obesity and diet-related NCDs

Examples of nutrition actions to which stakeholders can commit:

  • Decrease prevalence of overweight from X% to Y% in children under 5 years of age
  • Decrease prevalence of obesity from X% to Y% in children under 5 years of age
  • Decrease prevalence of overweight from X% to Y% in children and adolescents aged 5–19 years
  • Decrease prevalence of obesity from X% to Y% in children and adolescents aged 5–19 years
  • Decrease prevalence of overweight from X% to Y% in adults (over 19 years of age)
  • Decrease prevalence of obesity from X% to Y% in adults (over 19 years of age)
  • Decrease prevalence or incidence of diabetes from X% to Y% in the population (or specific population groups)
  • Decrease prevalence or incidence of cardiovascular diseases from X% to Y% in the population (or specific population groups)
  • Decrease prevalence of high blood pressure from X% to Y% in the population (or specific population groups)
  • Decrease prevalence of high LDL cholesterol levels from X% to Y% in the population (or specific population groups)
  • Decrease prevalence of high triglyceride levels from X% to Y% in the population (or specific population groups).

Last updated: 13 September 2022.

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Footnotes

  1. World Health Organization. Commitments. https://www.who.int/initiatives/decade-of-action-on-nutrition/commitments. Accessed 13 September 2021.

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  2. World Health Organization. Global Target Indicators. https://apps.who.int/nutrition/globaltargets_indicators/en/index.html. Accessed on 13 September 2021; World Health Organization. About 9 voluntary global targets. Global Monitoring Framework for NCDs. https://www.who.int/nmh/ncd-tools/definition-targets/en/. Accessed on 13 September 2021.

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  3. United Nations. The 17 Sustainable Development Goals. https://sdgs.un.org/goals. Accessed 13 September 2021.

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  4. Starr L. Theory of Change: Facilitator’s Guide. Washington, DC: The Technical and Operational Performance Support (TOPS) Program; 2019.

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  5. The designation direct and indirect seeks to differentiate between nutrition-related actions that have a direct (specific) or indirect (sensitive) focus on nutrition. Those with a direct focus directly target nutrition, for example aimed at improving infant and young child feeding practices, food and nutrient intakes, nutrition-related health outcomes (stunting, wasting, obesity and diet-related NCDs etc), such as promoting and supporting breastfeeding, implementing food taxes and subsidies (food prices), treating severe acute malnutrition and integrating a nutrition counselling program for obesity therapy in the health system. Those with an indirect focus target broader factors that can affect and improve the causes and manifestations of malnutrition in all its forms, for example education, agriculture, social protection, water, sanitation and hygiene (WASH), infectious disease control and reproductive health.

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  6. World Health Organization, 2019. Essential nutrition actions: mainstreaming nutrition through the life-course. Geneva.

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