75963 February 2013 NUTRITION in the POST-2015 DEVELOPMENT AGENDA REPORT OF AN EXPERT CONSULTATION SUMMARY AND CONCLUSIONS Poor nutrition impairs health and human capital development , with significant consequences to economic growth and development: Reducing malnutrition in all its forms will contribute to eliminating preventable maternal and child deaths and to building smart, strong and resilient individuals, families, communities, and populations. This unfinished agenda requires greater focus and attention in the successor framework to the MDGs. Positioning nutrition in the post-2015 framework: There are several ways that nutrition could be addressed in the post-2015 framework. There was support for a single nutrition goal, leveraging the UN Secretary General’s Zero Hunger Challenge, with its aspirational ‘0 stunting’ goal and establishment of achievable nutrition targets based on lessons from the 2015 MDGs. Thoughtful incorporation of key nutrition indicators into multiple development goals, including health, poverty reduction, education, water and sanitation, agriculture, and governance is a powerful complementary approach to galvanizing action to reach the most vulnerable. This approach recognizes the foundational role that nutrition plays in achieving lasting progress in these other sectors as well as the contribution of these sectors to improved nutrition. Priority nutrition indicators: Among the indicators discussed, childhood stunting was given highest priority, based on its power to capture inequity and chronic conditions of poor health, diet and caring practices during the crucial 1000 days from pregnancy through age 2 of a child’s life. However, participants felt that a focus on stunting alone WORLD HEALTH ASSEMBLY-ENDORSED would be insufficient and that other World Health GLOBAL NUTRITION TARGETS FOR 2025 Assembly-endorsed indicators and targets should be incorporated. Given global trends, future  40% reduction of the global number tracking of child overweight was strongly of children < 5 years who are stunted recommended. It is now recognized that we do not live in two worlds, the wealthy suffering from  50% reduction of anemia in women overweight and the poor from undernutrition. of reproductive age Today, it is the same households, families, and at times, the same individuals who are simultaneously  30% reduction of low birth weight stunted, overweight and deficient in key micronutrients.  No increase in childhood overweight Urgent need for systems and tools for data  Increase the rate of exclusive collection: Future attention must be paid to breastfeeding in the first 6 months systems and tools for gathering better data, particularly on micronutrients and diet quality, up to at least 50% important for health and development throughout the lifecycle. Routinely collected nutrition  Reduce and maintain childhood indicators are needed to drive commitment and wasting to less than 5% accountability for achieving our goals. THE WORLD BANK Introduction Further, nutrition has often been equated with availability of staple foods, ignoring the critical The World Bank and the Bill & Melinda Gates issues of access to food quality, dietary diversity, Foundation co-hosted a meeting on February 20, health, and optimal care, especially in the 2013 in Washington, D.C. of nutrition, policy, and thousand day “window of opportunity� from advocacy experts from the research, development, pregnancy to age two when the consequences of and civil society communities to advance the undernutrition are the most severe and largely dialogue on nutrition in the post-2015 irreversible. development agenda and to recommend next steps to incorporate select nutrition Nutrition challenges for the next 15 indicators/targets in the post-2015 discussions. years Collaborating agencies for the meeting included Bread for the World, The 1000 Days Partnership, Over the last twenty years, the global burden of the Canadian International Development Agency disease has shifted dramatically. Whereas in 1990, (CIDA) and the International Food Policy Research child underweight was the leading cause of death Institute (IFPRI). and disability overall, today the nutrition picture is far more complex. Child underweight remains a This expert consultation reviewed the rationale leading cause of death and disability among and success of the current nutrition MDG children below 5 years of age, but overweight and structure and the priority nutrition challenges for obesity are rising rapidly, even in the developing the next 15 years. Participants also discussed the world2. pros and cons of potential nutrition indicators and targets that would best capture and respond to Ending undernutrition is an unfinished agenda: these challenges. This report summarizes the key 165 million children under five years of age are messages that emerged from this consultation and stunted, and while the proportion is declining in articulates broadly held opinions about what and several regions, the number of stunted children is how to position nutrition in ongoing institutional actually rising in sub-Saharan Africa. In addition, and high-level dialogue and engagement with the today there are 52 million children suffering from post-2015 consultation process through 20131. wasting, with reduced numbers in Asia but increases in Africa, yielding little improvement Lessons learned from the Millennium globally since 1990. Low birth weight, sub-optimal Development Goals (MDGs) breastfeeding, and anemia have remained relatively stagnant, while the number of In the current MDG framework, nutrition is overweight children has doubled since 1990, featured as an implicit target under the poverty reaching 43 million in 20103. MDG1, with both positive and negative consequences. The incorporation of a nutrition It is now recognized that we do not live in two target under the poverty goal likely wielded some worlds, the wealthy suffering from overweight clout given its link with hunger, which received and the poor from undernutrition. Today, it is increasing attention due to rising and volatile food often the same households, families, and at times prices and the triple threat of the food, fuel, and the same individuals who suffer from multiple financial crises in 2007-2008. However, despite forms of malnutrition. Exposed to poor and the potential benefits of bundling the underweight micronutrient-deficient diets, children stunted in and hunger targets, it was acknowledged that early life are at heightened risk of becoming nutrition did not receive the same level of attention as hunger and poverty, and momentum 2 Lim et al. A comparative risk assessment of burden of disease was lost when it seemed clear that the poverty and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global target would be achieved. Burden of Disease Study 201. Lancet 2012; 380: 2224-60. 3 United Nations Children’s Fund, World Health Organization, 1 This is not a peer reviewed publication. Any opinions stated The World Bank. UNICEF, WHO-World Bank Joint Child herein do not necessarily reflect the policies or opinions of the Malnutrition Estimates. (UNICEF, New York; WHO, Geneva; participating organizations. The World Bank, Washington, DC; 2012). Nutrition in the Post-2015 Development Agenda EXPERT CONSULTATION | February 2013 overweight, with subsequent increased risks for numerous non-communicable diseases later in 3. Pursue the above two options in tandem; a life. stand-alone nutrition goal as well as targets linked to relevant sectors. An implicit and ongoing challenge for nutrition is that of addressing equity so that the most 4. Maintain nutrition as part of a single poverty vulnerable and disadvantaged populations are goal, similar to MDG1, changing from reached with a package of key interventions to underweight to stunting as the indicator for prevent and treat malnutrition in all its forms. measuring progress on poverty. This option Lack of progress in nutrition has been, in part, a was deemed insufficient. reflection of rising inequality across multiple aspects, ranging from gender to socioeconomic Priority nutrition indicators for the next status to geography, religion, ethnicity, and others. Addressing the range of equity challenges in MDGs nutrition is most effectively done by incorporating nutrition objectives and goals across a range of A wide range of anthropometric, dietary, sectors; however, this approach is often difficult consumption, and micronutrient indicators were and dis-incentivized given the complexity of presented and the pros and cons of each were institutional and political structures and program discussed. implementation arrangements in countries. Anthropometric indicators measure nutritional status by using weight and height What do these nutrition challenges measures and comparing them to a global mean for the next MDGs? reference standard, providing information on the prevalence of children who are stunted, wasted, Given the identified nutrition and equity underweight, and overweight. Anthropometry challenges – and the need to sustain the also includes adult height and weight improvements that have been achieved under the measurements, which are used to calculate body current MDG framework – a number of scenarios, mass index (BMI) for the categorization of priority nutrition indicators and targets were underweight, overweight, and obesity in adults. presented during this consultation Anthropometric indicators are relatively easy to collect and are included in most population-based Scenarios and potential frameworks for nutrition and health surveys and increasingly, in nutrition in the next MDGs household consumption and expenditure surveys such as the living standards measurement surveys Four principal options were presented: (LSMS). 1. Nutrition in a single goal. In this framework, Food consumption indicators fall into two improved nutrition would be a stand-alone categories: 1) measures of household food goal, possibly packaged with hunger as in the consumption, and 2) measures of individual UN Secretary General’s Zero Hunger dietary intake. These indicators are resource and Challenge, with a suite of indicators and time-intensive and, for that reason, are not usually targets that would explicitly link to other included in routine data collection. Moreover, the sectors but that would fall under one goal. disadvantage of household, compared to individual measures, is that they do not provide 2. Nutrition integrated across many goals. Here, accurate intake data on each household member, a a suite of nutrition indicators would be limitation when information is sought on nutrient thoughtfully integrated in multiple sectors’ gaps in nutritionally vulnerable women and young goals. Key sectors that have been identified children. Simple dietary diversity indicators based include health, water and sanitation, on recall of food group intake are a potential agriculture, education, governance, and alternative for measuring diet quality; they have others, and relevant nutrition indicators been shown in cross-country studies to accurately would be proposed for each, as appropriate. predict micronutrient density (in breastfed Nutrition in the Post-2015 Development Agenda EXPERT CONSULTATION | February 2013 children) and adequacy (in adult women) of the diet. One limitation of these indicators is the Targets for nutrition indicators in the inability to identify a universal cut-off point that would reflect an adequate versus inadequate next MDGs micronutrient intake. Targets for indicators, and whether they should be Micronutrient indicators are problematic due realistic or aspirational remains an important to insufficient advances in measurement question. Aspirational targets, such as zero techniques. Of the four principal micronutrients stunting, can galvanize high-level visibility and measured – iron, vitamin A, iodine, and zinc – only attention. At the same time they are difficult, if not one has a field-ready and minimally invasive impossible to reach, particularly by countries with application: hemoglobin testing. Hemoglobin, the highest burden. The group favored however, measures anemia rather than iron aspirational goals that are compelling and easy to deficiency, and while extremely useful, it does not understand by lay people, paired with targets that accurately capture progress addressing this are achievable and for which decision-makers can important nutritional deficiency. be held accountable. There is an urgent need to develop better The targets endorsed by the World Health micronutrient measurement tools. Coverage Assembly in May 2012 were deemed suitable to indicators for key interventions such as vitamin A cover the broad scope of global nutrition supplementation and adequately iodized salt were challenges presented as potential alternative micronutrient indicators. Routinely gathering coverage data was In the current MDGs, targets are global rather than felt to be important to avoid ‘backsliding’ on these country- or region- specific. More discussion is two nutrition programs, which have achieved needed on whether the next development relatively high coverage (>70%) throughout the framework should be tailored to specific contexts, world. regions, and countries. Key Messages  Reducing malnutrition will save maternal and child lives and build strong and resilient individuals, families, communities, and populations.  It is critical that nutrition receive greater focus and attention in the successor framework to the MDGs.  A single nutrition goal with a suite of indicators, building on the World Health Assembly-endorsed targets with explicit links to other sectors, is the preferred framework for galvanizing action.  A powerful alternative or tandem approach is to thoughtfully incorporate key nutrition indicators into multiple sectors’ development goals, recognizing the foundational role that nutrition plays as well as the contribution of these sectors to improved nutrition.  Childhood stunting is the priority nutrition indicator, given its power to capture inequity and chronic conditions of poor health, diet and caring practices during the crucial thousand day ‘window of opportunity’ from pregnancy to age 2.  Child overweight is also recommended for future progress tracking given its increasing prevalence and emerging contribution to death and disability around the world.  Future attention must be paid to systems and tools for gathering better data, particularly on micronutrients and diet quality, to monitor progress and drive commitment and accountability for achieving these goals. Nutrition in the Post-2015 Development Agenda EXPERT CONSULTATION | February 2013