|Ending Malnutrition by 2020: An Agenda for Change in the Millennium - Final report to the ACC/SCN by the commission on the nutrition challenges of the 21st century (ACC/SCN, 2000, 104 p.)|
|6. Vision and Goals for the Future|
To live a life without malnutrition is a fundamental human right. The persistence of malnutrition, especially among children and mothers, in this world of plenty is immoral. Nutrition improvement anywhere in the world is not a charity but a societal, household and individual right. It is the world community's responsibility to find effective ways and means to invest for better livelihood and to avoid future unnecessary social and economic burdens. With collective efforts at international, national and community levels, ending malnutrition is both a credible and achievable goal.
The Commission now wishes to extend this vision to encompass a new paradigm of nutrition which incorporates the double burden of undernutrition and diet-related adult disease. This double burden is amplified by the link between maternal and fetal undernutrition and a population's later susceptibility to adult diet-related disease. This susceptibility is displayed when food consumption patterns change during economic development. Thus, there is a synergy between early undernutrition together with adult lifestyles which may help to explain the pandemic of non-communicable diseases. Our vision encompasses the development and implementation of national and international strategies which will allow societies and individuals to improve their life expectancy with minimum health handicaps from these preventable disorders in middle and old-age. It is not enough to acknowledge this moral imperative. The commitment needs to be translated into effective and strategic action.
We now know what needs to be done and have seen that rapid but sustained improvements in nutrition are possible. It is clear that current international support systems are inadequate. Current UN goals relating to undernutrition are incoherent and unambitious, which is why the Commission is challenging the UN to consider a new goal of ending malnutrition by 2020.
This, we believe, is ambitious but achievable. The 2020 date was chosen recognising that international conferences and summits have specified targets already for 2010 and 2015. This Commission is reporting well after these meetings, so a 2020 date is chosen to allow time to both formulate and implement new strategies. To specify an early date for achieving radical improvements in health would be unrealistic.
The 2020 date also takes account of our analyses of the potential rate of improvement in the global burden of underweight, children when this rate is based on the success of one country i.e. Thailand (see figure 6.1). The Commission highlights the issue of childhood undernutrition since it contributes long-term to the global burden; combating undernutrition and other forms of malnutrition, i.e. obesity, diabetes, coronary heart disease and cancer, now needs to be brought into a single strategy so that developing countries can limit the double-handicap of diet-related diseases (see below),
To assess how goals should be achieved, there is a need to assess why the international community has failed to implement existing knowledge before now. The outcome of such an assessment, coupled with proposals put forward in this Report, should then be the basis for regional taskforces to develop coherent strategies. We challenge the UN, national governments and other agencies to implement these proposals and turn words into action.
The requirement for achieving rapid reductions in undernutrition on a national basis is new purposeful action: a determined political commitment, clear goals, good strategic and programme planning, sustained action and systematic monitoring through a physical and administrative infrastructure. To this must be added a process for mobilising the public at large. Community participation and consumer demand need to be promoted by a three-way communication between the people, the community's non-governmental organisations and its government. With these three elements in place, experience with undernutrition, with micronutrient deficiency in developing countries and with diet-related chronic disease of adults in the developed world shows that rapid progress is possible.
Given the remarkable international agreements embodied within the International Conference on Nutrition and the World Food Summit to develop new approaches to combating undernutrition, it is unclear why more has not been achieved. This Commission concludes that several factors are involved:
the lack of a locus within many countries for highly motivated academics and non-governmental organisations to interact with political leaders and decision-makers, and thereby help drive forward a nutrition initiative;
the frequent failure of health and agricultural sectors to combine forces to ensure coherent plans of action. These plans need to be endorsed as necessary for improving the intellectual and physical capital of the population by enhancing their health and welfare and for increasing food security and sustainable high quality food production;
within-country rivalries: these may be amplified by the selective support of specific national programmes by charities, NGOs, bilateral and UN organisations;
the failure of some major financial institutions to follow the World Bank initiatives which require intersectoral measures to improve food security and human health when developing plans for economic reform and development. These inadequacies are evident in the approaches taken to deal with the current economic crises;
the failure of political leadership in many countries to realise the possibilities of making rapid improvements by prioritising nutrition when allocating national resources.
The Commission sets out in Chapter 7 mechanisms for initiating change and provides some potential approaches to policy development in Annex 4.
Figure 6.1 Elimination of undernutrition: a global deficit in policies and priorities
Note: If current trends continue, the International Food Policy Research Institute (IFPRI) predicts that the numbers of underweight (weight-for-age <-2SD) children less than six years will only drop to 150 million by 2020. The World Food Summit set a goal to halve the number of food insecure people in 1996 by 2015. In this diagram it is assumed that the number of underweight children should also be halved during the same time frame. If the World Food Summit goal were to be achieved, 84 million preschool children would still be underweight in 2015. Experience from Thailand show what is potentially achievable with the benefit of political, social and organizational commitment. Thailand was able to reduce the prevalence of underweight from over 50% in 1982 to 10% in 1996. The diagram shows the same proportional change applied to the world's underweight preschool children. The Commission suggests that with an amplified effort from governments and the UN system, eliminating underweight in preschool children by 2020 may be possible. The residual 2.5% reflects the accepted statistically derived lower cut-off point for normal growth in well-cared-for children from a reference population.
The practical value and impact of existing goals has already been demonstrated because sufficient time has elapsed to both mobilise and achieve results. Experience shows that the main need is for strong national action, often mobilised by the catalytic efforts and support of one or more of the UN agencies and its field staff. Many of the current goals relate to the year 2000 (a table listing existing goals is in Annex 2). As this year approaches, work is now needed to adapt and carry forward the goals into the 21st century. The World Food Summit established a goal to halve the number of food-insecure people in 1996 by no later than 2015. WHO's Health for all in the 21st century sets its proposals for the next century in the context of "strengthened support for key values: human rights, equity, ethics and gender sensitivity". Nutrition is then identified as the leading goal for improved health outcomes by the year 2020, as follows:
"By 2005, health equity indices will be used within and between countries as a basis for promoting and monitoring equity in health. Initially, equity will be measured on the basis of a measure of child growth: the proportion of children under five years who are stunted should be less than 20 per cent in all countries and in all specific sub-groups within countries by the year 2020." (WHO, 1998b)
We strongly endorse the goal set out at the World Food Summit and the focus on health, equity and child stunting in the WHO document. However, there are new issues which WHO, and others in the UN system concerned with action to reduce undernutrition, now need to address:
regional and/or national goals are now needed given the wide range in stunting rates. A single goal as a global objective needs to be supplemented by regional and national goals which challenge prevailing national trends. Consistency also needs to be developed to ensure that goals for reduction of 'undernutrition' are seen essentially as those for preventing the stunting of children. As noted in Chapter 2, stunting is the dominant contributor to childhood underweight.
experience shows that goals for 15 or 20 years ahead need to be supplemented by shorter-term goals for the next 5 or 10 years if they are to have political relevance and impact
the UN would benefit from ensuring that the goals for reducing poverty and poor nutrition are consistent, even if the two are not necessarily linked.
Our proposal is therefore that the UN agencies, with the help of the ACC/SCN, work together to identify global, regional and country-level intermediate goals for the reduction of childhood underweight by the year 2010, as well as 2015 (see Figure 6.1). As a basis for discussion, we would suggest that by the year 2005 each country should halve the proportion of its children under five classified as underweight or stunted in 1995, and halve it again by the year 2015. This is a relevant but feasible challenge for most countries because it would:
incorporate implicitly the reduction in the total number of pre-school underweight or stunted children in all countries by 2020, as well as the concern about equity within provinces. A major requirement would be to reduce stunting rapidly in the worst-affected regions.
form a bridge with the World Food Summit goal of halving by 2015 the number of people estimated as chronically food insecure.
apply to all countries as broad guidelines, but could be modified and adapted to each country's specific situation and prospects.
draw on the positive experience of UNICEF and UNFPA in using goals expressed in terms of reducing the national proportions of people affected by specific forms of deprivation.
There is also a need to explore other nutrition goals in four areas:
Rapid reduction in micronutrient deficiencies is vital. This, together with an assurance of improved levels of maternal nutrition, should be linked to the stunting goals.
A new goal specifically related to the need to transform maternal nutrition and health in many countries is essential.
The International Conference on Nutrition introduced a goal for ending deaths from famine. There is a need to elaborate indicators concerned with selective vulnerabilities - e.g. because of seasonal deprivation, in times of drought or other natural disaster and at times of war and economic crisis.
Goals to stem the rapid rise in overweight and obesity in adults as well as children are needed with a clear need to integrate these goals into a broader strategy against the major adult diseases of diabetes. Cardiovascular disease and cancers.
Until now, the UN has followed the convention of considering nutritional deficiencies and "excesses", i.e. the diet-related adult chronic diseases, as separate. This is no longer sensible. The Commission recognises that both dietary deficiency and adult chronic disease now affect developing countries as well as the developed world and Central and Eastern Europe. The two sets of disorders are fundamentally linked through poor maternal nutrition. Thus, policy developments with community involvement must simultaneously take on this broader range of issues and develop coherent approaches for tackling the problems.
It is vital that all countries wake up to the increasing problem of non-communicable diseases and develop goals to deal with this problem. The Commission proposes the following (adapted from WHO, 1998c and World Cancer Research Fund, 1997):
establish a population strategy to reduce morbidity and mortality from coronary heart disease in people under 70 years by 50% by 2020, taking account of the Norwegian and Finnish experiences. Dietary guidelines will be needed to take account of local food patterns.
reduce the incidence of NIDDM progressively by halving the rate in the adult population by 2020. This will require a major programme to prevent overweight and obesity in all age groups.
establish a public health goal that population average BMI throughout adult life should be within the range 21-23 kg/m2 thus ensuring that a very high proportion of the population have a BMI within the designated normal range of 18.5-24.9 kg/m2. This target should probably be lower for Asia with average BMIs of 20-21 kg/m2 and individual BMIs not exceeding 23 kg/m2.
reduce the incidence of common types of cancer by 30% through amplifying vegetable and fruit consumption (World Cancer Research Fund, 1997).
reduce incidence of hypertension progressively by halving the rate in the adult population by 2020 through comprehensive strategies aimed at reducing salt and alcohol consumption and limiting excess adult weight gain.
a physical activity goal should be one where adults maintain a physical activity level of over 1.75 times the basal metabolic rate (i.e. activity costing 75% more than basal requirements), with opportunities for vigorous physical activity.
WHO and FAO recently developed a strategy for translating the traditional nutritional population goals into a more practical formulation. Dietary goals should be developed nationally and could be based on recent analyses of the optimum nutritional content (Box 6.1).
It is appropriate to set regional and/or national goals for ending undernutrition and micronutrient deficiencies in refugee camps and in the community, for halving the prevalence of low birthweight by transforming maternal nutrition and health care, by developing breast feeding goals and focusing on improving the education and the economic capacity, as well as the health, of women.
Ultimately, success in achieving the goals outlined in this Report will depend upon political choice and public action. A blend of political choice and commitment, professional skill and community participation will be essential if every child, woman and man is to have an opportunity for a healthy and productive life. Policies which integrate various aspects of health, food production and education will be fundamental. Strategies to implement these policies are needed at local, national, regional and global levels. Appropriate institutional arrangements could clearly enhance national, regional and global capability. At every level, it is important to designate responsibility for setting priorities, developing implementation strategies and monitoring progress.
The vision of reducing malnutrition presents both a challenge and an opportunity to the United Nations today:
a challenge - the goal of rapid poverty reduction has already been adopted at the World Summit for Social Development in 1995 and identified by the Secretary General and by many of the UN development agencies as a central goal for UN effort;
an opportunity - because with the recent reforms agreed, the UN agencies now have the potential structure and commitment for working more closely together, globally and in support of country action. Accelerated improvements in nutrition on a world-wide basis are sufficiently fundamental to be worthy of a special place within these new efforts.
The United Nations will need to play a key role if the goal of ending undernutrition by 2020 is to be realised and new integrated goals met on a regional and national basis, Supportive action needs to be worked out on a collaborative basis in such key areas as:
support for country-by-country action, led nationally, involving many groups within each country, supported as appropriate by the international community and donors;
a harmonization of support, analysis, monitoring and evaluation by different agencies. This will allow the resources to be used more effectively with a sharing of results and lessons learned.
Just as action against malnutrition will require action in many sectors, supported by professionals from many disciplines, so most of the main UN agencies must necessarily have a role in reducing malnutrition on a global scale. A strengthened mechanism is needed at UN level to ensure that its agencies can combine their best efforts. This is needed to ensure a totally coherent policy by different UN agencies, bilateral and international financial institutions, to prevent the current disruption of local effort and national talent. In the next chapter the Commission sets out the stages needed for translating this vision into practical action.
Nutritional, activity and dietary recommendations as public health goals
Populations should consume nutritionally adequate and varied diets based primarily on foods of plant origin.
Promote year-round consumption of a variety of non-tuber vegetables and fruits in amounts equivalent to >400 g/day to provide at least 7% of total energy per individual.
A variety of starchy or protein-rich foods of plant origin, preferably minimally processed, to provide the majority of total energy (e.g. grains, legumes, roots, tubers). These recommendations imply a limited intake of sugars and starches with a high glycemic index. Benefit also accrues from limiting the frequency of sugar consumption in drinks, snacks and foods to improve dental health. In practice, this means free sugars should be <10% total dietary energy.
Where animal protein is in limited supply, preference should be given to pregnant women and children.
Red meat should provide <10% of energy. Fish, poultry and game are preferable.
Total fats and oils to provide at least 15% of total energy. Fat intake for women of reproductive age should provide at least 20% of energy. From weaning until 2 years of age children should consume 30-40% of their energy as fat. Active individuals in energy balance should not consume more than 35% of their energy from fat. Saturated fat should provide no more than 10% of energy. A total fat intake of 20-25% should not be exceeded if fat intakes are increasing from low levels in societies becoming more sedentary. Omega-3 fatty acids from fish, and fish and vegetable oils, should be selectively targeted to pregnant women and young children when the supply is limited. The ratio of n-3 to n-6 fatty acids should be increased to at least 1:5 to 1:10.
Dairy products, where culturally appropriate, may be included if they do not exceed the fat recommendations.
Salt from all sources should not exceed 6 g/day for adults.
Alcohol consumption is not recommended. It should be restricted to <5% of energy for men, 2.5% for women.
Perishable food should be stored in ways that minimize fungal and other contamination.
Perishable food, if not consumed promptly, should be kept frozen or chilled.
Safety limits should be established and monitored for food additives, pesticides, residues, and other chemical contaminants in the food supply.
Safe, hygienic methods of food preparation and cooking should be encouraged.
Production, promotion and use of tobacco in any form should be discouraged.
Based on WHO (1990); FAO/WHO (1994.1998); WHO (1998c); World Cancer Research Fund (1997); WHO/FAO (1996).