Children at a project we support in Bangladesh (photo: Darren Fletcher/Save the Children)

You’ve got to admit even in a world drowning in facts, the four below from the 2015 Global Nutrition Report are really staggering:

1. 794 million people do not get the energy they need from their food.
2. 2 billion do not get the nutrients they need from their food.
3. 1.9 billion are overweight or obese.
4. No country is immune to the serious economic and social burdens of malnutrition.

Together these facts mean that one in three people are not benefiting from the food they need. When the failure is this big, it can only mean one thing: there are serious problems with the systems that bring us our food.

Wherever you live, your country’s food systems are simply not delivering the right quality of food, in the right quantity, at the right price. To the detriment of one in three people’s health.

This is no trifling matter (excuse the awful pun) – countries can lose up to 11% of GDP as a result of maternal and child undernutrition. Meanwhile, up to 20% of governments’ health budgets are being eaten up  by obesity and its related diseases.

Given that an estimated 10% of all human ingenuity is dedicated to getting us our food, you’d be forgiven for expecting better. Want to know what’s wrong? This year’s Global Nutrition Report is a good place to start.

For me, the biggest innovation of this year’s Global Nutrition Report is its focus on food systems. A food system is everything involved in the conversion of natural resources – including sunlight, water and CO₂ – into the food we eat. It includes researching, growing, harvesting, processing, packaging, distributing, marketing, trading, consuming, and disposing of waste.  So everything from ‘farm to flush’.

The Global Nutrition Report’s food systems approach adds to our understanding of the links between food, environmental sustainability and human health. It explores the marked shift in global diets towards the consumption of energy-dense food, high in fat and sugar, but low in micronutrients.And radically, it places a responsibility for fixing the world’s high rates of undernutrition, rocketing obesity rates, and climate change at the doorstep of the people with the power to influence our misfiring food systems.

A systems approach makes spotting the underlying reasons for malnutrition far easier. Causes of malnutrition – such as food’s price, safety, wastage, composition, and marketing – become visible; as does the food system’s impact upon environmental degradation, income inequality, time scarcity and market structures.

The Global Nutrition Report, however, is far from a problem merchant. In fact, the report’s authors propose a set of outcome indicators which could help policy-makers, duty-bearers and citizens build food systems with nutritional health and sustainability at their very heart. The report also provides a menu of food system policy interventions that show promise in creating a better nourished, healthier, more prosperous world.

It’s beyond doubt that opportunities to reduce the prevalence of malnutrition through food system reform are currently being missed. It’s exciting then that at the Rio Olympics next year the Government of Brazil will invite Heads of State to the next Nutrition for Growth event to intensify policies that promote environments that encourage healthy and adequate diets. And we at Save the Children will be working with our partners to ensure this Nutrition for Growth event generates specific political and financial commitments, ambitious enough to attain global nutrition commitments, including Goal 2 of the Sustainable Development Goals and the WHA 2025 Nutrition Targets.

Safie, 17, from Kroo Bay settlement in Sierra Leone’s
capital, Freetown. (Photo: Anne-Sofie Helms/Save the Children)

There are at least 1.2 billion adolescents and young people alive today, more than ever before. It may be clichéd to say they are our future… but it’s true! They really are critical to breaking the intergenerational cycle of malnutrition. Teenage years are a time of rapid physical and mental development, during which it’s vital we get the right food and nutrients. This is all the more important for the 16 million adolescent girls who still endure childbirth each year.

Unfortunately, when it comes to nutrition, adolescents are too often an excluded, malnourished group. For example, UNICEF predicts that 50% of girls aged 15-19 in India are underweight. And further, adolescent pregnancies, particularly where girls are themselves stunted, are more likely to result in low birth weight, premature birth and small for gestational age babies.

This is tragic news, but perhaps not surprising in light of Save the Children’s recent review of national nutrition strategies. Fewer than half of the countries we reviewed included any detail on adolescent nutrition in their strategies. The reality is that governments, donors and civil society continue to overlook the problem.

In order to prevent malnutrition being passed to the next generation, adolescent girls, their families and communities must be supported not only to improve adolescents’ access to nutrition but also to delay marriage and pregnancy. The economic benefits of reducing adolescent pregnancy could amount to 30% of a country’s gross domestic product (GDP) (Chaaban and Cunningham, 2011).

This week I’m going to the International Summit on the Nutrition of Adolescent Girls and Young Women to present on our review of adolescent nutrition policies and programmes in Scaling-Up Nutrition Countries. This will be a small, but significant step as we strive to focus coordinated international attention on finding remedies for adolescent nutrition in time to achieve the World Health Assembly’s 2025 Nutrition Targets.

The Japanese Global Nutrition Report

Japan has the longest life expectancy in the world, with people on average living to 86 years of age. This impressive achievement is in part due to the diet that many Japanese people enjoy.

I was in Tokyo this week for a roundtable discussion on the Global Nutrition Report. The room was full of around 80 participants from the Government of Japan (the Ministry of Foreign Affairs, the Ministry of Finance, the Ministry of Health, Labour and Welfare, the Ministry of Agriculture, Forestry and Fisheries, and the Cabinet Office), parliamentarians, civil society organisations, representatives from the UN and World Bank, and representatives from the private sector. The report has clearly attracted some attention here.

It was evident from the discussion that Japan sees nutrition as key to sustainable development and human security. This point was encouragingly reiterated time and time again. It was also clear that many in the room recognise the need to maintain the international momentum around nutrition, citing opportunities such as Japan’s presidency of the G7 in 2016 and the commitment to use the Tokyo 2020 Olympics to improve nutrition.

Keizo Takemi, a senior politician and influential player in global health in Japan, wrote the foreword for the Japanese Global Nutrition Report. In it he says: “There is a need to maintain international momentum around nutrition. I hope that Japan will engage in further work around nutrition. Tokyo 2020 will be an important moment to enhance the position of nutrition in policies and plans in Japan.”

Japan has been a supporter of nutrition for many years. It was one of the first investors in the Scaling Up Nutrition movement and today the country is the fourth largest contributor of overseas development assistance to nutrition in the world.

One fact that seemed to grab the attention of those at the roundtable was a finding from the Global Nutrition Report that for every $1 invested in nutrition, the return is $16. Clearly investing in nutrition is a smart investment – and the Japanese government understands this.

The government of Japan is proud of its public–private partnerships and is keen to share this experience with the world. If these partnerships take place in the context of multi-sector, multi-stakeholder platforms for nutrition, which the government reiterated its support for at the event, then they will add great value to efforts to address malnutrition.

It was very encouraging to see so many government ministries and stakeholders coming together for the Global Nutrition Report launch in Japan. Coordination of these stakeholders will be key if Japan is to make the most of the opportunities ahead.

The conference, organised by the Food and Agriculture Organization (FAO) and the World Health Organization (WHO), brings together ministers and representatives from 193 governments to demonstrate their commitment to ending malnutrition in all its forms. Member states have agreed two conference outcome documents:

• a Rome Declaration on Nutrition, which is a political declaration of intent
• a voluntary Framework for Action (FFA) – containing a set of policy options and strategies for signatories to achieve the principles of the Rome Declaration.

Save the Children is calling for governments to:

• make the policies and actions put forward in ICN2 Framework for Action specific and time bound to ensure they’re implemented
• work through existing initiatives and architecture for nutrition – for example, the Scaling Up Nutrition movement should not only be used as a monitoring and accountability tool, but as a major partner in implementing ICN2 commitments
• ensure the post-2015 Sustainable Development Goals hold governments accountable for delivering on improvements in nutrition for their citizens.

We value many elements of the Rome Declaration on Nutrition and Framework for Action. However, ICN2 does not guarantee a positive outcome for nutrition. We have the following concerns::

1. The framework lacks specific, time-bound, prioritised, detailed, and measurable recommendations. This will make it very hard for populations and their civil society representatives to ensure implementation of recommendations at the necessary scale. We urge ICN2 signatories to individually take the floor to commit to specifics of the FFA, with measurable, time-bound detail.
2. We doubt that the FFA’s recommendations for accountability will be adequate – especially because the establishment of national targets, intermediate milestones and national monitoring frameworks have been left as voluntary, state-centric processes. The accountability mechanism will need careful stewardship, starting with ICN2’s Roundtable 3 ‘Governance and Accountability for Nutrition’. We feel accountability can be enhanced if: a) states commit to establishing (and resourcing) multi-stakeholder platforms for nutrition, as per recommendation for an enabling environment; b) the UN establishes a formal follow-up process, requiring state actors to account for their progress; c)  the proposed biennial UN accountability report is annual and is done in conjunction with existing nutrition architecture, especially the Global Nutrition Report.
3. We’re deeply concerned by the ‘recommended actions to promote, protect and support breastfeeding’. These priority actions need to be highlighted and strengthened to ensure the International Code of Marketing of Breast-milk Substitutes is adopted (not adapted) into national law and then enforced and monitored. All reference to the need for governments to protect consumers, especially children, from inappropriate marketing and publicity must be made in relation to drinks as well as food. Member states should bring their maternity leave policies into line with the International Labour Organization minimum recommendation.
4. Neither outcome document explains ICN2’s fit with the post-2015 Sustainable Development Goals. A concerted effort is needed to ensure a positive outcome is taken-forwards from ICN2’s Roundtable 1 ‘Nutrition in the Post-2015 Development Agenda’.
5. The UN has not detailed how all its nutrition-related agencies, funds and programmes will coordinate their future work. We will call for these concerns to be addressed, starting with ICN2’s Roundtable 3: ‘Governments and Accountability for Nutrition’.
6. The nutritional status of adolescents has not been prioritised, relatively speaking. We will call on our civil society parents to help ensure adolescents are recognised, alongside other vulnerable groups, as an essential constituency for breaking the intergenerational cycle of undernutrition.
7. There’s a lack of information for the proposed decade of action on nutrition. It will now be important to influence these plans to ensure they do not lack the necessary ambition to deliver WHA 2025 Global Nutrition Targets.
8. The Scaling Up Nutrition movement was not mentioned as a means for creating an enabling environment for action or ensuring accountability for commitments. In this way, ICN2 risks duplicating existing nutrition architecture and may violate the ‘do no harm’ principle – governments do not need competing national nutrition plans and nutrition action plans. Instead, initiatives should support existing efforts to scale up nutrition.
9. There’s a relative dearth of recommendations for nutrition-specific interventions – particularly a failure to recommend all ten cost-effective interventions evidenced in the Lancet (2013) Maternal and Child Nutrition.
10. It’s lamentable that member states missed an opportunity to specify the level of increased investments needed to eradicate malnutrition. It is also a failure of the declaration not to put a time-frame on its goals.
11. The recommended actions for wasting miss the opportunity to promote the improvement of identification and measurement of wasting – both for curative and preventative purposes. 
12. Social protection recommendations need to target interventions at the 1,000 day window and incorporate empowerment activities for women and adolescent girls. Furthermore, consideration must be also given to achieving sustainable livelihoods and behaviour change through national social protection systems.

These concern’s must be resolved either during the conference in the follow-up work.

I’ll be blogging again at the end of the week with updates from the conference.

On that day, the Nutrition for Growth bonanza brought together on an massive scale, governments, civil society, donors and businesses in London. They pledged $23.15 billion to tackle malnutrition ($4.15 billion for programmes that address the immediate determinates of nutrition and $19 billion to address the underlying causes of malnutrition) and made other vital political commitments necessary to improve global nutrition by 2020.

Berhanu, from Ethiopia, with a cup of yogurt produced from cows his family received as part of a Save the Children livelihoods project.
(photo: Colin Crowley/Save the Children)

Who’s responsible?

But a year and a half since and vigilance is still needed to ensure that glitzy nutrition announcement results in lasting change. After all, who is to ensure high-profile nutrition commitments are fulfilled once the spotlight is turned off and the signatories return to their day jobs?

And who can advocate to ensure that action secures a tangible benefit to the 805 million people worldwide who are chronically undernourished, the 165m children stunted by the age of five, or the 3.1m children under 5 still destined to die each year as a result of malnutrition?

Accountability is key. Especially in the field of nutrition, where good solutions require the input of multiple actors in multiple sectors – health and water, sanitation & hygiene, education and care, agriculture and food systems, and social protection and livelihoods, to name but a few.  As a result, it’s all too easy for nutrition to become everyone’s problem, but no one’s responsibility. Without the appropriate accountability mechanisms, nutrition risks a triangulation of responsibility and gridlock.

Massive step forwards

Next week sees the launch of the first-ever #NutritionReport – a ground-breaking, comprehensive narrative on progress in all forms of nutrition and its drivers. It’s potentially a massive step forwards in improving accountability for nutrition. The report will, among other things, track the progress of countries, civil society, businesses, donors and the United Nations against their Nutrition for Growth commitments. (Save the Children was found to be “on course” for its own commitments.) It will also put forwards a plethora of recommendations for action that could yet prove a seminal guide for driving action at a local, national and global level.

It’s what we do with it that matters

But, as with all reports, no matter how ground-breaking, without a receptive and well organised constituency it risks just gathering dust on a shelf. If the report’s potential is to be fulfilled, it must be supplemented by the immediate building of a robust, targeted and sustained advocacy movement of civil society organisations capable of:

• raising awareness of nutrition
• advocating for the implication of #NutritionReport recommendations
• catalysing national Nutrition Action Plans
• holding nutrition investors (like governments and businesses) to account
• providing support to decision-makers.

Scaling Up Nutrition (SUN) has made valiant progress fostering such a movement. Already, more than 1,500 national and international civil society organisations are engaging under the banner of the SUN Civil Society Network, which is working in 30 countries to create an enabling environment for good nutrition governance.

Our challenge now is to improve collaboration among civil society alliances to better support national nutrition priorities. After all, as John Gaventa and Gregory Barrett concluded in their 2012 study of citizen engagement, “when civil society and communities put pressure on stakehold­ers, social change happens more quickly.”

‘Nutrition November’ takes place at a time when every day 805 million people are chronically undernourished and 162 million children under the age of five are stunted, meaning that their physical and cognitive development has been restricted because they have not received the nutrients they need.

Over two billion people suffer from one or more micronutrient deficiencies and the number of overweight or obese children (up to five years old) has increased from 31 million globally in 1990 to 44 million in 2012.

Here’s what these initiatives are hoping to achieve, and why they are so important…

SUN Global Gathering

The SUN Global Gathering is a chance to reflect on the huge amount of progress that has been made in efforts to scale up nutrition and to look at how the movement can continue to address the needs of the 54 countries that have joined to date. To support these efforts, the SUN movement has developed four ‘Communities of Practice‘ which will form the basis of discussions at the gathering.

Second International Conference on Nutrition

ICN2 is taking place 22 years after the first ICN and is a rare opportunity for all UN Member States to demonstrate greater commitment to ending malnutrition in all its forms. Heads of state, ministers and officials from 193 governments will come together for ICN2 with the aim of advancing policies and actions in order to more effectively address the world’s major nutrition challenges.

Member States have been negotiating two outcome documents – a political declaration and a framework for action. The documents contain a number of voluntary commitments which Member States will hopefully sign up to in November, but to ensure implementation the policies and actions put forward in the ICN2 Framework for Action must be specific and time-bound.

Global Nutrition Report

Finally, the first Global Nutrition Report – an outcome of the Nutrition for Growth Summit held in London in 2013 – will be launched during ICN2 on 20 November.

The report is a comprehensive effort to accelerate progress in reducing malnutrition by improving our collective ability to monitor ongoing efforts and promoting accountability for commitments, actions and outcomes. It will cover nutrition status outcomes and programme coverage, as well as underlying determinants such as food security and water, sanitation and hygiene, resource allocations, and institutional and policy transformations.

The many nutrition-related activities taking place in November offer an important opportunity to share experiences and knowledge of what works in efforts to address malnutrition. To make the most of these opportunities we need more than just ambitious commitments – we need a clear vision for implementation.

‘Devastation everywhere’ – the view over Estancia

“Seeing those broken boats makes you realise the scale of the destruction”, says Julia Schurch, Health Manager, looking at the sea. We’re standing on the roof of Save the Children’s field office in Estancia, Panay Island, which was badly hit by typhoon Haiyan, three months ago. There are heavy showers, grey skies and the wind is howling. Julia has been here since before Christmas and will finish her mission in a couple of days but the overall picture, she says, is very difficult.

“Don’t forget, this is a poor island so even a minor typhoon would have caused serious damage,” she adds. “With a typhoon like Haiyan, structures that weren’t solid enough stood no chance.” We’re now looking out over Estancia: there’s devastation everywhere. And this is not even the worst-hit area of the Philippines. “It’s difficult to say which are signs of poverty and what is damage caused by the typhoon,” remarks Julia. Many houses have tarpaulins instead of iron roofs. In other places, the iron is bent or has been tied down, making the house beneath look like it’s been gift-wrapped. These are some of more than a million homes devastated by the typhoon.

Back to basics

Three months on, Julia’s team have shifted from treating injuries and diseases to providing basic healthcare. Two mobile clinics are run from Estancia. The health team also visits island communities with limited access to services, while the nutrition teams are busy preventing a rise in malnutrition levels.

Before Haiyan hit, at least one third of all children under five in this area already suffered from chronic malnutrition. Those figures could easily rise due to reduced access to food and the disaster’s impact on water, sanitation and hygiene – putting children’s lives in danger.

“So far, we have not seen a huge rise in numbers”, says Jessica Bourdaire from Save the Children’s nutrition team in Estancia. We‘ve only documented a small number of cases, but “if those cases are not treated, those children will die”.

An area with chronic malnutrition – even before Haiyan

That is why Save the Children is making it a priority to inform mothers in the hardest-hit areas about feeding practices, nutrition, and the importance of breastfeeding. Given the area’s chronic malnutrition problem this is not an easy task. “Changing behaviour takes time,” Jessica says. “We are taking this opportunity to raise people’s awareness of malnutrition, how to identify, treat and prevent it”. The idea is also to educate local health workers on malnutrition in order to pass the knowledge on, making them capable of tackling any future malnutrition issues.

In fact, the majority of Save the Children’s staff in Panay Island are local people. “Really amazing and so qualified”, says Julia. Since half of the area’s health structures were damaged by the typhoon, many of them would now be out of work. Save the Children is  providing them with both training and an income, and is also rebuilding some of the damaged buildings they used to work in. Helping them will enable them to help others. “For me, they are the heroes,” says Julia.

Nirob, 5 months, at his home in Bosikali village, Bangladesh
(Guilhem Alandry/Save the Children)

In Bangladesh, we met five-month-old Nirob, who was battling against a terrible combination of malnutrition and disease. He’d been losing weight since he was born and wouldn’t feed regularly.

Nirob’s mother Shipra didn’t know what was wrong and wished she could take him to a doctor. But she told us that no health workers visit their rural village and they can’t afford to make the 50km journey to the nearest clinic.

“Where can I go for help?” she asked. “I just want Nirob to be safe and well. Only then can I think about his future.”

The links between health and nutrition

Malnutrition is an underlying cause of almost half of child deaths worldwide. However, there is often little discussion about the role that health workers – doctors, nurses, midwives and community-based healthcare providers – play in preventing and treating it.

Health workers are vital for promoting good maternal and child nutrition, particularly during the crucial 1,000 day window between conception and a child’s second birthday. For example, community health workers in India proactively go out into the community to identify pregnant women and children at risk of malnutrition.

A severe shortage of health workers

However, the children at greatest risk are also the least likely to see a health worker. Our new policy brief shows that of the 30 countries with the highest rates of stunting, 29 are classified as having a severe health worker shortage. In Afghanistan, where almost three out of five children are stunted, there are just seven doctors, nurses and midwives to serve every 10,000 people.

The global shortage of skilled health workers means that children in the world’s poorest countries don’t get the care that would stop them dying from causes related to malnutrition. It also means that pregnant women don’t receive counselling about how to ensure optimum nutrition for themselves and their baby.

We need more health workers who are trained and supported to prevent and treat malnutrition in the places of greatest need.

As part of broader efforts to end preventable maternal, newborn and child deaths and achieve Universal Health Coverage, Save the Children is calling on governments, with the support of development partners such as the UK government, to take a number of actions, including:

• Ensure that global nutrition initiatives recognise the role that health workers play in improving maternal and child nutrition
• Increase investment in the recruitment and training of new health workers
• Develop and implement plans for continued training and professional development for health workers, including better support and supervision, fair pay and incentives to encourage them to work in under-served areas
• Ensure that nutrition is a core part of training curricula for all levels of health workers.

In November, the Third Global Forum on Human Resources for Health takes place in Brazil. We’re calling on world leaders to use this opportunity to ensure that every mother and child has access to a health worker with the skills and support needed to improve nutrition and save lives.

Read our full briefing Nursing for Nutrition to find out more.

Two years ago, donors came through with vital commitments to save millions of children’s lives through immunisation. Over £2.76 billion was pledged at the GAVI Alliance pledging conference to help immunise 250 million children and save nearly 4 million lives.

Save the Children has been monitoring those promises: our briefing last year reported that as of June 2012, all donors were on track to fulfil their commitments, while shedding light on areas requiring further action. But we must keep the pressure on to make sure all donors follow through and keep their promises. More recently, we have recognised further commitments made to GAVI’s Matching Fund.

Aid works

In addition to charting progress, the anniversary of such a ground-breaking summit is also a moment to recognise the vital importance of aid and the impact it has on saving children’s lives.

Immunisation is one of the most cost-effective and successful health investments for child survival, contributing significantly to reductions in child mortality across the globe. Commitments made at the GAVI Pledging Conference and the impact of this funding on children’s lives show just what can be achieved by aid.

New commitments on nutrition

This year, the anniversary of the GAVI Pledging conference falls just a few days after another breakthrough for child survival and development. At the high-level Hunger Summit that took place in London on 8 June, world leaders pledged over £2.7 billion in the fight against malnutrition, which will help save the lives of 1.7 million children.

This is yet another example of the vital importance of life-saving aid, and a historic moment in the fight against hunger.

The link between immunisation and nutrition

These two important moments focus on two closely linked issues, both vital for child survival.

A recent GAVI briefing highlights this bi-directional link between immunisation and nutrition. For example, an un-immunised child is at greater risk of vaccine-preventable disease, diseases which can then lead to difficulty in retaining essential nutrients, thus perpetuating malnutrition. Repeated episodes of illness can also lead to under-nutrition. On the other hand, a malnourished child is at greater risk of dying from infectious diseases.

Taking an integrated approach

The clear linkage between immunisation and nutrition militates for a comprehensive response. Moreover, taking an integrated approach can be a more efficient use of resources and has the potential to reach children with a broader range of essential services and interventions.

As we build on the momentum of key moments such as the 2011  GAVI Pledging Conference and the Hunger Summit, we must break down silos to promote a more comprehensive approach, so that all children have access to all the services and interventions they need for a fair chance at survival.

As Nutrition Programme Manager for Save the Children in eastern Congo, I’m responsible for the day-to-day running of our nutrition projects.

It’s a challenging job – coordinating with other aid agencies and the UN, getting updates on the latest malnutrition levels, visiting health centres to make sure our work is happening on time and to the required standard, supervising staff,  monitoring budgets… the list goes on, and there is never a quiet moment!

Chronic and complex

When people think of Congo, conflict and displacement are often the first things that come to mind – I have found that people rarely think about malnutrition. But conflict directly affects a child’s ability to get enough of the right foods, and the nutrition situation here is chronic and very complex.

The reasons behind malnutrition are endless – a family may not have enough money to buy food, or know which foods are nutritious, they may be forced to flee their home and so can’t farm their fields, or they may be unable to reach a health centre due to an outbreak of violence.

Treating malnutrition

In response to the outbreak of conflict in November last year, Save the Children launched an emergency nutrition project. Through this project, our teams identify, refer and treat malnourished children in 24 health structures through the region.

As well as treating the symptoms of malnutrition through these health centres, we also educate communities on nutrition, teach healthy hygiene practices and explain how to identify a malnourished child.

Through this work we are fighting the deepest causes of malnutrition – and so making our work more sustainable.

Tackling the root causes

A few weeks ago, at a displacement camp, I met a three-year-old child suffering from Kwashiorkor. I could tell instantly that she was suffering from this type of malnutrition – her hair had turned orange and her face, legs and arms were swollen.

It’s so important not to focus just on the symptoms and how to treat them, but to remember that behind them there is a little girl being overwhelmed by this devastating disease.

Save the Children not only saves lives by providing emergency care, but we also tackle the root causes of the problem.

No child born to die

What we are doing here, little or big, depends on donations. We believe that no child is born to die and I know our nutrition work is saving the lives of some of the most vulnerable here in eastern Congo.

Donate to support our emergency work.