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Nutrition, global health and Norway’s development policy

Liv Elin Torheim, Anne Hatløy, Tone Sommerfelt About the authors

Nutrition has emerged as an important factor on the global development agenda during recent years. Five years ago, a Fafo report commissioned by Save the Children Norway concluded that nutrition was not a priority in Norwegian development policies. Results from a follow-up study indicate that this is still the case.

During the last ten years, development policy makers have become increasingly aware of the importance of improving nutrition to achieve development goals. Nutrition is central to several of the Sustainable Development Goals to be reached by 2030 (1), and in particular the second goal which reads: End hunger, achieve food security and improved nutrition, and promote sustainable agriculture (2).

It might seem self-evident that nutrition should play an essential role in lifting people and countries out of poverty, since malnutrition is so widespread and has such serious consequences for both individuals and societies. However, nutrition is complex and cross-sectoral in nature and has often become marginalised by other sectors in their quest for development results. Furthermore, malnutrition is largely invisible and can only be detected through measuring and monitoring (3).

We believe that the increased focus on nutrition is the result of an improved understanding of malnutrition among development practitioners and policy makers during the last decade, partly due to the two series on malnutrition published in the Lancet in 2008 (4) and 2013 (5).

The scale of the malnutrition problem

Malnutrition encompasses undernutrition, micronutrient deficiencies and overweight/obesity (6). Suboptimal food intake over time and/or infectious diseases in children can result in stunted growth, while acute reduction in food intake and/or severe infectious diseases lead to wasting.

Around 155 million children below five years of age (23 %) are stunted, whereas 52 million (7.7 %) are wasted (7). The global prevalence of stunting was 33 % ten years ago, and has thus decreased substantially (7). However, most of this progress has taken place in South America and Southeast Asia. Especially in Sub-Saharan Africa and South Asia, levels of stunting and wasting continue to be very high. Gains in reducing undernutrition have been reversed in some countries by man-made and natural disasters. Climate change will lead to lower crop yields and food insecurity in vulnerable areas, and this is expected to cause increases in hunger and undernutrition (8).

Concurrently, worldwide rates of obesity are rising (9), caused by energy-dense, nutrient-poor diets and reduced physical activity. The consequence is a rapid rise in cardiovascular diseases, diabetes, and some cancers (10). These diseases are among the leading causes of death globally, and increasing rapidly in low- and middle-income countries (9). Unhealthy diets constitute the largest risk factor responsible for the global burden of disease (11).

The Lancet series not only described the scale and severity of the malnutrition problem, but also recommended evidence-based strategies to prevent and treat malnutrition (1214). These strategies reflect the complex web of causes of malnutrition at different levels of society (individual, household, community and policy level). The Lancet series, and other more recent reports, emphasise the importance of integrating and promoting nutritional considerations and goals across sectors such as health, food production, water and sanitation, social protection and education (14).

The root causes of malnutrition are poverty, discrimination and inequalities. Malnutrition has a strong social gradient, whereby poor and marginalised groups typically experience the highest rates. Children are by far the most vulnerable to malnutrition, with their high nutritional needs and dependence on others for receiving food. Adolescent girls and pregnant and lactating women are also vulnerable to malnutrition.

At the second International Conference of Nutrition in 2014, the world’s leaders described the main nutritional challenges and reached agreement on how to solve them (15, 16). As a follow-up to the conference, the UN Decade of Action on Nutrition was declared in 2016 (17).

Norwegian development policies

To follow up on a previous report (1), we have examined whether the focus on nutrition in Norwegian development policies has changed since 2012, in light of the heightened emphasis on nutrition described above (18). We combined analysis of relevant Norwegian policy documents and official speeches; examination of disbursement of Norwegian aid funding to nutrition; and interviews with relevant politicians and civil servants.

The main findings of our analysis show that nutrition is not a priority in Norwegian development policies and that a policy framework is lacking. However, the analysis of relevant policy papers and speeches from the period 2012−2017 demonstrates increased government understanding and consciousness of the importance of nutrition, particularly for child development and education (18).

The analysis of disbursement of development aid showed that from 2011 to 2016, almost no aid was allocated to specific nutrition projects. There has been a large increase in disbursement to emergency food aid (18). In addition, nutrition-related areas such as health, education and humanitarian assistance were priority areas for Norwegian development cooperation. The only area where there was a specific focus on nutrition was that of seafood. Norway recently announced the establishment of a sustainable fisheries action network under the umbrella of the Decade of Action on Nutrition (19).

Interviews with politicians and civil servants in the Norwegian Ministry of Foreign Affairs and Norad confirmed these findings. Several of the respondents were of the opinion that targeting the nutrition-related areas (health, education, humanitarian assistance and food security) in Norwegian development would lead to improvements in nutrition. However, the research shown in the Lancet series and others demonstrates that nutrition must be given specific attention in order to ensure improved nutrition outcomes.

We presented these results at a seminar with politicians from different parties. Those in office defended their nutrition-related work, again mentioning that health and education take the highest priority. Representatives from several of the opposition parties, on the other hand, demanded that nutrition receive more attention and even asked for a separate nutrition strategy to be developed.

The unprecedented global focus on nutrition as central to development, and its position in the Sustainable Development Goals, seems to have slowly begun to change the Norwegian development discourse. However, this has not yet translated into the explicit prioritisation of nutrition in the Norwegian Government’s development agenda. The international development community sees it as necessary to integrate nutritional objectives into policy areas such as health, education and food security. As an important development actor, Norway could take a leading position in this work, but has so far limited its leadership to integrating nutritional considerations in the area of seafood. By not engaging more in nutrition, Norway is missing important global trends, and its potential to influence the agenda is put at risk. The countries in the forefront of action on nutrition are the USA, Canada, the EU, Japan and Germany (20). Finally, Norwegian development is likely to benefit from integrating nutritional objectives and considerations into existing programmes; this will help to translate development at macro level into human development for the most vulnerable individuals with the aim of ensuring rights to health, food and education.

The article refers to results from a study funded by Save the Children Norway.

This article is part of the series ‘Global Health in the Era of Agenda 2030’, a collaboration between Norad, the Centre for Global Health at the University of Oslo and The Journal of the Norwegian Medical Association. Articles are published in English only. The views and opinions expressed in the articles are those of the authors only.

1

UNSCN. Nutrition and the Post 2015 Sustainable Development Goals. https://www.unscn.org/files/Publications/Nutrition__The_New_Post_2015_Sustainable_development_Goals.pdf (9.10.2017).

2

United Nations. Sustainable Development Goals. https://sustainabledevelopment.un.org/sdgs (9.10.2017).

3

Haddad L. How can we build an enabling political environment to fight undernutrition? Eur J Dev Res 2013; 25: 13 - 20. [CrossRef]

4

The Lancet. Maternal and Child Undernutrition, Special Series 2008. http://www.thelancet.com/series/maternal-and-child-undernutrition (9.10.2017).

5

The Lancet. Maternal and Child Nutrition, Special Series 2013. http://www.thelancet.com/series/maternal-and-child-nutrition (9.10.2017).

6

Black RE, Victora CG, Walker SP et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013; 382: 427 - 51. [PubMed][CrossRef]

7

UNICEF, WHO, World Bank. Levels and trends in child malnutrition. Joint child malnutrition estimates. http://www.who.int/nutgrowthdb/estimates/en/ (9.10.2017).

8

Jankowska MM, Lopez-Carr D, Funk C et al. Climate change and human health: Spatial modeling of water availability, malnutrition, and livelihoods in Mali, Africa. Appl Geogr 2012; 33: 4 - 15. [CrossRef]

9

WHO. Global status report on noncommunicable diseases 2014. http://www.wsmi.org/wp-content/uploads/2015/01/Global-Status-Report-NCDs-2014.pdf (9.10.2017).

10

GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388: 1459 - 544. [PubMed][CrossRef]

11

Forouzanfar MH, Alexander L, Anderson HR et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; 386: 2287 - 323. [PubMed][CrossRef]

12

Bhutta ZA, Ahmed T, Black RE et al. What works? Interventions for maternal and child undernutrition and survival. Lancet 2008; 371: 417 - 40. [PubMed][CrossRef]

13

Bhutta ZA, Das JK, Rizvi A et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet 2013; 382: 452 - 77. [PubMed][CrossRef]

14

Maternal and Child Nutrition Study Group. Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Lancet 2013; 382: 536 - 51. [PubMed][CrossRef]

15

FAO, WHO. Rome Declaration on Nutrition. Second International Conference on Nutrition. http://www.fao.org/3/a-ml542e.pdf (9.10.2017).

16

FAO, WHO. Framework for Action. Second International Conference on Nutrition. http://www.fao.org/3/a-mm215e.pdf (9.10.2017).

17

United Nations General Assembly. United Nations Decade of Action on Nutrition (2016-2025). Resolution adopted by the General Assembly on 1 April 2016. Seventieth session. Agenda 15. New York, 2016.

18

Torheim LE, Hatløy A, Sommerfelt T. Ernæring er sentral i 2030-agendaen: Hvor står norsk utviklingspolitikk? Oslo: Redd Barna, 2017.

19

WHO. Norway announces the establishment of a sustainable fisheries action network. http://www.who.int/nutrition/decade-of-action/norway-commitment-6jun2017/en/ (9.10.2017).

20

International Food Policy Research Institute. Global Nutrition Report 2016: From promise to impact: ending malnutrition by 2030. http://www.ifpri.org/publication/global-nutrition-report-2016-promise-impact-ending-malnutrition-2030 (9.10.2017).

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