Target 2 – Zero stunted children less than 2 years
The consultation on Dutch food security policy was closed on September 15, 2014. The consultation was originally opened by the Food & Business Knowledge Platform on July 01, 2014. The purpose of the consultation was to ensure that the newest topics and debates on food security are included in the food security policy paper, which the Ministries of Foreign Affairs and Economic Affairs will send to the Dutch Parliament at the end of this year.
On September 30, 2014, the F&BKP has published its final report (PDF), which has been sent to both ministries. All contributions posted during the consultation remain available online and can be downloaded in a document (PDF) with an easy search tool.
Please find below all comments received concerning Target 2: How can the Netherlands most effectively contribute to achieving the target Zero stunted children less than 2 years? We thank all contributors for their participation and inspirational input.
Questions which have been addressed in the contribution are:
- What do you consider the biggest challenges in achieving the target Zero stunted children less than 2 years?
- What are the most effective intervention strategies to address these global challenges? Which actors need to play a role to make this happen?
- How does that relate to the Netherlands’ strengths and to actors from government, the business community, knowledge institutes and civil society?
- What implications would this have for the policy choices of the Dutch Ministries of Foreign Affairs and Economic Affairs?
Target 2 – Zero stunted children less than 2 years
Ensuring universal access to nutritious food in the 1000-day window of opportunity between the start of pregnancy and a child’s second birthday, supported by nutrition-sensitive health care, water, sanitation, education and specific nutrition interventions, coupled with initiatives that enable empowerment of women, as encouraged within the Movement for Scaling Up Nutrition.
Source: Zero Hunger Challenge
The goal of a National Food Security Policy is to ensure dependable food security for all people of the country at all times.
In the context of Bangladesh, three indicators are used to monitor progress towards the goal: prevalence of undernourishment, child underweight and child stunting – and these are complemented by four indicators from the National Five Year Plans.
Bangladesh met the MDG target for undernourishment in the early 2000s. After flat-lining for much of the past decade, undernourishment has risen in the last three years reaching 16.3% in 2012/13. Undernourishment estimates are determined from inequality-adjusted aggregate food balance data, and the picture from direct calorie consumption using household food expenditure surveys shows that between 2000 and 2010 both severe (<1,805 calories) and moderate (<2,122 calories) calorie deficiency declined per year by -2.15% and -1.42%, respectively.
Underweight and stunting declined between 2007/08 and 2011/12. Estimates for 2012/13 show child underweight at 35.1% and child stunting at 38.7%. Overall, if the improvement recorded for stunting and underweight can be sustained it is likely that the targets for 2015 could be met. From 2000 to 2010, income poverty declined faster than calorie deficiency, child stunting and child underweight and this reverses trends from 1990 to 2000 when declines in all except moderate calorie deficiency exceeded or matched declines in income poverty.
The following strategies need to be implemented and promoted:
Community based nutrition programmes and services
• Improve facility and community based support to caregivers;
• Scale-up nutrition sensitive agriculture;
• Mainstream nutrition beyond the health sector;
• Strengthen capacities to plan, implement, monitor and evaluate nutrition interventions;
• Scale up ‘one farm, one household’ approach as part of integrated family farming for ensuring household food and nutrition security
Orienting food and nutrition programmes through data
• Harmonise existing food security and nutrition information systems;
• Promote use of updated food composition tables, complementary feeding guidelines and improved complementary feeding recipes and food based dietary guidelines;
• Accelerate implementation of comprehensive nutrition interventions;
• Strengthen leadership and capacity for nutrition.
Food safety and quality improvement
• Sensitise stakeholders on implementing National Food safety Acts including protecting and promoting Baby Friendly Hospital Initiative and appropriate infant and young child feeding
• Accelerate the establishment of a suitable national food safety authority
• Formulate food safety rules;
• Establish standards and ensure compliance;
• Put in place a national food safety emergency plan;
• Strengthen food safety laboratories;
• Control diarrhoeal prevalence (with a focus on addressing the first 1000 days of life) and improve safe water supply;
• Scale up healthy street food vending in urban areas.
Selected examples of nutrition mainstreaming in agriculture and related sectors
Nutrition sensitive agriculture
Because agriculture is the primary source of all nutrients for humans, agricultural systems including livestock and fisheries need to be strengthened to contribute adequately and efficiently towards meeting nutritional needs of the population, notably in the 1st 1000 days of life. Agriculture/food systems must necessarily encompass activities related to production, acquisition, and utilization of food to prevent both under and over nutrition in an economically, environmentally, socially and culturally sustainable way. Narrowing the nutrition gap is the challenge ahead– the gap between what foods are grown and available and what foods are needed for better nutrition – means increasing the availability, access and actual consumption of a diverse range of foods necessary for a healthy diet. It is also important to improve young child feeding practices including exclusive breastfeeding for the first six months of life and appropriate complementary feeding from 6 months along with continuation of breast feeding until 2 years.
Priority areas for diet and nutrition improvement are nutrition education across nutrition relevant sectors with a focus on the first 1,000 days of life; processing, preservation and storage of foods with a view to enhancing nutrient/micronutrient content and preventing losses particularly when abundantly grown or available; food fortification, food safety, consumer awareness and social protection through safety nets. These areas of opportunity need to be explored and promoted for strengthening the nutrition orientation of existing food systems.
Particularly for children, the type of dietary protein seems to have a specific stimulating effect on weight and length gain, and dietary fat has important functions including providing energy and helping the absorption of fat-soluble vitamins. Analysis from surveys points to the low quality and diversity of diets of children above two years who share the family meal and of pregnant and lactating women (contributing to low birth weight). Milk intake is positively associated with better bone and brain development as well as linear body growth. In contrast, meat consumption has been found to affect cognition. The consumption of milk in Bangladesh for example is as low as 34 ml/capita as also is a very low aggregate consumption level of animal source protein in Asia – barely 9% of protein derived from animals since the mid-2000s compared with over 30% for countries like Pakistan and Myanmar.
Studies show that although mother’s retention rate of nutrition messages was high, what they are able to practice at home was limited. Nutrition programmes often fail to enable mothers to transfer this knowledge into practice. Community centered food based nutrition education strategies need to be institutionalized and mainstreamed in agriculture and health service delivery structures to establish sustained nutrition behaviors. Additionally along with infectious diseases, faulty weaning practices that are some of the prime causes of underweight throughout the pre-school years need to be addressed.
Agricultural intervention programmes need to include explicit objectives of improving nutritional status with a focus on reducing child under nutrition. Child stunting should be addressed through building strengthened linkages between complementary feeding requirements/practices and agricultural production. The most sustainable, cost effective way to improve complementary feeding of children in poor rural households is by ensuring that nutritionally appropriate foods are available and utilized at household and community levels.
Access to safe water and sanitation facilities is directly linked to the overall health of individuals and communities, including childhood under nutrition, cognitive delays and stunting. Interventions, such as nutritional supplements, combined with improved sanitation and hand washing with soap can reduce child stunting by 4.5%, compared to 0.1% decrease with nutrition interventions alone. Besides, awareness and practice of hygiene, such as hand washing and in food preparation, are critical to reduce the morbidity. Given that one of the major determinants of child stunting is poor sanitation, there is need to accelerate sanitation access by all and be on track towards reaching MDG-7.
The contribution of the agriculture sector to national food security objectives makes it a key player in the achievement of national nutrition objectives. However, to effectively address the multi causal issue of malnutrition, multiple and synergistic interventions embedded in true multi-sectoral programs need to be
implemented. Addressing the challenge of malnutrition requires both short- and intermediate-term and long-term sustainable approaches. A variety of actions, including agricultural and micronutrient interventions and partnerships for improving nutrition, of safe drinking water and sanitation, education and support for better diets, special attention to gender issues and vulnerable groups such as pregnant women and young children, and quality health services along with livelihood improvement will be promoted. Investments in capacity strengthening of national agricultural/food systems to integrate nutrition outcomes in planning and policy processes will make significant contributions to the zero stunting challenges and improving nutrition on a sustainable basis.
Dietary diversity in relation to diverse agriculture. Dutch food security policy has added nutrition as a new angle since 2011. The Ministry of Foreign Affairs is working on a results report to parliament but indicates that it appears difficult to measure success. We propose that nutritional value in the diet as an expression of nutrition security becomes the key result indicator for the coming years. A good indicator would be the so-called ‘Minimum acceptable diet’: the proportion of children 6–23 months of age who receive a minimum acceptable diet.
Hunger as undernourishment (too low calorie intake) is no longer the most important problem of malnutrition. The major problem today is the problem of micronutrient deficiency. Many women and their young children are suffering from a deficit in iron, deficits in vitamins A and C, zinc, and iodine, for example, which results in growth impairments and intellectual and physical disabilities. These children are also more vulnerable to diseases.
These deficits are due to:
1. The fact that since the 60’s-70’s our food system has focussed on agricultural commodities to satisfy the need of the food processing industry. It is difficult to change the infrastructure and institutions that have developed. There are many regions where, for example, local food processing facilities are basically absent so that farmers are encouraged to produce maize or soy bean for the food processing industry. The investments that were made, that are now sunk investments, make a transformation very difficult; nevertheless efforts to promote agricultures that provide a varied diet locally should start NOW.
2. Even if a lot of people may absorb enough calories per day, they do not consume enough of the essential micronutrients. We have developed food systems that have made people sick in rich countries and increasingly in emerging economies; people have become addicted to salty, fatty and sweet food. Obesity means shorter lives, it means the risk of developing type II diabetes, a greater risk of cardio vascular diseases, and a greater risk of gastro intestinal cancers.
Governments in the South should be encouraged to move towards social protection schemes including health schemes for women and children, reinvest in local agro-ecological production, redevelop local food, and reduce their dependency on international markets.
At the same time governments in the North must move away from the export-led agriculture that is making it difficult for governments in the South to make this transition. This double transformation will be difficult to achieve because of technical, economic, cultural and above all political obstacles (see target 1)
Food democracy / food sovereignty is important: we need to democratise the food system from the local level upwards, in Europe as well as in developing countries, where women should be the main actors. People need food policies that integrate food production with social protection, health and environment. ( see http://www.voedselanders.nl for conference report and speeches)
At the international level trade regulations should be adjusted. In that area there is as yet no serious attempt to link negotiations to global food security and other concerns, such as health; on the contrary (TTIP negotiations). There are alternatives, see e.g. http://www.alternativetrademandate.org.
In order to achieve all this the focus of Dutch development strategies should change radically. We suggest that Dutch politicians and institutes and citizens focus on the more detailed recommendations in the documents mentioned above.
Human rights (including the right to food), women’s rights, labour, environment and climate should have precedence over trade and investment regimes.
It is challenging to see a nutrition indicator. At the same time nowadays it is by far insufficient to focus on one single nutrition problem, while countries are increasingly facing complex combinations of malnutrition. In the current areas of attention in both the Zero Hunger vision and the Dutch nutrition policy (development) the focus is too much on undernutrition, whereas the number of people with obesity with related NCDs is increasing. WE cannot afford t just look at stunting whereas the problem is much bigger. Several nutrition problems are found in one country, one household and even in one individual!
Focusing on just one area of malnutrition (in this case stunting) may increase problems in other nutritional areas. Tools are needed to analyze the multiple causes of malnutrition and define, prioritize and sequence actions to solve the multiple causes that are interlinked and influence each other.
Netherlands could take a leading role in tackling malnutrition to commit itself for a 10 years period to invest in improvement of nutrition (anticipating a decade for nutrition). Netherlands could also make the link with the Sustainable Development Goals and ensure Nutrition is linked to all SDG targets. The Global Nutrition Report that will be launched in November 2014 is a call for action and a call for accountability. One of the pleas in the report is about the need for accountability and lack of good data: Lack of these stifles action. Netherlands would do good if Netherlands, apart from sound nutrition policies for ODA, would also invest in making available its own data about nutrition problems in the Netherlands and ensure transparency – contact WHO how to make national data compatible with global databases- with regard to its actions and policies here. This will motivate other countries to do so and promote global accountability and global action.
About stunting: Stunting is a chronic problem that develops over time. Stunting is associated with the following other (nutrition related) problems: low birth weight, anemia of the mothers as well as stature of the mothers. To solve stunting longer-term commitment is needed at least over a period of 10 years. Evidence from Ethiopia and India- Maharashtra where stunting has declined considerably over the past years, shows that a mixture of several interventions that tackle immediate and underlying causes as well as a positive enabling environment are needed: economic growth and governance, women’s status (age of mother at first pregnancy, literacy rate) both in the household and in society, spending on nutrition doubled, access to improved water sources. Furthermore antenatal visits and delivery under the supervision of a birth attendant, as well as adequate child feeding practices (among which exclusive breastfeeding. (Haddad, 2014)
There is sufficient evidence that nutrition specific interventions such as promotion of breastfeeding and improved complementary feeding (either through home fortification with micronutrient powders or improved quality complementary foods). Of course, interventions targeting women before they become pregnant and during their pregnancy are part of the intervention strategies that have been well researched (in clinical settings).
In AIM we are working with companies to develop market based approaches to make nutritious foods available, accessible and used. Some of these approaches target the whole community (e.g. local markets for locally grown fruit and vegetables), others (e.g. micronutrient powders) are specifically meant for young infants.
Both have a common bottleneck: consumer demand, which is closely linked to the awareness, understanding, and willingness to use these products as part of their diets. With other words, Behaviour Change is the critical factor.
Traditional approaches in nutrition have not proven very successful. Here is something we can learn from the private sector. Why is it possible that Unilever can successfully engage whole communities and sell a “dull” product as Lifebuoy soap? (see http://www.unilever.com/sustainable-living-2014/our-approach-to-sustainability/embedding-sustainability/encouraging-behaviour-change/index.aspx)
I believe we need to put much more emphasis on clever behavior change campaigns, with single minded messages. The Worldcoaches program of the KNVB might be a good vehicle to reach girls and empower them with important lifeskills.
If business such as DSM or Unilever, civil organizations including the KNVB, government and academic partners work together, we can create innovative solutions that have impact and can reach scale.
The first 1000 days from the moment of conception until a child’s second birthday represent a critical window of opportunity for shaping the health, development and well-being of a child and to contribute to that of his/her mother. Women’s empowerment and gender equality throughout the lifecycle are essential to improving infant and young child food and nutrition security. Protection, promotion and support of optimal breastfeeding practices are amongst the most effective interventions to reduce under five mortality and morbidity according to recent scientific evidence. If applied globally, optimal breastfeeding could prevent about 830.000 of under 5 deaths annually. However, violations of the International Code of Marketing of Breastmilk Substitutes and subsequent relevant WHA resolutions (the Code) are widespread and national implementation and enforcement of the Code insufficient. Moreover, appropriate and adequate maternity protection measures for working women, critical to ensure an enabling environment for optimal breastfeeding, are absent in many countries, in particular in the global south.
Essential interventions include the protection or improvement of local breastfeeding practices; ensuring that marketing of products for infants and young children complies with local marketing laws and regulations or the Code, whichever is stronger; empowerment of women to make decisions about how to feed their children based on unbiased information and free from commercial pressures; and advocacy for adequate enforceable maternity protection for all working women. The Netherlands, being home to a large export-oriented dairy sector, can play an important role in setting an example by ensuring policy coherence with human rights standards in this area. This would require that the Netherlands fulfil their human rights extraterritorial obligations by ensuring that producers of breastmilk substitutes and other baby foods residing in the Dutch territory do not violate the Code in their – or their subsidiaries’ – operations abroad. Furthermore, as a member of the SUN donor network, the Netherlands should work to guarantee that conflicts of interest mechanisms that effectively put a check on private interests’ influence be established for the global SUN Movement including through the SUN’s Lead Group and other networks. The Netherlands should also ensure that the SUN Movement does not bypass multilateral bodies and mechanisms or inter-governmental bodies in its actions.
As for access to food, also for combatting stunting ensuring small scale food producers’, particularly women’s, direct access to and control over natural resources and support to local food production and local food systems is key (see targets 1 and 3).
Achieving this target among others also requires:
• Awareness creation and training on preparation of affordable nutritious food with ingredients to be easily accessed from local food systems.
• The general empowerment of women and men sharing full responsibly of child care and unpaid care tasks
• Guaranteeing sufficient access to proteins, like dairy products and other nutritious food for infants and women.
• Improve Sexual & Reproductive Healthcare SRHC), maternity and infant healthcare, as well as general healthcare for women and men
• Invest in literacy and functional literacy and skills training for women
• In particular support to women in producing and/or sourcing food for their children, ensuring men take their responsibility to support supply for healthy food to their households and infants ; support to single mothers, female headed households, orphans.
• Support community level crèches, nursery schools and child care if this would facilitate women to farm or otherwise earn an income
• Social Safety nets in particular orphans, and women living with HIV-AIDS, other illnesses or disabilities
• Avoid HIV vertical transmission and provide extra care and support to infants living with HIV-AIDS and other illnesses.
Evidence shows that under nutrition has a negative impact on the ability of people to learn and produce, and in turn undermines social cohesion and the ability to build relationships. This is particularly true for young children, in the early years of their life. In particular, it has been proved that starvation, especially among children under five, undermines their ability to learn and concentrate, even years later, when they go to school.
For example, studies in Ethiopia demonstrate that stunted children are more likely to repeat grades at school. Almost 16 per cent of all repetitions in primary school were associated with stunting and on average, stunted children achieved 1.1 years less in school education. This leads to additional costs, both for the families and the state, particularly for the children that have to repeat grades or need special assistance.
As the price of food increases or food become less accessible, children are more likely to drop out of school and be sent to work. Longer-term, children’s weak performance in school leads to low productivity later in the workforce, with profound loss for affected individuals but society.
To address these interrelated problems, future policy and advocacy should tackle the links between stunted children and low education performance, and their combined knock-on effects on society and the state. This calls for increased awareness but also a more coordinated policy approach in terms of nutrition and education to address children stunted under 2 years and the specific needs of those above 2 years.
If Target 1 is reached, Target 2 will be reached as well. Dutch food security policy should support a balanced approach to different groups in society – i.e. women, men, youth, babies, etc. Good food is essential for health. The quality and the availability of maternal milk is a key issue in the first 1,000 days, as is hygiene (i.e. access to water and sanitation, and healthcare for prevention and cure when required).
Cordaid believes in a Dutch food security policy that supports education and training on diversified local diets for mothers and babies, and on the importance of crop- and biodiversity.
It is all too often assumed that access to nutritious food is equal to increased consumption of nutritious food. This is unfortunately not at all the case. Improving the status of children under 2 years old, including the pregnancy period of their mothers starts with an in-depth understand of eating patterns and local beliefs. We were recently looking at these in Asian countries and came across local beliefs that pregnant women should not eat fish, this was in Lao. There exist many of these local beliefs that are passed on from generation to generation through grandmothers and mothers but also local mid-wives.
Changing what people eat needs a massive attention to behaviour change. Knowing what is good for you is not going to change what people actually do. So it is about knowledge about food, what is nutritious and what not?; how can I get access to it?, produce myself of purchase; how much do I need of it?; how to prepare it?; etc. But it is equally about women empowerment to get more control over household decision making towards nutrition. Women need to be able to control what is produced on the farm, what is consumed and what part of the family income is spent on nutritious food.
An answer is often sought in the provision of fortified food or supplements. Whereas this provides a (short term) increase in access to essential nutrients, this can also have a negative impact to local food production systems. Focus should in the first place be on increasing of local agro-biodiversity (the work of Target 1) and only where it is not possible to locally provide essential micro-nutrients should the pathway of supplements be chosen. There is good interaction needed there between agriculture extension, who need to use nutrition value of crops much more as a guiding principle for promotion of varieties, and health workers / mid-wives who often all-to-easy promote the use of baby formula etc.
When speaking about reducing stunting in children and providing more nutritious food, it is not just about the mothers. It is also about understanding who plays what role in the feeding and up-bringing of the children. In many situations we experience that the mothers, for economic reasons, return to the farm fields after a few months and that the young children are left at the care of the grand-parents, elder children in the house or others. So nutrition education and behavioural change has to focus and include those as well.
A key success to effective behaviour change, as we have learned in our sanitation programmes, is also the role of local (village) leadership. Key people who lead by example have a positive effect on whole communities. This is also needed for nutrition. A strong combination in that is also awareness raising and simple self-measurement tools that parents can use to track on a continuous (or very regular) basis the growth of their children. National growth curve charts and simple scales to which parents have access can do miracles in monitoring of stunting and malnourishment.
The Netherlands should bring this holistic focus to reduction of stunting to the local policy debates. We have long term experience on health services (like our “groene kruis”), effective nutrition awareness through public and private communication campaigns and agricultural extension for agro-diversification. The Dutch agro-private sector, research and development organisations can work closely together on this. The Agri-Profocus type of networks should also look at the challenge of nutrition and decide on a course of action.
Many households feed their children without considering the nutritional quality. Extended sensitization projects prioritised by the local Ministry of Health by nutrition organisations are needed on three types of foodstuffs: construction food, protein and energy.
Mothers should be well nourished themselves to well breastfeed their babies, and family planning should be taken into consideration. Local governments need technical and financial support and formation. Educational and research institutes also play a role here.
The biggest challenges
• Poor sensitization on the nutritional education within households, especially in rural areas of developing countries;
The most effective intervention strategies
• Sensitization on use of 3 types of foods (building, protection and Eergy)
Involved actors
• Primary, secondary schools, households responsible; Universities, Ministry of health and education within the counties, civil societies, ONG,…
Relation to strengths actors
• Helping these stakeholders to achieve their objectives.
Malnutrition is at the center of a nexus of interrelated issues, all of which must be solved together. Gender discrimination is a primary root cause of malnutrition, particularly in the key “1000 Day” window from a woman’s pregnancy through her child’s second birthday. We need to empower women as the key to 1000-Day Nutrition. This is a big year for nutrition, with the ICN2 and the Zero Hunger Challenge – and yet the fundamental cause of poor 1000-Day Nutrition is too often ignored. More on this in our reaction to the ‘what’s missing’ reflection area.
We must also keep up pressure for more rapid progress on the MDGs that are lagging – particularly in maternal and child health; and to keep up the pressure for the post 2015 goals to include strong stand-alone goals on gender, climate resilient and sustainable food and nutrition security, and transparent, participatory local governance.
As an afterthought – integrated strategies are also particularly important for zero stunting. So is halting open defecation, and massive social mobilization campaigns to educate people on the messages of the Essential Nutrition Actions (ENA) Framework.
In more than one situation I have heard “it was good enough for me so it will be good enough for my children”. So some adults who have suffered chronic or acute malnutrition and survived to adulthood may be of the mind that that is ok for their children too. I am not thinking of insufficient calories but of insufficient diversity in the diet.
But not all children in the same society suffer stunting, there is the possibility of positive deviance.
Start with the population: who knows what? Where are the examples of positive deviance? What are they accessing that others and not and why? Can it be copied or shared? What are the consequences for farming practice?
Do the parents know the consequences of chronic malnutrition for children under 2? Do they know that they can do something about it?
A grass roots education information process is needed to help parents know the risks of malnutrition, how to feed their children and confidence that they can make a difference for their children.
I really hope The Netherands does not endorse the SUN Initiative with all its conflicts of interest with private sector involvement and not really using a Human Rights based Approach.
People who file claims to secure their right to adequate nutrition cannot wait for a whole generation.
Moreover, despite good intentions and new investments coming from outside, overseas development assistance for nutrition has left the world’s poor people’s nutritional status still in a dire state. Through top-down vertical programs, the international community and the countries receiving the aid have too often squandered the historic opportunity to improve the nutrition of poor people. Quite consistently, no attention has been paid to the social determination of nutrition. There is a disconnection between donor contributions and the actual needs of the poor in recipient countries. As we know, aid is channeled in a way that often rather interferes with countries’ funding mechanisms. As we also know, money alone is insufficient; changes in the global aid architecture are needed. Many development agencies simply still need to overcome the crisis–of-legitimacy they find themselves-in right now by adopting the HR-based framework to development. The HR-based framework opens totally new policy spaces.
In short, countries are spending money on programs in manners that do not reflect their people’s most urgent health, nutritin and HR priorities. Countries should challenge donors on this so they allocate funds according to real needs. Instead, governments have (are) often reduced(ing) their own spending in the areas favored by donors. You know who the losers are given such a state of affairs.
The insufficiency of sensitization of good eating habits and food self-sufficiency in households is the biggest challenge for this target.
New methods and approaches of sensitization specifically adapted to each target with sustainable and supportive measures should be designed.
Everyone has a crucial role to play: household members, civil society, churches, local organisations, health institutions, schools, universities, media, public and private technical services, nationally and internationally.
The Dutch government should focus on reaching results in time based on lessons from experiences with effective and adapted tools.