Since 2014, the World Health Organization has published a Global Nutrition Report (GNR) each November to articulate the progress toward—and continued challenges of—addressing the global burden of malnutrition in its many forms.
We caught up this week with Amie Heap, MPH, RDN—Director of Health Policy, Education & Alliances, and Director of Abbott Nutrition Health Institute—to hear her thoughts on the GNR’s latest findings. Below, you’ll find a transcript of that conversation.
THE 2018 GLOBAL NUTRITION REPORT OPENS BY SUGGESTING CERTAIN GROUPS ARE VULNERABLE TO MALNUTRITION. FROM A POLICY STANDPOINT, WHAT CAN BE DONE TO HELP ENSURE MARGINALIZED GROUPS GET THE HELP THEY NEED TO IMPROVE THEIR NUTRITION?
I think it’s helpful to start by considering how we define vulnerability—and what causes it. Nutritional vulnerability can occur in anyone at any age who has a reduced physical reserve or resilience. This reduced physical reserve limits recovery if any other acute health event occurs—including reduced dietary intake or poor nutrition. (Starr, McDonald, Bales 2015) A few examples:
- We tend to find reduced physical reserve in infants and young children who have increased physical needs for growth.
- We find it in the aging population who may have a higher need for calories and protein to maintain their lean muscle mass and strength.
- Vulnerability also occurs in pregnant and lactating women who have increased physical demands through the gestation and breastfeeding period.
- We also see nutritional vulnerability in those who have infectious or chronic diseases whose bodies are experiencing increased stress.
Many of these same individuals also experience social vulnerability—a measure of the resilience of an individual or community to external stresses, such as disasters, disease, displacement or a host of other causes. The collision of nutritional and social vulnerability can create a high probability for malnutrition and is a barrier to improved health and socioeconomic outcomes.
Each vulnerable group has acute nutrition needs, which if met can prevent both short- and long-term poor health outcomes. Perhaps the best way to ensure that these needs are met for vulnerable populations, is to increase understanding of and advocacy for the life-changing role nutrition plays in the foundational health of populations. From a policy perspective, we see a few trends that must change:
- Recognition of nutrition as one of the key drivers of health must improve at all levels (global, national, regional and individual). One of the interesting things about nutrition is it takes a fair amount of time to see a measurable change in outcomes at a population level.
- Constant advocacy is usually required to maintain the political will to support long term efforts. Experts who contributed to the Global Nutrition Report make it clear that support for evidenced-based nutrition protocols with strong implementation plans and clearly measurable outcomes can assist in making the health and business case for including nutrition in annual national plans.
- A multi-sectoral approach is also a key component of reducing nutritional vulnerability. Nutrition is most frequently considered a health sector issue—or occasionally a social protection issue. In reality, nutrition touches almost every sector within a national government. For instance, nutrition is a key component of education in several ways. Children who are well-nourished are more likely to have the physical and cognitive health to participate in their studies. Education also contributes significantly to an understanding of basic health and sanitation principles, including the importance of good nutrition. Nutrition touches other sectors as well. A well-nourished, healthy individual is more likely to be able to participate in and contribute to the national economy and experience higher socioeconomic stability. These are just a few examples that illustrate the need for constant advocacy for short and long-term nutrition efforts and the need for a multi-sectoral approach to nutrition at the national level.
CONSIDERING THE PREVALENCE OF MALNUTRITION ACROSS THE GLOBE, IT'S NO SUPRPRISE THAT THE REPORT NOTES SOME SOBERING STATISTICS. BUT IT ALSO NOTES SLOW PROGRESS IN A POSITIVE DIRECTION. HOW HAVE THESE STATISTICS CHANGED IN RECENT YEARS?
Progress on meeting global nutrition targets remains slow. Of the nine key global indicators, one has continued to make slow improvement—stunting. Stunting is the measurement we use to determine if a child’s height is appropriate for their age. When a child’s height for age is less than two standard deviations from the mean—that is termed stunting. Stunting is usually a sign of chronic malnutrition and can have serious long-term consequences. The number of stunted children globally has decreased by about 47 million since 2000 and the prevalence of stunted children has decreased from 32%-22% within the same time period. However, over 150 million children (22% of those under five) remain stunted. In some areas of the world prevalence of stunting is decreasing—but sheer number of stunted children is still increasing. This is the case in sub-Saharan Africa. So we are seeing progress in some areas, but we have a long way yet to go.
THE REPORT NOTES THAT ALL FORMS OF MALNUTRITION ARE ASSOCIATED WITH VARIOUS FORMS OF ILL HEALTH AND HIGHER LEVELS OF MORTALITY, AND TO THAT END, IT ADDRESSES MALNUTRITION IN ALL ITS FORMS. DO PROTOCOLS CHANGE BASED ON THE TYPE OF MALNUTRITION, AND WHAT COMMON THERAPIES EXIST?
One of the key aspects of successfully addressing the issue of malnutrition is the ability to identify it wherever it exists. It is difficult to ever effectively treat and monitor malnutrition when it has not been identified and the root causes are not understood and addressed. Inclusion of nutrition as part of core primary care—increasing the capacity of healthcare workers within all levels of the health system to screen for malnutrition can help us gain tremendous ground. The ability to identify malnutrition and to begin to treat it earlier—and prevent it wherever possible—is the ultimate goal. When patients are screened for malnutrition, the appropriate therapies can be identified and provided. For individuals with acute severe malnutrition, some form of medical nutrition therapy is usually required to nourish the patient back to optimal health. Optimal calories, sufficient protein, micronutrient supplementation and access to clean water (and sanitation) are part of almost every therapeutic plan. In many cases, these therapies are not available when and where they are needed. It is also important, while addressing acute nutrition needs, to consider long-term, sustainable solutions—solutions that address food insecurity, that increase agricultural productivity, that give local farmers market accessibility and to create opportunities for economic stabilities. This emphasizes, again, the key point that malnutrition at the global, national and individual level is a multi-sectoral issue. And it will require an integrated response to create sustainable therapies and solutions.
THE REPORT ALSO NOTES THAT MALNUTRITION IS A SOCIAL AND ECONOMIC PROBLEM, HOLDING BACK DEVELOPMENT ACROSS THE WORLD WITH UNACCEPTABLE HUMAN CONSEQUENCES. CONVERSELY, IT NOTES THAT IMPROVING NUTRITION CAN HAVE A POWERFUL AND POSITIVE MULTIPLIER EFFECT ACROSS MANY ASPECTS OF DEVELOPMENT, INCLUDING POVERTY, ENVIRONMENTAL SUSTAINABILITY, AND PEACE AND STABILITY. CAN YOU BREAK THAT DOWN FROM A POLICY STANDPOINT?
I think that international data bears out that we disregard the impact of malnutrition at our peril. When children are well-nourished their probability of suffering morbidity and mortality are lower. They have a better chance of achieving optimal growth. When they are healthy and well they are more likely to participate fully and succeed in primary education. That education gives them a greater opportunity for economic stability as individuals and as families. Economic stability is likely to result in decreased food insecurity. Families with economic stability, consistent health and food security are more likely to have the opportunity to send their children to school—this is particularly true for girls. (In many parts of the world girls are the first to be removed from school if the family has a crisis and requires income support.) And the cycle goes on and on. This foundation of food security, health and the potential for economic prosperity contribute greatly to peace within communities, nations and society. Of course, the solutions are not simple, they are incredibly complex. But the foundation of good nutrition touches so many points along the life cycle and within society. In my opinion it is a key investment toward sustainable health, and economic progress.
WE'VE TOUCHED ON SOME OF THIS ALREADY, BUT LET'S TALK ABOUT THE BURDEN OF MALNUTRITION. MAYBE IT'S OBVIOUS, BUT WHAT'S HOLDING US BACK?
I think what the GNR makes clear is that we need sustained commitment to nutrition at the global and national level. To address issues like stunting, wasting and overnutrition—to make progress on issues like reduction in prevalence of anemia and low birthweight—to assist mothers to breastfeed—and to reduce non-communicable chronic diseases requires a significant level of commitment at all levels within the health system. The GNR makes five clear points for progress:
- Break down malnutrition silos: Different forms coexist and need integrated approaches. All stakeholders must take a more holistic view of malnutrition.
- Prioritize and invest in the health data needed and the capacity to use it: Designing actions that result in impact is impossible without adequate knowledge of who is affected by malnutrition and why. Without good data, we’re just guessing.
- Scale up financing for nutrition: Ultimately we cannot make progress without adequate funds, and those who control resource flows need to prioritize nutrition.
- Galvanize action on healthy diets: The poor quality of diets among infants, young children, adolescents and adults is unacceptable. With malnutrition having such a universal and devastating impact, there is a role for all sectors in improving the quality of the world’s diets.
- Make and deliver better commitments: Concerted efforts to tackle malnutrition will only continue if signatories consistently deliver against SMART (specific, measurable, achievable, relevant and time-bound) commitments.
THE REPORT MENTIONS THREE ISSUES IN CRITICAL NEED OF ATTENTION, WHAT ARE SOME PRIORITY ACTIONS FOR EACH OF THESE THREE CONCERNS?
- We need more and better data about the burden of micronutrient malnutrition.
- We need a new approach to address malnutrition in all its forms during crises.
- We need to address the burden of malnutrition in adolescence, especially as it relates to adolescent girls.
Micronutrient deficiencies impact approximately 2 billion people globally in a world population of 7 billion. And so many short term—and long-term debilitating issues find their root in this cause. There are a couple key priority actions that make sense on this issue.
- Invest in research that helps us understand and address the key driver of micronutrient deficiency. Only when we understand what is causing the problem, can we create a strategic plan to document the prevalence and improve our strategic plan to address it.
- Work at the primary health care level to increase capacity to assess, treat, document and report micronutrient deficiencies could make a tremendous different in global reduction of micronutrient deficiencies.
Creating an integrated method to address nutrition during crises is becoming increasingly important in order to ensure progress toward the SDGs. Crises—be they political or environmental—create a disruption in what is often an already fragile health system capacity to respond to need. And essential funding needed to support sustainable nutrition programs must be diverted.
- This is already happening at a high degree—but further coordination between individuals who oversee humanitarian relief efforts and those who oversee long term development strategies will be key.
- To quote the report, “Humanitarian and development communities need to build common platforms and establish frameworks and joined-up financing mechanisms to effectively address nutritional needs, for immediate and longer-term impact.”
- This will assist us to keep moving forward to meet key nutrition goals and minimize disruption of needed resources, even in the midst of crises, to the greatest degree possible.
In my former work in the international nutrition and HIV response, involving adolescents in choices about health, potential therapies and advocacies was a primary goal of our work. Receiving insights and input from adolescents on how to improve their health and well-being is key. They will become the future leaders on whom the responsibility for leading this effort will rest. We have much to learn from their needs, experiences and insights about solutions. This is particularly true of adolescent girls. The report highlights key priority actions for improving adolescent health and nutrition status—a couple that stood out to me included:
- Ensure that the adolescent age category is captured in routine reporting and data from health surveillance work. We need to clearly understand where we are and are not making progress in this key demographic.
- Conduct quantitative and qualitative research to measure, analyze and address the underlying determinants of malnutrition and the context-specific factors affecting adolescents’ food choices, diet and eating practices, physical activity and social and emotional well-being. I think this will be key, particularly in emerging economies where nutrition choices and very different than those of their parents. New health and nutrition patterns are being developed, understanding them will be so important as we develop policies and guidance for the future.
FROM A PRIORITIZATION STANDPOINT, WHAT'S THE "LOW-HANGING FRUIT" FOR ACHIEVING SOME OF THESE GOALS? WHAT WILL TAKE A BIT LONGER?
One thing we haven’t really discussed yet, is the critical role education plays in the achievement of health and nutrition goals—really all of the SDGs. Education—and ultimately an increased understanding and deepened perspective—of the powerful role nutrition plays in the advancement of health will do so much to move us toward these goals.
- For leaders and policy makers—education on what the data is telling us about nutrition, where further efforts are needed, and where we are seeing progress and wins is so important.
- Education and tools to assist healthcare professionals who are on the front lines providing care for individuals to integrate essential nutrition actions into their practices will help establish inclusion of nutrition as part of gold standard of care globally.
- Education for individuals to understand how and why nutrition plays such a key role in their health and the health and development of their families—to help them make the best possible nutrition choices, whatever their circumstances, and to assist them to advocate for the assistance and resources they need.
HOW IS DATA CHANGING PROGRESS?
It’s impossible to describe how important good data is in this effort. It is the only way we can know if we are making progress, and to help understand where, and how, and why we are making progress. Innovations, such as geospatial and disaggregated data is helping us understand who is malnourished and where and how to target action at subnational levels.
DID ANYTHING ABOUT THE 2018 REPORT SURPRISE YOU?
I’ve been an avid consumer of this report from the first time that it was released. In fact, I was in Geneva the first time Lawrence Hadaad did a public review of the data. So, I’m not sure there was anything in particular that surprised me in this report. But I am constantly amazed at the amount of advocacy that is required to keep the nutrition agenda moving forward.
WHAT MAKES YOU FEEL HOPEFUL AFTER READING THIS YEAR'S GLOBAL NUTRITION REPORT?
The fact the Global Nutrition report has continued to be produced for the past five years and that we have a collective global mechanism for measuring progress and identifying opportunities is very hopeful. This is the WHO Decade of Action on Nutrition. Nutrition holds one of only 17 spots for the SDGs. Nutrition is part of the global nutrition conversation like never before—I think this is the most exciting time to be involved in the field of nutrition! Nutrition—particularly for the vulnerable—has been my lifelong profession and passion. Everything I have studied and everything I have observed in over 25 years of practice has made me even more certain that the solution to so many health issues we face, and the opportunity to progress in achieving better health globally, can be found in investing in nutrition—globally, nationally, in families and as individuals. Nutrition really can change lives.
WANT TO LEARN MORE?
Get the full report on anhi.org.