The Second International Conference on Nutrition (ICN2) was a high-level intergovernmental conference that focused global attention on malnutrition in all its forms—undernutrition, micronutrient deficiencies, overweight and obesity. It was the first world forum to address global nutrition issues and challenges in the 21st century. The Rome Declaration on Nutrition and Framework for Action for its implementation were endorsed at ICN2.

ICN2 addressed the persistent and unacceptably high levels of malnutrition that have serious consequences for individuals and families, societies and nations. While the global food system has succeeded in increasing the quantity of food produced to feed a growing population in terms of providing enough dietary energy, ensuring the availability, accessibility and affordability of a variety of food products that contribute to healthy diets for all remains a challenge. Poor and monotonous diets—high in carbohydrate-rich staples but lacking in variety, diversity and micronutrient content—are a major contributing factor to malnutrition.

Today, we have a clearer understanding of the complex nature of malnutrition and we know what is needed to address the multiple challenges of malnutrition. Global nutrition problems require global solutions—that’s why countries came together to move nutrition issues higher up the development agenda.

There has been a significant improvement in overall nutritional status of the world’s population since the 1992 ICN. Millions of people have been lifted out of poverty and hunger (down 21% from the 1 billion hungry in 1990–92 to 805 million 2012–14). Today, more people are eating better, are enjoying more balanced diets and safer foods and are better able to meet their nutritional needs than ever before. As a result, people are living longer and healthier, thanks also due to improvements in water and sanitation, health services and rising incomes.

However, not everyone has benefited from such development and many have been left out. Progress in reducing hunger and undernutrition has been uneven and unacceptably slow. Some 805 million remain undernourished and 2 billion people are estimated to suffer from micronutrient deficiencies. To have so many people be hungry and malnourished in the 21st century is unacceptable. Moreover, alongside the problems of undernourishment and micronutrient deficiencies, today, many countries in the world are facing increasing problems of overweight and obesity, often starting during childhood, creating a “double burden” of nutrition-related ill-health. Over half a billion adults are obese while the incidence of diet-related non-communicable diseases (NCDs)—such as heart disease, stroke, diabetes and some cancers—is increasing globally.

The Rome Declaration on Nutrition and the Framework for Action were endorsed at ICN2. Through the Declaration, countries commited to eradicate hunger and prevent all forms of malnutrition worldwide—particularly undernutrition in children, anaemia in women and children, and other micronutrient deficiencies—as well as to reverse the trend in obesity and diet-related NCDs. It aims to do this by increasing investments in sustainable food systems to ensure access to balanced and healthy diets and nutrition for all.

The Framework or Action sets out how to create an enabling environment for effective action, and calls for strengthening sustainable food systems, including through investments in pro-poor agriculture and smallholder agriculture to improve diets and raise levels of nutrition; nutrition education and information; social protection; strengthened health systems for addressing specific conditions; improved water, sanitation and hygiene; and improved food safety. The Framework is underpinned by recommendations for ensuring accountability.

Malnutrition is an abnormal condition caused by deficiencies, excesses or imbalances in energy and/or nutrients necessary for an active, healthy life. Therefore, it refers both to undernutrition and overnutrition, as well as to conditions arising from dietary imbalance leading to diet-related non-communicable diseases.

Undernourishment or hunger affects 805 million people; chronic malnutrition as measured by stunting (low height-for-age) has declined, but still affects 161 million children under five years of age, while acute malnutrition as measured by wasting (low weight-for-height) affects 51 million children under five years of age; micronutrient deficiencies (also referred to as hidden hunger) affect an estimated 2 billion people. At the same time, about 500 million adults are obese.

Anaemia affects more than 1 billion people. It afflicts more than a third of all children under five in developing countries and accounts for 20% of maternal mortality. Vitamin A deficiency disorders, which cause blindness and weaken immune systems, also affect more than a third of young children in developing countries and cause 1 million child deaths annually. Zinc deficiency is another major risk to health; notably, it exacerbates diarrhoea, a major cause of illness and death among children.

More than one-quarter (27%) of all children under five in developing countries are stunted, meaning they are short for their age due to chronically inadequate intake of food. Infectious diseases such as diarrhoea, tuberculosis, malaria and HIV/AIDS contribute to severe undernutrition in mothers and children.

Five percent of global deaths (2.7 million) can be attributed to overweight/obesity. An estimated 6% of children under the age of five (42 million) are overweight.

Many developing countries now face multiple burdens of malnutrition, with people living in the same communities—sometimes even the same households—suffering from undernutrition, micronutrient deficiencies and obesity.

Every country is affected by some form of malnutrition. The highest levels of undernutrition and multiple micronutrient deficiencies are found in South Asia and sub-Saharan Africa, while rising obesity levels are a major concern worldwide, including in low- and middle-income countries. Countries facing particular challenges related to undernutrition include India, where almost half of all children are stunted, and Nigeria, where more than half of the poorest children are stunted. National data do not tell the whole story. In China, for example, food security and nutrition has increased significantly, but children in poor rural counties are six times more likely to be stunted than their urban peers.

Everyone has the human right to adequate food and the highest attainable standard of physical and mental health. The Rome Declaration on Nutrition emphasizes the importance of all individuals having a diversified, balanced and healthy diet at all stages of life. In particular, it calls for special attention to be given to the first 1000 days from pregnancy to two years of age, pregnant and lactating women, women of reproductive age, and adolescent girls by promoting and supporting adequate care and feeding practices, including exclusive breastfeeding for six months and continued breastfeeding until two years of age and beyond with appropriate complementary feeding.

Other groups that will receive priority attention are the most vulnerable, neglected, socially excluded and economically marginalized parts of the population, including those affected by humanitarian crises. These groups must be included in the development process, and provided with decent employment as well as essential water, sanitation, hygiene and education services.

The Framework for Action strongly recommends both the promotion of universal health coverage and the use of cash and food transfers, including school lunch programmes, to ensure that vulnerable populations can improve their diets.

Malnutrition reflects socio-economic and gender inequalities in access to food, incomes, productive resources and other essential goods and services. Women have specific nutritional requirements that need to be acknowledged and met. In addition, gender-sensitive interventions should recognize and address women’s critical role in food production, food purchase, processing and meal preparation and in providing care and support for family members. Empowering women and improving their access to, and control over, resources, opportunities, services and information can increase their productivity as food producers as well as incomes from other sources, resulting in better nutrition, health and education outcomes for all the family.

Strengthening women’s role in policy development is key for poverty alleviation and the eradication of malnutrition. Women’s voices should be heard in decision-making from the household to the political level.

Food systems comprise the resources, environment, people, institutions and processes with which food is produced, processed, stored, distributed, prepared and consumed. The food system influences the availability and accessibility of diverse nutritious foods and thus the ability of consumers to choose healthy diets. The food system – in terms of how food is produced, processed, distributed and marketed – as well as the culture of food influence consumer choices, diets and nutrition. In turn, the demand generated through consumer preferences affects the food supply.

Food systems are changing rapidly, generally becoming more industrial, commercial and global, with profound implications for diets and nutrition, as well as for farmers. Governments have a role in shaping food systems to ensure food safety and balanced diets for all.

Nutrition transition refers to both quantitative and qualitative changes in the diet often associated with globalization, modernization of food systems, as well as urbanization and lifestyle changes that reflect reduced physical activity at work and during leisure time. The adverse dietary changes include shifts in diets towards a high-calorie diet with a greater content of fats and sugars and greater intake of saturated fats (mostly from animal sources) and reduced intake of fruits and vegetables. On the other hand, the nutrition transition has led to reductions in hunger. Increased dietary diversity may also have led to a fall in the proportion of those suffering from micronutrient deficiencies.

The shift experienced by most of the world population, from early death due to infectious diseases and hunger to death later in life due to other causes, can be viewed as a technological, social and economic success. However, these changes have brought some negative impacts, with obesity and associated non-communicable diseases such as heart disease, stroke, cancer and diabetes having emerged as major public health concerns, in developed and developing countries alike. People are leading more sedentary lifestyles and consuming more processed foods and drinks high in sugars, fats and salt than ever before. These changes in production and consumption have also come at a cost for the environment, with increased pressure on ecosystems and reduced biodiversity.

As much of the projected global population growth through 2050 will be urban, authorities are urged to anticipate such trends and try to shape food systems to sustainably produce foods and enable consumption that is conducive to better health.

Collective action—requiring collaboration between governments, the private sector, civil society and communities—is instrumental to improving nutrition. The private sector, including smallholder farmers, has an important role to play in ensuring the availability, accessibility and distribution of diversified food products which contribute to healthy diets.

However, it should be noted that governments have the primary responsibility for taking action at country level, in particular those related to policy development. 

The private sector has a role to play in producing and promoting the quality foods needed by consumers for a healthy diet.

The Framework for Action is “voluntary” and notes that there is no “one-size-fits-all” nutrition solution or ideal shape of a food system. The Framework provides a set of policy options and strategies which governments can consider in relation to national needs and conditions, as well as regional and national priorities including in legal frameworks.

A key principle in the Rome Declaration on Nutrition and the Framework for Action is the call for “coherent policies” from production to consumption and across relevant sectors. This should sustainably improve nutrition by providing people with year-round access to food that meets their nutrition needs and promotes safe, diversified, healthy diets. The food -systems approach is meant to assist food, agriculture, health, trade, water and sanitation, social protection, education, transport and energy ministries to make integrated policy decisions.

Food fortification involves deliberately increasing the content of essential micronutrients (i.e. vitamins and minerals, including trace elements) in a food so as to improve the nutritional quality of the food supply and to provide a public health benefit with minimal risk to health. Food fortification may also be used for the purpose of preventing or correcting a deficiency of one or more nutrients in the population or specific population groups. Commonly fortified foods include widely used products such as salt, flour, sugar, vegetable oil, and rice.

Biofortification is the process of using traditional breeding practices and modern biotechnology to produce food crops such as rice, sweet potato, beans, wheat, millet or cassava that are rich in micronutrients.

Nutrition guidelines generally suggest that healthy diets are diverse, containing an appropriate amount of energy, fat and protein, as well as micronutrients from a combination of cereals, vegetables, fruits and animal-source foods. Dietary diversity—defined as the number of different food groups consumed over a given time period—is an indicator of a high-quality diet.

WHO recommends that adults eat a mix of foods, with at least five portions of fruit and vegetables a day, less than 10% of total energy from free sugars added to foods, and less than 30% of total energy from fats, and that salt should be limited to less than 5 g (approximately 1 teaspoon) per day and it should be iodized. Advice on a healthy diet for infants and young children is similar, but these elements are also important.

• Infants should be breastfed exclusively for the first six months of life;
• Infants should continue to be breastfed until two years of age and beyond;
• From six months of age onwards, breast milk should be complemented with a variety of adequate, safe and nutrient-dense complementary foods. Salt and sugars should not be added to complementary foods.

With incomes rising in developing countries, where traditionally people have had low disposable incomes, meat consumption is bound to rise. However, nutrition advice is for consumption to be in moderation. Too much of anything is not healthy.

Animal foods are good sources of high-quality protein and vitamins and minerals such as iron and zinc, which are especially important for children and lactating mothers. Increasing access to affordable animal-source foods could significantly improve many people’s nutritional status and health, especially in sub-Saharan Africa, the one region in the world where per capita meat consumption is not increasing. However, excess consumption of high fat-containing meat is associated with heart disease and other non-communicable diseases.

It should also be kept in mind that livestock offer many rural households non-food benefits such as a store of wealth, a risk-management service, energy in the form of draught power, and often boost women’s employment.

We need to learn from the past to create a better future. We can learn from success stories as well as from mistakes and even failures. One lesson is that adopting a “multi track” approach may be best: malnutrition in all its forms cannot be solved by one miracle solution: it needs concerted and coherent systemic approaches implemented by multiple actors working in very different areas of health, trade, agriculture, education, social protection, etc. Mainstreaming nutrition into food and agriculture policy frameworks and bolstering local institutions’ capacity to identify problems and deliver solutions is crucially important, but so is providing resources and services to those households most at risk of malnutrition.

Nutrition can be improved by ensuring that increases in food production are channelled into well-functioning markets, narrowing the gap between locally available foods and the foods required for a healthy diet. Other strategies include increasing small-scale production of micronutrient-rich foods, reducing post-harvest food losses, selecting and breeding plants to increase micronutrient levels, and education and social marketing strategies to encourage the production and consumption of foods rich in needed micronutrients. Introducing weather-risk insurance schemes may help, and public–private partnerships that engage with farmer organizations and civil society groups to promote local food purchases also show promise. Many developing countries have had positive experiences with locally sourced school feeding programmes, and investing in women’s and girls’ education is a clear winner for nutrition.

The ICN2 agreements call for all countries, and especially for developing countries, to improve food and nutrition information systems and increase their capacity for data collection and analysis. It is especially important to have good data if we are to accurately identify nutrition problems and craft solutions and ensure accountability.

Globally, about one-third of the food that is produced for human consumption is lost or wasted. In developing countries, most losses occur at the farm level and along the supply chain before they reach the consumer. Reducing those losses by improving harvesting, storage, processing and distribution practices could increase food supplies, reduce food prices and reduce pressure on land and other scarce resources. In developed countries, the bulk of waste occurs after purchase, so greater focus should be placed on consumer education and information.