Good Nutrition
Perspectives for the 21st Century“This insightful and timely book rightly argues that
addressing malnutrition is crucial to achieving sustainable development.”
KOFI ANNAN | CHAIR OF THE KOFI ANNAN FOUNDATION, FORMER SECRETARY-GENERAL OF THE UNITED NATIONS (1997-2006)“Nutrition is a complex subject, affected by many intertwining factors.
Good Nutrition: Perspectives for the 21st Century pulls it all together in one easy-to-follow volume.”
ANNA LARTEY | PRESIDENT OF THE INTERNATIONAL UNION OF NUTRITIONAL SCIENCES AND
DIRECTOR OF NUTRITION AT THE UNITED NATIONS FOOD AND AGRICULTURE ORGANIZATION (FAO)Preface
A moment for concerted thought – and action
Nutrition brings the world together. All human beings, everywherein the world, have broadly the same nutritional needs. Nutrition also
divides the world – into those who have enough to eat and those whohave not, those who enjoy safe, quality foods and those who do not,and those who have highly specific nutritional requirements andthose who do not. The food we eat is a potent symbol of both theunity and the division of the world we live in.

The world’s population is growing at an unprecedented rate, and isdue to pass the 7.5 billion mark as this book is just about to go topress. It is also ageing, with people living longer than ever, especiallyin the developed world. Yet even as we consider the age-related
nutritional needs of our growing populations of senior citizens, wehave to recognize that the trend towards ever-increasing life
expectancies may not continue, even in the supposedly affluent
developed world. We are at a potential tipping point in history.

“

Not only are poverty and deprivation widespread in some of ourmost affluent societies; non-communicable diseases (NCDs) also are
growing at an unprecedented rate, placing a massive strain on
current healthcare and social protection systems and promising alevel of demand in years to come that will be patently unsustainable.
NCDs have replaced communicable diseases as the greatest threat tohuman life. Yet – irony of ironies – many of these NCDs are directly
attributable to changing lifestyles and, in particular, changing
dietary habits.

We all face common challenges aroundthe need for healthy, nutritionally adequate
diets that are safe and affordable. The
complexity is, however, never far away.
Global trends such as urbanization, thenutrition transition, social inequity,
continued shocks and conflict, andchanging public health concerns all meanthat there is no ‘one size fits all’ solution.
This book collects some of our brightest
minds and best ideas, but in addition, it
represents one of the most precious
ingredients for our success in achieving
the Sustainable Development Goals(SDGs): the global sharing of knowledge,
innovation and creativity by multistakeholders, in which we embrace thiscomplexity and direct our combined
efforts towards developing tailoredsolutions. I hope this book will spur new
partnerships and joint action towards
delivering good nutrition for all, keeping in“

mind balance and equity, and above all,reaching those furthest behind.
Ertharin Cousin

Executive Director of the UN World Food Programme

Next to breathing and hydrating, eating is the most essential of all
bodily requirements. For this reason, it is sometimes considered asimple matter. Nothing could in fact be further from the truth.
Continuing advances in nutrition science, genetics and genomics
show how complex the many biochemical processes involved innutrition are, while the dramatically increasing rate of population
growth is placing unprecedented strains on natural and man-madefood systems alike. Nutrition is anything but simple.

The trend towards highly processed foods and beverages containing
high levels of sugar, salt and saturated fats is leading to an epidemic
growth in cardiovascular disease, obesity and type 2 diabetes. Thishas happened in the course of a generation, in most parts of theworld. It will take much longer than a generation to bring undercontrol. At the same time, the nutritional inadequacy of many
contemporary diets has led to the reappearance in the developed
worlds of dietary deficiency diseases that not long ago wereconsidered to have been eliminated, with cases of rickets (vitamin D
deficiency) and scurvy (vitamin C deficiency), for example, making
the headlines in the countries of the developed world. One thing isclear: the traditional division between the “developed” and the“developing” world is not as neat as it used to be. While thedeveloping world still carries a massive burden of poverty andnutritional deprivation, many nutritional problems are shared acrossthe globe: the same challenges present themselves not only on thestreets of ever-more crowded cities but also in increasingly
depopulated rural areas. Changes in food habits around the world
are creating populations whose health status will place
unprecedented burdens on health systems. Unless something is done
to reverse current trends, the world’s ever-growing population will
also be increasingly illequipped to help solve the planet’s problems.
Whether we have a lot or a little on our plate, literally or
metaphorically, we are staring at a ticking time bomb.
Defusing that time bomb will call for a concerted effort – not justfrom governments, but also from non-governmental organizations,the private sector, and civil society, working across sectors, regions,cultures and religions. There has arguably never been a time when
the individual has had such potential to shape his or her own future,and the future of the world with it, through his or her dietary
choices. Nor has there ever been a moment when concerted“systems” thinking about nutrition has been so necessary – andconcerted action, even more so.
The global nutrition community has become both moreinterdisciplinary and closer-knit in recent years, as the effects ofglobalization have made themselves felt in every corner of the world.
If there is much to alarm us in the spread of industrialized eating
patterns, massive food wastage and the state of chronicmicronutrient deficiency known as “hidden hunger,” there is also
reason for hope. The Millennium Development goals brought us
closer to one another. The Sustainable Development Goals will bring
us closer still, as we strive to work together across sectors, frontiersand cultures to provide better nutritional solutions for the world.
As the Editorial Board that has overseen the development of thisbook, it is our hope that Good Nutrition: Perspectives for the 21st
century will help show that we do indeed all share one world, andthat poor nutrition has an impact far beyond its effect on theindividual who suffers from an inadequate diet, wherever he or she

may be. We also hope that this book will help point the way towards
practical solutions based on trusted science and robust programming– multisector and multidisciplinary solutions that offer improved
nutritional value while at the same time helping to protect the fragile
ecological balance of our planet. Our thanks go to all the
distinguished experts who have graciously made themselves available
to contribute to this important work, and to everyone else who has
helped to make it happen.
Nutritious, accessible, affordable and sustainable food for all ispossible – if we all work together to make it a reality.

Manfred Eggersdorfer

Klaus Kraemer

Senior Vice President, DSM Nutritional
Products (Member of the LeadershipCouncil DSM Nutritional Products);
Head of DSM Nutrition Science &Advocacy, Kaiseraugst, Switzerland;
Honorary Professor Healthy Ageing at
the University Groningen, theNetherlands

Managing Director of Sight and LifeFoundation, and Adjunct Associate
Professor in the Department ofInternational Health of Johns Hopkins
Bloomberg School of Public Health,Baltimore, MA, USA

John B Cordaro

Jess Fanzo

Global Food Security, Nutrition
and Safety Consultant, Mars,
Incorporated

Bloomberg Distinguished Associate
Professor of Global Food and Agriculture
Policy and Ethics at the Berman Institute of
Bioethics and the Nitze School of
Advanced International Studies at theJohns Hopkins University, Baltimore, MA,
USA, and Director of the Global Food
Ethics and Policy Program

Mike Gibney

Eileen Kennedy

Emeritus Professor of Food and Healthat University College Dublin, Institute ofFood and HealthProfessor of Nutrition and former Deanof the Tufts University, Friedman Schoolof Nutrition Science and Policy, Medford,
MA, USA

Alain B Labrique

Jonathan Steffen

Director, Johns Hopkins University
Global mHealth Initiative & Associate
Professor Department of International
Health/ Epidemiology (jt) Johns
Hopkins Bloomberg School of Public
Health Baltimore, MA, USA; Departmentof Community-Public Health, Johns
Hopkins School of Nursing (jt); Divisionof Health Sciences Informatics, Johns
Hopkins School of Medicine (jt)Managing Director,
Jonathan Steffen Limited, Cambridge, UK(Technical Editor)

Foreword

Prof. Hilal Elver

UN Special Rapporteuron the Right to Food

Embeddingnutrition in a humanrights agenda
Good Nutrition: Perspectives for the 21st century offers awideranging view of the challenges and opportunities for nutrition in theera of the Sustainable Development Goals (SDGs). Nutrition has arole to play in all 17 goals. If nutrition is accepted as a human right,
then its potential to bring about positive change on a global scale isvast. If it is not, however, even our best efforts to implement theSDGs will be very limited in their effect.
International law instruments provide a normative and legal
foundation for the human right to adequate food and nutrition.
Subsequent to Article 25 of the Universal Declaration on Human
Rights, Article 11 of the International Covenant on Economic,
Social and Cultural Rights (ESCR) recognizes the right to adequate
food and the fundamental right of everyone to be free from hunger.
Yet, nearly 800 million people worldwide remain chronicallyundernourished, and over 2 billion suffer from micronutrient
deficiencies, also known as hidden hunger. Another 2 billion are
overweight, with 600 million of these being obese. Meanwhile some
159 million children under 5 years of age are stunted, approximately
50 million children from this same age bracket are wasted, and 42
million are obese. For the first time in human history, there are more
obese than underweight adults in the world. As a result, noncommunicable diseases (NCDs) associated with obesity have surpassed
undernutrition as the leading cause of death in low-income countries.

These figures indicate that the challenges of malnutrition in all its
forms are daunting. Nevertheless, in many developing and least
developed countries (LDCs), policies against hunger receive more
attention than does the prevention of malnutrition in general, or thestunting and wasting of children. Therefore it is important toemphasize that the right to adequate food includes nutrition.
Adequacy with respect to food simply embraces nutritional value.
This means that the quality of the food we consume has to become
as important as the quantity. It is not enough to provide quantities offood as measured by caloric intake to eliminate hunger. This caloric
intake must include the necessary ingredients for human health.
Like access to food in general, access to nutritious food is often a
key indicator of economic inequalities, as well as of discrimination.
Therefore including nutrition in a rightsbased framework is criticalto ensuring that marginalized and vulnerable segments of the
population are able to access adequate, healthy, and nutritious food.
Dealing with global nutrition challenges through a rights-based
perspective is not only desirable, but also obligatory, since several
key principles recognize nutrition as an inherent element of the rightto food. The human-rights-based approach to nutrition enables theimplementation of procedural rights. These include participation,accountability, non-discrimination, transparency, empowerment andrule of law – each a demonstration of respect for human dignity. At
the International Conference on Nutrition 2 (ICN2), in Rome in
November 2014, the implications of a human-rights- based approachto nutrition were explained as follows: “[e]mbedding nutrition in ahuman rights agenda makes issues of governance and accountability
central to effective implementation.”
The legal duty to provide access to adequate nutrition
There are several human rights documents that support the claimthat the right to adequate food and nutrition is not only legitimate
but constitutes a legal duty. The clear inclusion of a nutrition
dimension of the right to food reveals that the right to food, properly
conceived, is closely linked to the right to health. The Covenant of
the ESCR Article 12.1 recognizes “the right of everyone to theenjoyment of the highest attainable standard of physical and mental
health.” If there is insufficient nutritious food available andaccessible, there will be adverse consequences for physical andmental health.
In its General Comment 12, the Committee on Economic, Social
and Cultural Rights (CESCR) Paragraph 8 interpreted the right toadequate food as follows: “Every State is obliged to ensure foreveryone under its jurisdiction access to the minimum essential food
which is sufficient, nutritionally adequate and safe, to ensure theirfreedom from hunger.” Furthermore, General Comment 14
Paragraph 43 (b) reiterates that one of the core State obligations
under the right to health includes ensuring “access to the minimum
essential food which is nutritionally adequate and safe, to ensure
freedom from hunger to everyone.”The Voluntary Guidelines to Support the Progressive Realization of
the Right to Adequate Food in the Context of National Food
Security (Voluntary Guidelines) of 2004 notes that “States shouldtake measures to maintain, adapt or strengthen dietary diversity andhealthy eating habits and food preparation, as well as feeding
patterns, including breastfeeding, while ensuring that changes inavailability and access to food supply do not negatively affect dietarycomposition and intake.”

Malnutrition does more harm to vulnerable populations, particularly
to poor women and children. Therefore, besides the universally
protected right to food and nutrition for all, children, pregnant andlactating women are selected for further protection in universally
accepted human rights conventions. The Convention on the Rights of
the Child (CRC) in Article 24 acknowledges that “to pursue the full
implementation of the right of the child to the enjoyment of thehighest attainable standard of health… States shall take appropriate
measures to (c) combat disease and malnutrition… through, inter alia,
the provision of adequate nutritious foods.” Article 27(3) states that:“Parties… shall take appropriate measures to assist parents and others
responsible for the child to implement this right and shall in case ofneed provide material assistance and support programs, particularly
with regard to nutrition, clothing and housing.”
The Committee of the CRC in its General Comment on Article 24 callson States to ensure that all segments of society are informed of theadvantages of breastfeeding. The CRC further states that “exclusive
breastfeeding for infants up to 6 months of age should be protected andpromoted and breastfeeding should continue alongside appropriate
complementary foods preferably until two years of age, where feasible.”
The protection and promotion of breastfeeding is also enshrined in
the International Code on Marketing of Breast-milk Substitutes,
which was adopted by the World Health Assembly in 1981. The
Global Strategy for Infant and Young Child Feeding, adopted in
2002, sets out the obligations of States to develop, implement, monitor
and evaluate comprehensive national policies addressing infant andyoung child feeding, accompanied by a detailed action plan.
The 1979 Convention on the Elimination of All Forms ofDiscrimination Against Women (CEDAW) highlights the importanceof children, as well as the importance of lactating and pregnant
women. Article 12 stipulates that all states shall ensure to women
appropriate services in connection with pregnancy, confinement andthe postnatal period, granting free services where necessary, as wellas adequate nutrition during pregnancy and lactation. Unfortunately,
CEDAW fails to fully protect a woman’s right to adequate food andnutrition as an individual, but only provides protection within theparameters of pregnancy and breastfeeding. Despite scientificevidence demonstrating that women have special needs due tophysiological differences from men, CEDAW surprisingly does notprovide special protection of the right to adequate food and nutrition
for women as individuals. It is vitally important to correct thisprotection gap as soon as possible.

Foreword

Considering the pivotal role of the private sector in the provision ofadequate food and nutrition, it is appropriate that the primary role ofregulating and monitoring the private sector should be given to thegovernments of sovereign states. A human rights framework underlines
the responsibility of corporations that produce food and shapenutritional standards to respect human rights and to contribute toequitable access for all persons to nutritious foods. Such responsibility
is implied in the Universal Declaration on Human Rights, which clearly
asserts that “everyone has duties to the community” (Art. 29), and thatgroups and persons must refrain from activities causing encroachment
on the rights enshrined within the Declaration (Art. 30).
In 2011 the UN Human Rights Council endorsed the UN Guiding
Principles on Business and Human Rights, formally recognizing the
responsibility of enterprises to avoid infringing on the human rights
of others and to address adverse human rights impacts arising fromtheir commercial activities. This responsibility extends to the adverse
impacts caused by the food industry in relation to the right toadequate food.
Although there is no significant resistance opposing a human rights
approach to adequate food and nutrition, several potential barriers
exist that affect proper implementation. Corporations greatly prefervoluntary commitments to regulatory frameworks. We see thisresistance at domestic levels. There are corporate initiatives against
several states dealing with such issues as labeling, taxing, limiting
excessive advertisements of junk foods, which covers highly
processed foods high in salt, sugar and saturated fats. Secondly,
there is a governance problem, since nutrition poses a multifaceted
challenge that needs to be coordinated through the cooperative
effort of several separate parts of government machinery. Finally, thecomplex character and long-term impacts of malnutrition on humanhealth, as well as the absence of indicators and lack of proper data,
creates difficulties when it comes to establishing workable
monitoring, accountability and transparency mechanisms.
The role of nutrition within the Sustainable Development
Goals (SDGs)
In September 2015, 170 world leaders gathered at the UN
Sustainable Development Summit in New York to adopt a 2030
Agenda. The new Agenda covers a broad set of 17 Goals and 167
targets and will serve as the overall framework to guide global andnational development action for the next 15 years. The SDGs areuniversal, transformative, comprehensive, and inclusive.
If we evaluate the SDGs from the perspective of nutrition policies,
we notice that nutrition is relevant to all 17 goals. As with all SDGs,
nutrition also has a universal character. Without achieving nutrition
targets, development policies cannot be successful. The present
burden of malnutrition on public health and the national budget has
become staggering. At the ICN2, world leaders recognized that a key
action for improving nutrition governance is to anchor nutrition
targets in the SDGs. While Goal #2 explicitly references “nutrition”(“end hunger, achieve food security, improved nutrition, andpromote sustainable agriculture”) and Goal # 3 refers to noncommunicable diseases, nutrition is arguably “interwoven” inrelation to all 17 SDGs, as at least 50 of the indicators set forth in
the 17 SDGs pertain to nutrition. The root causes of malnutrition
are more complex than the lack of sufficient and adequate food,reflecting as they do a variety of interrelated conditions addressed in
the SDGs with respect to health, care, education, sanitation andhygiene, access to resources, environmental degradation, climatechange and women’s empowerment. All of these conditions are
directly related to development policies. The underlying reality is
this: the SDGs cannot be achieved without special attention to
nutrition, and the nutrition Goals cannot be met without thefulfilment of other SDGs.
We conclude that despite the potential success of the SDGs on
account of their inclusion of nutrition (in contrast to the antecedent
Millennium Development Goals [MDGs]), they still arguably fail toestablish a framework that will facilitate the development ofsustainable food systems – something which is crucial in the fightagainst malnutrition. Moreover, some SDG targets lack the focus toenable effective implementation, and a number are not quantified.
Many targets are associated with several goals, and some goals andtargets may be in conflict with one another. Action to meet one
target could have unintended consequences for others if the pursuitof all is not coordinated. Among the 169 targets, only one isdedicated specifically to nutrition; and obesity is not evenmentioned. So the indefiniteness of the SDG framework seems tocreate gaps between the ambition of the goals and the likely
performance of states, which gives cause for concern.
Furthermore, the lack of an effective accountability and monitoring
system is a major obstacle to realizing the SDGs. Voluntary national
reporting and reviewing mechanisms through the High Level
Political Forum of the UN General Assembly are unlikely to beeffective enough to reach the nutrition targets in a timely andsufficiently thorough fashion. The multisectoral nature of nutrition,
its long-term impact on human rights and development, and theinvisibility of some of its consequences together make accountability
a complex and difficult challenge. Meeting such a challenge requiresa clear understanding of data collection. This calls for anunderstanding what is needed to improve nutrition coverage, as well
as developing a systematic tracking system for monitoring
investment and accountability at country and global levels.
Although significant progress has occurred vis-à-vis the Millennium
Development Goals, the 2030 Sustainable Development Goals still
avoid directly articulating a human-rights-based approach. We
cannot find anywhere in the text of the SDGs a direct affirmation of
the “right to adequate food,” or language imposing on states theduty to “respect, protect, and fulfil” human rights, despite the factearlier noted that all 17 goals are directly or indirectly relevant to
the fulfilling the 2030 Agenda for the
Sustainable Development Goals.
Overcoming barriers in the “Decade of Nutrition”? It is true thateven if the human rights approach to nutrition were recognized,
several barriers would still stand in the way of the adoption ofeffective nutrition policies and their implementation in pursuit of thevarious targets. At the height of the global food price crises in 2008,
The Lancet Series on Maternal and Child Undernutrition warned
that the international nutrition system was fragmented,
dysfunctional and desperately in need of reform. Since then,significant initiatives have taken place at the global level. On April 1,
2016, following the recommendation of the ICN2, the UN general
Assembly declared the Decade of Action on Nutrition that will run
from 2016 to 2025. The Decade presents a unique opportunity tocentralize globally agreed targets, align actors around
implementation, and address the shortcomings identified in thecurrent forms of nutrition governance. While ambitious targets havebeen set to ensure the global governance of nutrition, much more isForewordForeword

needed to meet the challenge of providing each person with enoughnutritious food to live a healthy and productive life, while at thesame time protecting the environment and natural resources,
including with regard to climate change.
The ICN2 Rome Declaration on Nutrition acknowledged that“current food systems are being increasingly challenged to provide
adequate, safe and diversified and nutrient-rich food for all that
contribute to healthy diets due to, inter alia, constraints posed byresource scarcity and environmental degradation, as well as byunsustainable production and consumption patterns, food losses andwaste, and unbalanced distribution.”Starting from the observation of the ICN2, the first barrier is theindustrial food systems, including production, processing, transportand consumption of food, that are currently dominant in many partsof the world. Food systems have a direct impact on overall diet andin determining what food is available in the market place. Industrial
food systems focus on increasing production and maximizing
efficiency at the lowest possible economic (and consumer) cost. This
type of system relies on industrialized agriculture, including
mono-cropping and factory farming, industrial food processing,mass distribution, and marketing. Due to considerations ofaffordability, availability and palatability, as well as marketing andpromotion strategies, food produced from industrialized foodsystems constitutes a significant portion of global food sales. The
adverse impact of industrial food systems on nutrition and publichealth is widely acknowledged. It is now obvious that excessive foodproduction neither eliminates hunger nor remedies malnutrition.
Removing these barriers depends on the appropriate transformationof current food systems into “nutrition-sensitive” food systems.
Reflecting the various conditions of specific countries, nutritionsensitive food systems need to be diverse, but the general principles
should be sensitive to global nutrition policies and the human rights
approach that gives a high priority to nutritionally deprived groups
and vulnerable peoples.
The second barrier is a set of factors relating to political, environmental
and socioeconomic conditions that have direct and indirect impacts
on nutrition in any given society. These conditions include economic
development without inclusive growth; population increase, poverty
as well as vertical and horizontal inequality; rural urban migration
and urbanization; trade and investment policies as well as economic
globalization; equal access to natural resources, sustainable resource
management, environmental degradation, and climate change.
These conditions are interrelated and give rise to negative or positiveeffects on nutrition depending on policy interventions. Therefore eachcountry should create a “national master plan for good nutrition.”
Addressing global nutrition challenges and ensuring that every
individual is guaranteed a right to nutrition requires significant reforms
in several areas: agriculture, education, health, social protection,water, sanitation and hygiene, gender, trade relations, socioeconomic
conditions, environmental degradation, and climate change.
To meet the Decade of Nutrition and 2030 Sustainable Development
Targets, political will is vital first and foremost. National
governments should take these global targets seriously and dedicate
substantive financial resources to reaching the targets. Governments
should also establish effective, transparent, and independentaccountability mechanisms to follow up and review the progress anddetect obstacles. Without such monitoring mechanisms and financial
resources, there will be little progress, and few nutrition targets will

be reached. Needless to say, effective monitoring and accountability
systems, as well as inclusive decision-making processes, would be
realized if a human-rights- based approach were to be credibly
applied to nutrition policies.
Perspectives for the 21st century
Good Nutrition: Perspectives for the 21st century showcases thethinking of some of today’s most influential and respected scientists
from a wide range of fields. With clear presentation and accessible
argumentation, it offers a composite view of where global nutrition
stands today and outlines a wide range of evidence-based approaches
for bringing about positive change. The fact that its scope covers thedeveloped as well as the developing world makes it all the more
powerful, for there are no countries in the world today, however
affluent they might be, that are not faced with significant
malnutrition challenges. I am confident that scientists and policymakers working in nutrition, food, agriculture and public health, aswell as non-specialists, will find this publication informative, useful,and thought provoking, and that it will inspire everyone who reads
it to help build a world in which nutrition is indeed recognized as afundamental human right.
Prof. Hilal Elver
UN Special Rapporteur on the Right to Food

Good Nutrition: Perspectives for the
21st Century is published by KARGER.
Copyright 2016 by S. Karger AG, P.O. Box,
CH–4009 Basel (Switzerland)
Editors: Manfred Eggersdorfer, Klaus
Kraemer, John B Cordaro, Jess Fanzo,
Mike Gibney, Eileen Kennedy,
Alain Labrique, Jonathan Steffen