Evidence and Program Guidance Unit, Department of Nutrition for Health and Development, World Health Organization, Geneva, Switzerland
The nutritional status of any population group is significantly affected by several factors beyond food consumption. These factors are known as the social determinants of health (SDH) and they are the circumstances in which people are born, grow up, live, work, age, and the structures put in place to deal with health and illness. As the World Health Organization (WHO) has pointed out, SDH include, among others, the distribution of power, income, goods and services, access to health care and, education. The manner in which SDH are structured and operate creates disparities within populations. When such differences are unjust, unfair and preventable, they are considered health inequities (1), understanding equity as a moral position that pursues fair opportunities for individual and community development. Therefore, in order to reduce health inequities, preventive and corrective actions must be taken to address social determinants. This is particularly important for nutrition programs as key contributors to sustainable development and the achievement of the Sustainable Development Goals (SDG), which are the cornerstone of the international development agenda post 2015. Preventing and treating malnutrition is at the core of the SDG because food is at the center of many social, cultural and economic dynamics and the double burden of malnutrition is unevenly distributed across and within countries. For instance, the prevalence of overweight and obesity has increased steadily during the last decades, primarily in middle- and low-income countries, due to complex multifactorial determinants, including SDH, which coexist with long-standing micronutrient deficiencies. Likewise is the case of anemia, a condition that causes impaired development and learning in children, fatigue, impaired physical capacity and work performance leading to impaired economic productivity and development. The prevalence of anemia in pre-school age children around the world varies significantly: 22% in Europe, 23% in Western Pacific, 29% in the Americas, 47% in Eastern Mediterranean, 66% in South- East Asia and 68% in Africa (2). Another example is insufficient iodine intake, which is related to goiter and preventable impaired cognitive and psychomotor development in children. The proportion of school age children with insufficient iodine intake is: 10% in the Americas, 26% in Western Pacific, 40% in South East Asia, 42% in Africa, 55% in Eastern Mediterranean and 60% in Europe (3). Addressing the SDH in the implementation of nutrition programs fosters more accessible, acceptable and available interventions and improves their quality. Overlooking SDH promotes shortcomings in the implementation of nutrition programs. For example, low purchasing power and cultural practices might explain the low impact of wheat flour fortification with iron and folic acid among poor, rural, indigenous populations in countries where maize is a staple (4). Also, social determinants such as low maternal education, poor sanitation facilities, and child feeding behavior might explain to a great extent the prevalence of stunting in children (5). For this reason, WHO has put forward several policy frameworks to address malnutrition and inequities. These include the Comprehensive implementation plan on maternal, infant and young child nutrition and the Global Strategy on Diet, Physical Activity and Health in order to support Member States when developing policies and interventions and promote community-based initiatives. WHO also includes appropriate guidance on SDH and implementation within its nutrition-related recommendations such as the guideline on fortification of food-grade salt with iodine for the prevention and control of iodine deficiency disorders, which recommends that country programs be culturally appropriate to the target populations so the intervention is accepted, adopted and sustained. Recently, WHO guideline on delayed umbilical cord clamping for improved maternal and infant health and nutrition outcomes also addressed SHD as an integral part of its implementation guidance. Action plans are also being executed within the countries at different levels: initiatives that come from civil society, industry, policy makers and health providers. WHO has gathered evidence suggesting that effective interventions are successful when they are multi-component and adapted to cultural and local context (6). Interventions that use the existing social structures of a community such as schools are more likely to be scaled up. The involvement of all community stakeholders in the planning, implementation, discussion and evaluation ensures that an intervention is well incorporated in the population. Industry has also been called to participate, playing an important role by reformulating their products, labelling appropriately and marketing adaptations to accomplish the regulations determined by policy makers. Nutrition programs promote health equity when the SDH are considered at the early stages of program design and during their development. When SDH are addressed, policies and actions to reduce malnutrition are more likely to have a positive impact in health outcomes and economic growth enabling people to live longer and healthier lives, reducing inequalities and enhancing the development of societies. The prevention and treatment of malnutrition, in all its forms, and at every stage in the lifecycle is a defining principle of sustainable development, and can act as a catalyst to diminish intergenerational transmission of poverty and ill health. References: 1. WHO. Equity, social determinants and public health programmes. E. Blas & A. Sivasankra Kurup (eds). Geneva: World Health Organization, 2011. 2. WHO. The global prevalence of anaemia in 2011. Geneva: World Health Organization, 2015. 3. Andersson M, Karumbunathan V, Zimmermann MB. Global iodine status in 2011 and trends over the past decade. J Nutr 2012; 142(4): 744-750, 4. Imhoff-Kunsh et al. Wheat flour fortification is unlikely to benefit the neediest in Guatemala. J. Nutr 2007; 137: 1017–1022. 5. Rohner F et al. Infant and young child feeding practices in urban Philippines and their associations with stunting, anemia and deficiencies of iron and vitamin A. Food Nutr Bull 2013; 34(2 Suppl): S17-34,. 6. WHO. Interventions on diet and physical activity: what works: summary report. Geneva, World Health Organization, 2009.