A human rights approach to the health implications of food and nutrition insecurity

Reflecting a growing understanding of its multidimensional character, the definition of food security has undergone many shifts over the years, moving from a food production-focused definition to one that largely embraces nutrition. The original definition arose in 1974 at the World Food Conference to focus on the “availability at all times of adequate world food supplies of basic foodstuffs to sustain a steady expansion of food consumption and to offset fluctuations in production and prices” [3]. Expanded over the ensuing years to focus on public health, the 1996 World Food Summit focused on the need for nutrition as a basis of health: “when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life” [4]. Today, the FAO conceptualizes food security as having four dimensions that should be fulfilled simultaneously: the physical availability of food, the economic and physical access to food, the body’s utilization of the nutrients found in food, and the stability of the previous three dimensions over time [5].

The focus on the body’s utilization of food for health essentially integrates nutrition security into food security, with the FAO defining nutrition security as “[a] situation that exists when secure access to an appropriately nutritious diet is coupled with a sanitary environment, adequate health services and care, in order to ensure a healthy and active life for all household members” [1]. By examining food, environment, and care together, nutrition security ceases to exist in the absence of food security, thereby more explicitly linking food security and health

The definition of “food security” has also come to include food safety, which is now recognized as key link between food and health [6]. Food safety requires all actions geared toward ensuring that food is as safe as possible [7]. In fact, in an effort to emphasize food safety as a critical component of food security, the FAO added the terms “safe and nutritious” to the definition of food security during the 1996 World Food Summit [8]. It is here where food security becomes strongly linked to water, sanitation, and hygiene (WASH). Lack of access to safe drinking water, sanitation, and hygiene can lead to infectious diseases like diarrhea and other intestinal diseases that can significantly undermine a person’s ability to absorb the necessary nutrients [9].

The FAO defines malnutrition as “an abnormal physiological condition caused by inadequate, unbalanced or excessive consumption of the macronutrients that provide dietary energy (carbohydrates, protein and fats) and the micronutrients (vitamins and minerals) that are essential for physical and cognitive growth and development” [2]. Malnutrition stands as a serious challenge to achieving both nutrition security and food security. Contrary to common misconception, malnutrition is not simply undernourishment. In fact, malnutrition is complex and can take multiple forms, all of which are tied to inappropriate nutritional diet. While undernourishment refers to the insufficient intake of food, undernutrition should be understood as its outcome, where a person’s body mass index (BMI) is equal to or falls below 18.5. While it is estimated that undernutrition has reduced globally—from 18.6% in 1990–1992 to 10.9% in 2014–2016—there remain 795 million who are undernourished [1] and approximately 2 billion with one or more micronutrient deficiencies (MNDs), especially iodine, iron, vitamin A, and zinc [10, 11]. Impacting public health, experts have underscored that MNDs “significantly contribute” to chronic diseases [12] and infectious diseases [13] in affected countries. The World Health Organization (WHO) has emphasized that “micronutrient malnutrition contributes substantially to the global burden of disease” and accounts for the “wide range of non-specific physiological impairments, leading to reduced resistance to infections, metabolic disorders, and delayed or impaired physical and psychomotor development” [12].

Furthermore, malnutrition affects one third of the world’s population, and close to half face more than one type of malnutrition [14]. It constitutes a serious economic development challenge for countries, especially for those that face a high prevalence in more than one type of malnutrition, including undernutrition and overweight. Facing this double burden of disease, there are over 1.4 billion people overweight across the world, including 500 million obese [2], with some nations’ overweight and obesity prevalence surpassing undernutrition [15, 16].

While malnutrition can affect anyone in any country, its harms fall most heavily on children and women of reproductive age, especially those in developing countries [11]. The global prevalence of malnutrition remains dire as a determinant of the health of the child, for whom long-term undernutrition and micronutrient deficiency can lead to stunting,¹ [1] and in turn impaired cognitive and physical development [16]. Globally, 26% of children under five are stunted, with approximately 160 million in developing countries [2]. Additionally, with the globalization of the high-sugar and high-fat diets, which are conducive to overweight and obesity, malnutrition can mean not only undernourishment and undernutrition but also overnutrition of children [2]. Largely due to marketing schemes and lack of adequate regulation of the food industry, an issue that will be elaborated further below, childhood obesity has been on the rise, with an attendant rise in non-communicable diseases (NCDs), and there are now more overweight or obese children living in low- and middle-income countries than high-income countries. Between 1990 and 2014, Africa experienced a doubling in the number of overweight children under the age of five, from 5.4 million to 10.3 million. According to the WHO’s Commission on Ending Childhood Obesity, approximately 41 million children under 5 years of age were overweight or obese in 2014—25% in Africa and 48% in Asia [17].

Women are likewise significantly affected and should form an essential part of any intervention designed to address food and nutrition insecurity. In many societies, women continue to face serious obstacles as a result of deep-seated gender discrimination that interfere with household food security and nutrition [18]. As a result, women experience difficulty accessing, and controlling, resources, despite being key players in food production in many developing countries. In agricultural communities, it is women who not only care for the children but also work the fields, especially in societies where urbanization is on the rise and men in rural communities are forced to migrate into the cities for work. However, they lack access to land, credit, education, and agricultural inputs [19]. The high nutrition requirements during pregnancy and lactation coupled with gender-based discrimination present in many parts of the world make women (especially poor women) more prone to malnutrition than men [20]. In Southern Asia and sub-Saharan Africa, women are more likely to experience obesity and other nutrition-related chronic diseases than men [20]. In Vietnam, where two sets of household surveys conducted 5 years apart revealed that men reaped proportionally more nutritional benefit from economic development than women, as reflected in food access and body weight data [21].

Contributing to the health of the entire population, maternal nutrition is critical to tackling malnutrition among children. Maternal undernutrition leads to restricted fetal growth, infant deaths, and if the child survives, stunting [16]. As the FAO has emphasized, poverty promotes a vicious cycle of undernutrition: “Poverty often begins with poor nutrition and health, especially in early childhood.... Moreover, stunted girls grow up to become stunted mothers; maternal stunting is one of the strongest predictors of giving birth to a low-birth-weight infant. Maternal and child malnutrition thus perpetuate the cycle of poverty” [22]. Further, maternal overweight and obesity can increase the risk of the child becoming obese and developing non-communicable diseases later in life [16]. Therefore, laws and policies that limit women’s access to key resources—including health care, land, and credit—have a disproportionate effect on women’s food and nutrition security [18].

Considering these challenges, raising the nutritional quality of food to address micronutrient malnutrition has entailed food fortification (addition of micronutrients to processed foods), dietary diversification, and supplementation efforts for groups at risk, including children and women [11]. Alongside nutrition education and public health and food safety measures, food fortification policy has “proven effective for prevention of specific diseases, including birth defects” [23] and has been more strongly promoted by WHO since the 1990s. With the aim of “eliminating iodine deficiency disorders as a major public health problem in all countries by the year 2000” (emphasis added), the World Health Assembly in 1990 passed what has been deemed a “landmark resolution” for addressing micronutrient malnutrition, urging WHO Member States “to continue to give priority to the prevention and control of iodine deficiency disorders through appropriate nutrition programmes as part of primary health care” [24]. Since then, the international community has achieved greater consensus around food fortification,² and more than 80 countries now have fortification policies to promote food and nutrition security [25].

The enjoyment of food and nutrition security at the community level is inevitably determined by factors taking place globally, such as climate change, increased urbanization, emergencies (both natural and human-made), and the globalization of unhealthy diet through the growth of the food industry. These global drivers of food and nutrition security call for innovating solutions involving efforts at the international level, and because they are more likely to affect vulnerable populations, a human rights approach is critical to comprehensively address their needs.

Human rights offer universal frameworks to advance global justice for food and nutrition security. Instrumental to human dignity, rights seek to address basic needs and frame individual entitlements to uphold a universal moral vision [47]. By addressing threats as “rights violations,” international law offers global standards by which to frame government responsibilities and evaluate policies and outcomes under law, shifting the policy debate from political aspiration to legal obligation [48]. Empowering individuals to seek accountability for these government obligations rather than serving as passive recipients of government benevolence, human rights law identifies individual rights-holders and their entitlements and corresponding duty-bearers and their obligations [49]. The state becomes the duty bearer under international law upon ratification of the underlying human rights treaty, with the government thereafter accepting resource-dependent obligations to “progressively realize” rights “to the maximum of its available resources, with a view to achieving progressively the full realization of the rights” [50, 51].

The codification of human rights under international law begins in the aftermath of World War II, with rights related to food and health serving to prevent deprivations like those that had taken place during the depression and the war that followed. [52] As a basis for building a just world out of the ashes of war, states worked under the auspices of the nascent UN General Assembly to enumerate and elaborate these human rights under international law, proclaiming on December 10, 1948, a Universal Declaration of Human Rights (UDHR) to create “a common standard of achievement for all peoples and all nations” [53]. With the UDHR developing a right to “a standard of living adequate for the health and well-being,” it specifically clarified a series of underlying determinants of health, “including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control” [53]. Building from this non-binding declaration, states continued to negotiate in the ensuing years to develop specific legal obligations under two separate human rights covenants, enacting in 1966 the International Covenant on Civil and Political Rights (ICCPR) and the International Covenant on Economic, Social and Cultural Rights (ICESCR). These three documents—the UDHR, ICCPR, and ICESCR, adopted separately by the UN General Assembly and referred to collectively as the “International Bill of Human Rights”—form the normative basis of the human rights system from which the human right to food and the human right to health would evolve as interconnected rights under international law.

As the Cold War came to an end, there arose a renewed international commitment to human rights, with international recognition in the 1990s that “[a]ll human rights are universal, indivisible and interdependent and interrelated” [58] creating a political space to address food security as central to individual dignity [4]. Shifting from global food supply to household food security, human rights scholarship at the intersection of food and health began to transition from a focus on calorie counts to an analysis of nutritional content [59]. Building from the UN’s drafting of the 2000 Millennium Development Goals—which focus pervasively on health and begin with a focus on the eradication of hunger—these human rights interpretations would seek to translate global norms into state obligations.

Memorializing such interconnected human rights and corresponding government duties, the UN Committee on Economic, Social and Cultural Rights (CESCR, the legal body charged with drafting official interpretations of, and monitoring state compliance with, the ICESCR [60]) issued a series of General Comments to provide authoritative interpretation of the norms inherent in these rights: in 1999 on the right to adequate food [61] and in 2000 on the human right to health [62].

The CESCR thereby included “an adequate supply of food and proper nutrition” under the right to health, linking the quantity and quality of food necessary for a healthy diet and thereby articulating a core state obligation “[t]o ensure access to the minimum essential food which is nutritionally adequate and safe, to ensure freedom from hunger to everyone” [62].

With these general comments sharing an interconnected focus on nutrition, the CESCR finds the right to food and the right to health to be intersectional rights—interdependent and interrelated and encompassing an array of underlying factors that impact health, with specific state obligations to address food insecurity as a means to adequate nutrition. As other human rights treaty bodies have come to address the specific health rights of women and children, they too have come to focus on the interconnections between food and health, with general comments and recommendations that elucidate the health harms of inadequate food supply [63] and the state obligations for adequate nutritious foods (with a malnutrition focus on both undernutrition and overnutrition) [64].

With the UN Commission on Human Rights developing a Special Procedure mandate for a Special Rapporteur on the Right to Food in 2000 [65] and a Special Rapporteur on the Right to Health in 2002 [66], these special rapporteurs have sought to clarify their respective rights while recognizing, if not addressing, their intersectionality. The Special Rapporteurs on the Right to Health have advanced an availability, accessibility, acceptability, and quality framework to elaborate the norms of the right to health, with annual UN reports on the health implications of hunger, the links between unhealthy foods and non-communicable diseases, and the role of nutrition in early childhood development [67, 68]. The Special Rapporteur on the Right to Food has similarly advanced an availability, accessibility, adequacy, and sustainability framework for the right to food, defining this right to provide “physical and economic access at all times to sufficient, adequate, and culturally acceptable food that is produced and consumed sustainably, preserving access to food for future generations” and applying this right to focus holistically on the health harms of malnutrition (including undernutrition, micronutrient deficiency, and overnutrition) [69, 70]. While clarifying their respective rights, however, the right-specific mandates of these special rapporteurs have limited them in addressing areas where these rights intersect.

This intersectional conceptualization brings into focus underlying determinants of health resulting from food and nutrition security: providing proper nutrition for physical and mental development and the prevention of diseases caused or abetted by malnutrition—either undernutrition, nutrient deficiency, or overnutrition. As a central component of human dignity, food and nutrition security can empower households to look beyond the uncertainty of hunger and malnutrition through government obligations to secure the conditions for a healthy, energized life.

From human rights to state obligations, the realization of a right to food for the protection of food and nutrition security under international law necessitates intersectional national policies. Food and nutrition security is assured through food sovereignty, understood as “the right of peoples to healthy and culturally appropriate food produced through ecologically sound and sustainable methods, and their right to define their own food and agriculture systems” [72]. By upholding the rights of producers, food sovereignty serves as a precondition for the right to food [76] and provides a basis by which states can be resilient in adjusting to global disruptions in food production and distribution. Such a shift toward national control over food systems implicates the need to translate the development of a right to food and nutrition security under international law into the implementation of this intersectional right through national policy [77].

Recognizing the limitations of international law in affecting the practice of national governments, this section explores and recommends avenues through which human rights obligations could be translated into national laws, policies, and programs, thereby operationalizing international law at the domestic level to address food and nutrition insecurity. Facilitating international accountability for national practice, the UN’s human rights treaty bodies provide space for civil society advocacy and constructive state dialog on the effective implementation of international human rights obligations.

The development of a human right to food and nutrition security under international law has codified an imperative to implement human rights in food insecurity policy. Where international law has no direct (or self-executing) effect on national governments, it becomes necessary to operationalize state human rights obligations through national laws, policies, and programs. [78] With policymakers, practitioners, and advocates translating international human rights into rights-based outcomes, these stakeholders implement rights through national policy [79], invoking a rights-based approach to food and nutrition security policy as a means to: frame the legal and policy environment, integrate core principles into policy and programming, and facilitate accountability for obligations [80]. Where food rights have long been thought of as “vague, if not unclear,” [81] the domestic codification of a right to food and nutrition security could concretize this right through its application [75]. Translating international law into national policy and practice, human rights are seen to “cascade” down to the national level, by which these norms gain broader international acceptance through national policy, and state duty-bearers internalize obligations to progressively realize rights through food insecurity policy [82].

Seeking to implement international law at the national level, the UN’s specialized agencies have provided support to states in implementing rights to food and nutrition security. The FAO worked with an Intergovernmental Working Group to develop the “Voluntary Guidelines to support the progressive realization of the right to adequate food in the context of national food security,” which provide practical guidance to states in their implementation of the progressive realization of the right to adequate food in the context of national food security [73]. In focusing states on the link between adequate food and disease prevention, Guideline 10 (Nutrition) encourages states to address food security through healthy eating habits, thereby preventing malnutrition, overconsumption, and unbalanced diets [73]. Supporting these efforts to realize food and nutrition security, the FAO’s Voluntary Guidelines encourage states to pursue food security through, inter alia, inclusive land-use policies (particularly expanding land access for women), social safety nets (to assure economic accessibility), local and regional markets (through transportation, storage, and distribution infrastructure), and sustainable agriculture (supporting farmers to diversify their crops based on nutritional content) [73]. Working with WHO and Office of the United Nations High Commissioner for Human Rights (OHCHR), FAO has followed up this governmental guidance with programmatic guidance to promote nutrition, recognizing the role of nutrition as an underlying determinant of health [74]. The WFP Nutrition Policy approved in 2012 includes previous policies on nutrition topics and strategies through which the WFP engages in nutrition, outlining nutrition-specific and nutrition-sensitive programs [83].

The range of international legal and practical guidance instruments available at the international level provide states with a basis on which to build a human rights-based and sound implementation approach to addressing food and nutrition insecurity at the national level. Recently, the World Health Assembly issued guidance on the importance of abiding by international obligations, as Member States look to undertake measures to combat the inappropriate marketing of foods. It urged them “to take all necessary measures in the interest of public health to end the inappropriate promotion of foods for infants and young children, including, in particular, implementation of the guidance recommendations while taking into account existing legislation and policies, as well as international obligations” [84].

Hence, these national legal avenues are critical to driving the implementation of international standards forward, imploring duty bearers to take action as a result of legal action framed in the language of a justiciable right to food, and to allowing for improved responses to food and nutrition insecurity on the ground. However, as discussed in the next section, international human rights bodies provide accountability mechanisms that can trigger or strengthen governments’ efforts to address the issue.

Focusing on food and nutrition security as an intersectional right poses obstacles to accountability for national implementation; however, international accountability mechanisms exist through the UN’s human rights treaty bodies. Human rights treaty bodies monitor state implementation of the international human rights treaties, facilitating accountability for rights realization through their formal review of state reports, constructive dialog with state delegations, and concluding observations on state obligations. Comprised of independent experts, who are elected in their individual capacity rather than as representatives of their states, treaty bodies have international legal authority to assess whether state parties are implementing their treaty obligations [96]. In addition to clarifying treaty provisions through general comments, recommendations, or statements [97], these treaty bodies also review state reports on the implementation of rights within their monitoring purview [98]. All core human rights treaties require that states report regularly on the steps they have taken to implement their duties [99] and the goal for these reports is not only to assess the implementation of rights but also to bring about the opportunity to debate these human rights within the country. Through the findings of these reports, the treaty body engages in constructive dialog with the state and issues concluding observations or recommendations. These treaty body authorities influence states and galvanize advocates to take action to realize rights, with subsequent state reports seen to respond to issues raised in previous concluding observations [100, 101].

At the intersection of the right to food and the right to health, the right to food and nutrition security has been addressed principally by the CESCR, the Committee on the Rights of the Child, and the Committee on the Elimination of All Forms of Discrimination Against Women. As seen in the CESCR, states are seen to report on food or nutrition security—with attention to the safety and nutritional adequacy of food (with focus on wasting, underweight, and stunting)—and the Committee has responded by recommending the adoption of “effective and urgent measures to combat hunger and malnutrition” [102]. Where state reports regularly discussed assessment of nutrition-related health indicators, fortification, and breastfeeding promotion—as assessing realization of a right to food through quantity of calories is easier to report and analyze than measuring the nutritional food content necessary for disease prevention and health promotion—states have begun to report on policies for the progressive realization of rights related to food and nutrition security, with states seen to report on the quality of food through: infrastructural improvements [103], food safety programs [104], healthy food policies [105, 106], and food support for women and young children [107]. Complemented by the 2008 ICESCR Optional Protocol, developing a supranational individual complaint mechanism under the CESCR, the role of treaty bodies will prove increasingly relevant to implementation and accountability for a right to food and nutrition security [108].

These binding obligations are reinforced by a growing architecture of monitoring mechanisms in the UN system. The Universal Periodic Reporting (UPR) process and the country missions of the special rapporteurs provide mechanisms to facilitate accountability for state implementation efforts to progressively realize a right to food and nutrition security. These efforts have been recently reinforced by the adoption of the 2030 Agenda for Sustainable Development. Paragraph 72 voices the UN General Assembly’s commitment to “a robust, voluntary, effective, participatory, and integrated follow-up and review framework” [109]. This commitment supports the monitoring infrastructure of a right to food and nutrition security by emphasizing cross-sectoral goals based on the rights to food and health, as well as a broader recognition of the role of human rights in accomplishing the Sustainable Development Goals (SDGs). Statements and resolutions by the Secretary-General [110] and the General Assembly [111] of the United Nations, as well as the presentation of the first 22 voluntary country reports in the SDG era [111], show continued international commitment to national monitoring.

Considering the wide range of international and national accountability mechanisms, it is important to underscore the importance of civil society in facilitating accountability for food and nutrition security and their role as partners providing expert technical capacity and financial support within countries. Civil society actors engage in a variety of activities at both the national and international levels that must not be overlooked: pressuring governments through advocacy efforts to comply with international human rights obligations, monitoring this compliance, investigating the human rights situation, providing data, and litigation. Within the international system, pursuant to the periodic reporting requirements described above, non-governmental organizations (NGOs) can also submit “shadow reports” to UN treaty bodies to either confirm or challenge reports submitted by governments. Additionally, NGOs are invited to “attend the UPR Working Group sessions and can make statements at the regular session of the Human Rights Council when the outcomes of the State reviews are considered” [112]. It is worth noting that the CESCR recognizes their importance to the whole process. For example, with respect to the right to food, the CESCR has held that establishing national legislation requires the “active involvement” of civil society. States are expected to specifically provide for collaboration with civil society, among other sectors, in its right to food framework legislation [61]. NGOs can thus play a critical role in furthering the protection of human rights and fostering accountability intersection obligations pursuant to the right to food and nutrition security.