Addressing Hidden Hunger in School-Aged Children and Adolescents within the Context of the Food System
Bianca Carduccia, bChristina OhaZulfiqar A. Bhuttaa–d
aCentre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning (PGCRL), Toronto, ON, Canada; bDepartment of Nutritional Sciences, University of Toronto, Toronto, ON, Canada; cCentre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan; dDalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Abstract
Over the past decade, public health advocates and policymakers have grappled with the increasing issue of the double burden of malnutrition. Building on the Sustainable Development Goals and the United Nations Decade of Action on Nutrition, strengthening food systems is paramount to addressing hidden hunger, otherwise known as micronutrient deficiencies, and the provision of healthy, sufficient quality and quantity, affordable, safe, and culturally acceptable food. Using the UNICEF Innocenti Framework on Food Systems for Children and Adolescents as guidance, this review identifies four evidence-based food system strategies to drive improvements in micronutrient deficiencies in low- and middle-income countries in the context of school-aged children and adolescents: agriculture, food supply chains, food environments, and social behavioral change communication. With multiple players and drivers in the picture, strong and reliable oversight from national and local governments is required, through accountability, regulation, and sustained commitment to creating policies and proper infrastructure to support healthy food consumption and limit access to unhealthy food items. Moreover, given the complexity of hidden hunger, a holistic systems approach with a “right to food” lens is required to begin addressing and improving the diets and nutrition of children and adolescents. This involves synergistic and collaborative actions from all actors within the food system, as well as interactions with systems that have the ability to deliver nutrition interventions at scale. These systems include health, water and sanitation, education, and social protection. Only through partnerships and collaboration between all drivers, determinants, and key components of the food system, including its interactions with other global systems, will we be able to appropriately address hidden hunger in school-aged children and adolescents.
© 2020 S. Karger AG, Basel
More than ever before, an estimated 821 million people worldwide are suffering from insufficient diets, indicating an unfortunate regression from previous efforts and gains [1, 2]. According to the 2019 Global Burden of Disease Study on the health effects of dietary risks (1990–2017), most regions are not meeting the optimal level of intake of fruits, vegetables, whole grains, nuts and seeds, milk, calcium, fiber, omega-3 fatty acids, and polyunsaturated fatty acids, while consumption of sugar-sweetened beverages, sodium, trans-fats, and processed meats are exceeding optimum levels [3]. These patterns not only threaten the survival of the world’s current children and adolescent populations, nations and their economies, but also their ability to thrive, and that of future generations. With substantial scientific evidence, various disciplines and sectors are now calling for the transformation of the global food system to address the future health and wellbeing of our population [4, 5].
The food system is defined as “a system that embraces all the elements (environment, people, inputs, processes, infrastructure, institutions, markets, and trade) and activities that relate to the production, processing, distribution and marketing, preparation and consumption of food and the outputs and outcomes of these activities, including nutrition and health, socioeconomic, and environmental outcomes” [6]. More specifically, there are three identified food system typologies: traditional, mixed, and modern. These typologies are based on distinct inputs, such as natural resources, human capital, agriculture, and food technology; processes that include food production, supply chains, and the food environment; and outputs, such as food purchasing patterns, diet, and health. In recent decades, the transition from traditional to industrial food systems has been linked to globalization, urbanization, policy liberalization, agricultural productivity, and income growth. However, in many ways our current global food systems are failing to provide and ensure safe, nutritious, and affordable foods that are accessible to everyone [7]. In their 2017 report, the International Panel of Experts on Sustainable Food Systems identified five key channels through which food systems were compromising population health and wellbeing: (1) poor and unhealthy working conditions; (2) water, soil, and air contamination and pollution; (3) consumption of unsafe foods; (4) poor-quality diets, and (5) food insecurity and inaccessibility of reliable, nutrition-adequate foods [8].
From these circumstances, a new kind of hunger has appeared, called “hidden hunger” (Table 1). Hidden hunger is the lack of vitamins and minerals that occurs when consumed food lacks the essential micronutrients necessary for growth and development [5]. Globally, almost 2 billion people, mostly in low- and middle-income countries (LMICs), suffer from “hidden hunger.” Together, with existing undernutrition (stunting and wasting) and overnutrition (overweight and obesity), this “double burden of malnutrition” indicates a growing, dire global food crisis [9]. The double burden of malnutrition, driven by poor diet quality, especially affects children and adolescents and undermines their capacity to grow, develop, and learn to their full potential. Some examples of hidden hunger include vitamin A deficiency, which is the main cause of irreversible blindness in children, and iodine deficiency, which can harm a child’s ability to learn [5]. Iron-deficiency anemia in children and adolescents is associated with fatigue and may prevent children from paying attention in class. Unfortunately, the effects of hidden hunger are often invisible or manifest too late for proper recovery, hence the term “hidden” [5].
Table 1. Malnutrition definitions
Tackling and preventing hidden hunger through an integrated, rights-based food systems approach is crucial to adequately address this issue and to ensure optimal growth and development of school-aged children and adolescents today and in future generations [10]. Using the Innocenti Framework on Food Systems for Children and Adolescents (2019) as guidance (Fig. 1) [11], there are various cost-effective, delivery intervention platforms through the food system, including agricultural production and food processing, promotion of enabling food environments, and behavioral change. Importantly, synergistic actions with other major systems, including social protection, water and sanitation, health, and educational systems are necessary for long-term impacts in nutrition and population health. This includes the use of supplementation and disease-control measures to mitigate hidden hunger, as recommended by the World Health Organization (WHO).
Interventions
