to Address Hidden Hunger through the Food System
Agriculture and Biofortification
Agriculture is the foundation to all food systems and is a critical aspect in the provision of healthy, sustainable, safe diets for children and their families globally. Although modern large-scale, industrialized, agricultural systems have exponentially increased in productivity (agricultural intensification), there are several notable implications to continuing with business-as-usual, including erosion of biodiversity, climate change, water depletion, land degradation, and increased pollution [12, 13]. Importantly, designing biologically integrated agroecosystems that rely on internal cycling of nutrients and energy and improved soil functioning will maintain an economically viable, but also sustainable, adaptable, and resilient production system. This can be achieved through structural shifts within the system and mobilizing efforts towards crop diversification [12].
Fig. 1. The Innocenti Framework on Food Systems for Children and Adolescents.
Currently, two-thirds of the world’s caloric intake is attributed to three staple foods – rice, wheat, and maize [7]. However, in order to address hidden hunger, dietary diversity is key. Conservation of genetic and varietal diversity of crops allows for improved system stability and, intuitively, availability of macro- and micronutrients from diverse foods. By extension, this strategy has the potential for greater impact amongst smallholder farmers [12]. Today, 4 out of 5 of the world’s rural poor subsist from agriculture as smallholder farmers. Through increasing crop species richness, smallholders not only contribute to the sale of diverse crops, but also their consumption in the household. Empirical evidence from eight developing countries illustrates a positive correlation between the number of crops cultivated, household income from crops, and the two indicators for dietary diversity, after adjustment for household characteristics [14].
Despite this, there are important considerations of such agrobiodiversity strategy on hidden hunger impact, as addressing diversity on the farm does not infer diversity in diets [15]. Determinants, such as market access (proximity, type, price-to-wage ratios, seasonality, consumer preferences), land size (including intra-familial subdivision), and women’s involvement in smallholder farming, drive great heterogeneity in nutritional outcomes, and should be considered to ensure fair access to dietary diversity and better nutrition for everyone. As women have substantial involvement in farming in developing countries, households headed by women, with direct influence on income and resource allocation decision making, show greater positive influences on household and child dietary diversity, as compared to households headed by men [12, 15]. Receiving greater dietary diversity and better nutrition in the home may better mitigate the negative influences, and subsequent poor dietary intake, children and adolescents may face in other environments.
However, it is important to note that despite agrobiodiversity, the reliance on calorically dense staple foods with inherently low micronutrient content is problematic for resource-poor populations. Therefore, biofortification, the process of selectively breeding staple food crops with higher micronutrient content crops, either through conventional plant breeding, genetic manipulation (transgenic), or agronomic interventions (nutrient-rich fertilizer application), has been positioned as a valuable long-term approach to combating hidden hunger, particularly in rural populations. Evidence from HarvestPlus indicates that at the end of 2017, approximately 6.7 million farming households were reached with biofortified planting material, benefiting about 33 million people in 14 countries across Africa, Asia, and Latin America and the Caribbean. In fact, mainstreaming biofortification through public and private programs, policies, and investments has produced over 290 biofortified crop varieties [16]. Examples of successful biofortification implementation include the vitamin-A-fortified orange-fleshed sweet potato (OSP), iron-fortified rice, and zinc-fortified wheat. Furthermore, foliar treatment of crops with micronutrient cocktails (zinc, iodine, selenium, and iron) has recently been shown to increase the yield and micronutrient concentration of wheat in six countries (China, Pakistan, Mexico, India, Turkey, and South Africa) [17].
In terms of improving the micronutrient status of children, biofortification of rice with iron alone or in combination with other micronutrients may make little or no difference to the risk of developing anemia. However, iron fortification may reduce the risk of iron deficiency and increases mean hemoglobin concentrations in populations aged 2 years and above [18]. In addition, efficacy studies have demonstrated that consuming vitamin A-biofortified OSP has resulted in increased circulating beta-carotene, and has a moderate effect on vitamin A status, as measured by serum retinol across all age groups in Uganda and Mozambique [19, 20]. Future areas of investigation include identifying sensitive measures of plasma zinc concentration, as the current biomarker has limitations [16].
Food Supply Chain
Rapid globalization and urbanization in developing countries have incited major changes to the landscape of food, especially transformations in food processing and modernized supply chains. This is observed upstream with trade liberalization and foreign direct investments by transnational food and beverage companies, including grocery and fast-food retailers. Downstream, a systemic shift in the composition and packaging of foods, as well as the ease of acquiring these foods is apparent. In the context of hidden hunger, reduction of processed and ultra-processed foods, as well as the introduction of large-scale fortification, are strategic solutions to ensuring children and adolescents meet their nutritional requirements [21].
Specifically, large-scale food fortification (LSFF) efforts have targeted the introduction of iron, vitamin A, folic acid, and iodine through various staples, including wheat, oil, rice, sugar, and salt to increase the micronutrient content of consumed foods. In some cases, fortification has been mandated and regulated by governments in response to evidence of population or subpopulation deficits in micronutrient deficiencies. In a recent review and meta-analysis, LSFF showed positive impacts on functional health outcomes in children and adolescents, including anemia and goiter in LMICs [22, 23]. Sustainable implementation of LSFF requires continual monitoring and quality control to ensure high compliance and effectiveness.
Food Environments
The food environment is a complex adaptive system, influenced by the wider food system, whereby various industries and actors operate interdependently and adaptively, and their interaction is often shaped through space and time. Food environments are especially dynamic and opportunistic in LMICs as a significant proportion of purchased and consumed food is acquired through traditional domestic channels, such as informal and unregistered vendors, wet markets, and street stalls [
