href="#ulink_9d067e23-dde8-56f9-b594-e79d5fc09147">6]. Food environment dimensions include food accessibility, food availability, food promotion, food policy, food pricing, and food safety.
Personal and external food environment interventions target the built and natural physical environments, legal and political environments, socioeconomic, and cultural environments. Food systems offer many entry points to improve children’s nutrition, and these environments are the points with which children and their families directly interact, including in the home, school, workplace, and consumer and retail spheres.
Consumer and retail food environments inadvertently shape food access, availability, affordability, and media promotion. Through laws and policy, governments should ensure multilateral and bilateral trade and investment agreements are aligned with encouraging healthy, micronutrient-rich, and safe food environments. At the same time, evidence-based subsidies and food taxation have become strategies to minimize food deserts and swamps. Additionally, improving public health nutrition literacy through national and local social and behavior change communication and food-based dietary guidelines all serve to increase awareness and influence consumer behavior [6].
At the household level, decision making and purchasing power relating to food, sociocultural beliefs, as well as intra-household food allocation, are key factors in addressing hidden hunger. Adolescents, but especially children, may not have full autonomy and choice over what is made available to them and what they consume. This includes what is available in their homes, what their parents or providers purchase, and what the household can afford. In a LMIC context, girls are at a greater risk for micronutrient deficiencies due to cultural and social norms that prevent equitable food distribution [5]. In parallel, globally, school-aged girls more often than school-aged boys do not enroll for or consistently attend school [24]. Therefore, interventions and social safety-net programs delivered through the school system, such as school feeding programs or increased availability in school cafeterias of micronutrient-rich foods like fresh fruits and vegetables, which offer an opportunity to improve the micronutrient status, are not advantageous to out-of-school children.
In addition, with nutrition transition on the rise globally, school food environments have become frequent sites for unhealthy, micronutrient-poor food access, availability, and promotion. In a review and meta-analysis of unhealthy food and beverage marketing interventions to children, there was a statistically significant increase in dietary intake (mean difference 30.4 kcal, 95% confidence interval 2.9–57.9) during or shortly after exposure to advertisements [25]. This finding led to the development of 12 recommendations adopted by the World Health Organization and endorsed by the World Health Assembly aimed at reducing the impact of marketing foods high in saturated fats, transfatty acids, free sugars, or salt to children. Examples of environmental interventions specific to school-aged children and adolescents include policies that incentivize school vendors (tuck shops, canteens) to offer healthier food options, and the removal of advertisements and media which promote unhealthy eating.
Behavioral Change
While efforts to improve accessibility and availability of healthy food options are essential to improve nutrition, behavior change in children and adolescents and their consumption practices are paramount to effectively address hidden hunger. This demographic should be equipped with knowledge and awareness of healthy and unhealthy food options, to guide their preferences and life choices, not only in their childhood and adolescence, but also into their adulthood. Children who consume fruits and vegetables in their childhood are more likely to maintain these healthy habits into adulthood, and to implement these habits with their children in their own households [26]. However, the low consumption of fruits and vegetables replaced by high consumption of micronutrient-deficient foods amongst children and adolescents is alarming. In LMICs, about 46% of adolescent girls eat fast-food at least once a week, 42% drink carbonated soft drinks at least once a day, with most skipping breakfast [27]. Moreover, the State of the World’s Children 2019 Report by UNICEF conducted workshops with more than 450 youth from 18 countries, evaluating their knowledge and understanding of what constitutes healthy or unhealthy food. The workshops pinpointed the limited understanding and knowledge of children and adolescents regarding the nutritional qualities of the foods they consume, with the majority unable to properly assess if a food item was healthy or unhealthy for at least one-third of their consumed food items [5].
Targeting behavior in school-aged children and adolescents is especially important given the unique transitional periods in growth and development at this age. When children begin attending school, they are also more aware of and take some responsibility for their dietary choices and intake. During this “middle childhood” period (ages 5–9 years), not only do children begin establishing eating habits and knowledge, but also experience steady continual growth and development. Thus, it is vital that this age group is well informed, supported, and encouraged to make healthy choices. Similarly, the adolescent period (10–19 years of age) is an extremely important and rapid time of physical and psychosocial development, including puberty. This period is marked by increased nutritional needs and demands for both boys and girls; boys have higher nutrient demands due to increased bone growth and muscle mass and a faster growth rate, while girls experience growth spurts and have greater micronutrient demands, such as iron, with the onset of menstruation [27]. Special considerations should be with adolescent girls living in LMICs given the fact that 16 million girls aged 16–19 years and 2.5 million girls under the age of 16 years give birth every year. This adolescent period is also characterized by increased autonomy and a greater disposable income to purchase unhealthy food items, as well as peer pressure and social desire to fit in among social groups and body image issues that influence dietary choices and intake.
In order to address hidden hunger and optimize the diets and nutrition of children and adolescents globally, positive behavior change must be achieved. This is dependent on many factors, including people’s knowledge and understanding, perceptions, and preferences of what is healthy and unhealthy, existing eating patterns, taste preferences, appetite and levels of physical activity, and cultural norms and practices of food preparation [5]. As such, nutrition programs and interventions that target children, adolescents, and caregivers should not only provide nutrition information, education, and counselling, but also work in tandem with cultural and social norms and traditions. For example, protecting and encouraging the preservation of traditional food preparation and cooking practices, such as sprouting and soaking of seeds, can increase bioavailability of vitamins and minerals [6].
The Way Forward
Although the Sustainable Development Goals and the United Nations Decade of Action on Nutrition (2016–2025) have prioritized nutrition, greater efforts and intentionality must be made to address the growing crisis of malnutrition and hidden hunger to reach our goals in the next 5 years, especially in school-aged children and adolescents living in LMICs. The nexus between the food system and hidden hunger in this specific demographic is complex and influenced by many macro-level factors, such as national policies, effects of climate change, and conflict settings on food security and nutrition, industrialization on agriculture, and large-scale processes of food production, distribution, and marketing; as well as micro-level factors, including the personal and external food environments with which they interact, unique physiological needs, and increasing autonomy over food choice and intake.
