About Programs Fellowship News Calendar
Salzburg Global Fellows explore recent advances in addressing the global syndemic and opportunities for novel interventions to improve nutritional status of children
The following article was produced by Salzburg Global Fellows, who attended Healthy Children, Healthy Weight, in 2018. The corresponding author is Margaret Hannah. Other authors include Kathryn Beck, Jeanne d'Arc Bisimwa, Angelica Herrera, Katherine Kreis, Kopano Matlwa Mabaso, Dorji Ohm, Shalini Rudra, Marysol Ruilova, Elvira Thissen, and Henrike Winkler.
Helping children survive and thrive is one of the greatest challenges we face as a global community. Infinitely complex in nature, we are just beginning to understand some of the more nuanced links between health, development, and the environment, and how they relate to health outcomes.
The landmark 2013 Lancet series on Maternal and Child Undernutrition identified this as the leading underlying cause of child morbidity and mortality worldwide[1]. Its publication galvanized the Scaling up Nutrition (SUN) movement among some 90 countries, spurring significant progress in addressing both acute and chronic undernutrition, and to some extent, vitamin and mineral deficiencies.
Yet despite this progress, overweight and obesity and related non-communicable diseases are on the rise. Many countries, most notably low- and middle-income countries, are now facing undernutrition and overweight and obesity, while high-income countries are having limited success in addressing rising rates of overweight and obesity[2].
This paper considers the “syndemic” of inter-related processes between obesity, undernutrition, and climate change[3]. It explores how cultural practices offer opportunities to act at the local level to improve food choices and points to recent developments in nutrition research, which offer new routes to enable current and future generations of children to thrive.
The world food system is under strain in many ways. As the world population grows, so the demand for food rises. Furthermore, as incomes rise, people increase their consumption of animal food sources, which in turn increases pressure on the natural resources of land and water as well as grains, which are used to feed livestock rather than people. An increased use of grains for biofuels is also depleting the available land for food production.
The increasing variability and extremes of climate brought about by global warming are having profound impacts on food security. In particular, the increasing frequency of floods and droughts makes each year’s harvest less predictable and affects yields. It is also leading to large scale migration as pastoralists around the globe have to go further to find food and water for their livestock.
Current food production is highly distorted by agricultural subsidies, particularly in high-income countries. In the USA and European Union alone, over $70 billion is spent each year in direct grants to farmers. These subsidies favor cereals and animal produce over fruit, vegetables, and nuts, which impacts on the price of the latter, even though they are healthier foods.
A further concern is the heavy dependency of modern agriculture on fossil fuels – as fertilizers, pesticides, and fuel for farm machinery. This dependency, as well as the high volumes of methane from livestock farming, make agriculture a heavy contributor to carbon emissions, further exacerbating climate change.
The EAT-Lancet Commission describes the Great Food Transition that is necessary for 10 billion people to live on the planet by 2050 within its ecological carrying capacity[4]. They set out a universal healthy reference diet to achieve this but recognize this can only be achieved if other aspects of food production and distribution are addressed. These include political commitments globally, regionally and locally, a shift from high volume to healthy food production, intensification of agriculture globally, better governance of land use and the oceans, and reducing food waste by half.
Strengthening the policy environment for food production, pricing, processing, and sales is a prerequisite to addressing this syndemic. This is itself a challenge as regulatory policies span many stakeholders in agriculture, government, non-government organizations, and the food industry. In addition, relevant policy areas cover complex international trade agreements, national sectoral policies (around agriculture, food, health and family welfare, women and child development), fiscal policies on taxes, subsidies, government procurement, and pricing. Yet reversing or substantial revision of these policies and subsidies could open up a new era of sustainable food production[5].
Fiscal policies informed by a public health evidence base may have a contribution to play. For example, introducing legislation on a sugar tax, mandatory fortification of foods (such as flour with folate), and control on the advertising, sale, and consumption of harmful products like tobacco and alcohol. In 2018, South Africa came into line with other countries, namely France, Mexico, the UK, and some cities in the United States, in introducing a “sugar tax” on sugar-sweetened beverages as a strategy to curtail the rising obesity rate. The sugar tax is equivalent to about an 11% levy on a can of Coca-Cola. However, the response of the World Health Organization (WHO) shows a clear challenge in the implementation of such taxes. While in 2017, WHO endorsed a 20% tax on sugar-sweetened beverages[6], an independent commission on non-communicable diseases was unable to reach a consensus on the use of taxation to reduce sugar consumption and failed to continue the endorsement of this recommendation[7].
Understanding decisions around the introduction of foods and their cultural meanings opens up a bottom-up approach for addressing nutritional challenges for families and communities.
Culture, defined here as a system of shared understandings that shapes and, in turn, is shaped by experience, plays an important role in families’ and children’s beliefs and practices regarding food selection, preferences, portion sizes, and meal preparation[8][9]. Interventions that fit into families’ cultural understandings are generally more accepted than those that are viewed as belonging to another culture. We examine how interventions in India, Rwanda, and Austria draw on cultural practices and values to impact families’ behaviors related to the provision and consumption of healthy foods.
Interventions focused on pregnant and lactating women and children below six-years-old are provided in Anganwadi Centres in India[10]. Annaprahshan is a traditional Indian ritual that celebrates the onset of weaning. Community health care workers leverage the Annaprahshan community-led celebrations at the Anganwadi Centers to raise awareness among mothers of the importance of timing of weaning and foods that are appropriate and healthy to use[11].
In Rwandan culture, the mother plays the primary role in caring for infants. Women generally carry their children on their backs for at least the first year or until they bear another child, and, at night, mothers sleep with the babies in the same bed. It is estimated that these practices result in 87% of children aged between zero and five months in Rwanda being exclusively breastfed[12]. Interventions in Rwanda focused on weaning and healthy foods for pregnant or lactating women have used the fortified blended food, shisha kibondo, which is used to make a highly nutritious porridge. Shisha kibondo is freely distributed to vulnerable populations in Rwanda with the intent to address malnutrition in children. Community health care workers also use Ongera Intungamubiri, a micronutrient powder of 15 essential vitamins and minerals that can be added to semi-solid or mashed food allowing a care provider the option to “home fortify” food.
Most Austrian households prefer to eat homemade meals, and many families eat regional, seasonal, and organic products[13]. However, many Austrians favor traditional dishes that have high amounts of animal proteins and fat, as well as sweet dishes, cakes, and pastries high in carbohydrates and fat[14]. Community- and national-level campaigns have been launched to change Austrian’s food habits. For example, several parent-child-centers offer workshops focused on nutritional education. “Baby isst mit” (“the baby eats with you”), a nationwide health promotion program rolled out by the statutory health insurance, focuses on pregnant and lactating women and nutrition for children up to three years[15].
New avenues of research are opening up different paths to supporting better nutrition in childhood. For example, studies have examined the role of gut health or enteric dysfunction (inflammation, reduced absorptive capacity, and reduced barrier function in the small intestine) in nutritional status, indicating that a child’s ability to absorb nutrients plays a key role in nutritional status[16].
Increasingly the literature suggests that animal-based proteins have an important role to play in contributing to the fight against stunting. Eggs, for example, are considered a perfect protein and packed with macro and micronutrients such as Choline, that promote the healthy growth of children and in most communities are relatively affordable and accessible[17]. A randomized controlled trial in Ecuador has found that giving an egg a day to children aged between six and nine months, in addition to their existing diet statistically significantly improved child growth outcomes, with stunting reducing by 47% in the intervention arm[18].
New data and recommendations are also emerging regarding the importance of the condition and care practices of the parent or primary caregiver starting in (pre-)pregnancy and into the early years of a child’s life in reducing stunting and overweight[19]. Integrating parental support, psychosocial stimulation of the child and nutrition interventions have the potential to target multiple child outcomes, with some studies showing additive effects of combined interventions over any one approach alone[20].
A further area for intervention is in relation to maternal mental health. Research from a South African cohort study found that women who suffered from postnatal depression were more likely to have stunted children[21]. Maternal depression has been found to negatively impact a pregnant or new mother’s motivation to attend routine health care visits, adhere to chronic medications, bond with her child, as well as persist with exclusive breastfeeding, all of which put the fetus at risk of low birth weight and the infant at risk of malnutrition and stunting.
The relatively new field of epigenetics, which studies biological factors affecting gene control, is also starting to shed light on the long-term effects of in utero conditions – including on metabolic disease in adulthood. A study of babies born to mothers who lived through the Dutch Hunger Winter of 1945, found exposure to an adverse environment during early development and health outcomes in adulthood are mediated by epigenetic factors, showing among other things higher rates of obesity by middle-age[22].
Infant sleep has also been linked to obesity in later life, and several studies have emerged that suggest newborns whose parents receive support to help their children sleep better were less likely to be obese in later life[23].
This paper highlights evidence of existing challenges and offers opportunities to support all children to reach and maintain a healthy weight. In addition to working towards a one-planet diet for all, successful action needs to take into account cultural diversity and specific bio-psycho-social issues affecting families and communities.
[1] The Lancet 2013, Maternal and Child Nutrition, The Lancet, <https://www.thelancet.com/series/maternal-and-child-nutrition>.
[2] Food and Agriculture Organisation of the United Nations 2018, The State of Food Security and Nutrition in the World 2018, Rome.
[3] Swinburn, A, Kraak I, Allender, S, Vincent, A et al. 2019, ‘The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission Report’, The Lancet, vol. 393, no. 10173, pp. 791-846.
[4] Willet W, Rockstrom, J, Loken, B, Springmann, M, Lang, T, Vermeulen, S, Garnett, T, Tilman, D, DeClerck, Wood, A, Jonell, M, Clark, M, Gordon, L, Fanzo, J, Hawkes, C, Zurayk, R, Rivera, J, Vries, W, Sibanda, L, Afshin, A, Chaudhary, A, Herrero, M, Agustina, R, Branca, F, Lartey, A, Fan, S, Crona, B, Fox, E, Bignet, V, Troell, M, Lindhal, T, Singh, S, Cornell, S, Reddy, K, Narain, S, Nishtar, S & Murray, C 2019, ‘Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems’, The Lancet, vol. 393, no. 10170, pp. 447-492, doi:10.1016/S0140-6736(18)31788-4.
[5] Nugent R 2019, ‘Rethinking systems to reverse the global syndemic’, The Lancet, vol. 393, no. 10173, pp. 729-728, doi:10.1016/S0140-6736(18)33243-4
[6] World Health Organization 2017, Taxes on sugary drinks: Why do it?, Geneva.
[7] World Health Organization, 2018, Time to deliver: report of the WHO Independent High-level Commission on Noncommunicable Diseases, Geneva.
[8] Caprio, S, Daniels, R, Drewnowski, A, Kaufman, R, Palinkas, A, Rosenbloom, L, Schwimmer, B 2008, ‘Influence of race, ethnicity, and culture on childhood obesity: implications for prevention and treatment: A consensus statement of shaping America’s health and the obesity society’, Diabetes Care, vol. 31, no. 11, pp. 2211-2221.
[9] Patrick, H, & Nicklas, A, 2005, ‘A Review of Family and Social Determinants of Children’s Eating Patterns and Diet Quality’, Journal of the American College of Nutrition, vol. 24, no. 2, pp. 83-92.
[10] Chaturvedi, A, Nakkeeran, N, Doshi, M, Patel, R., & Bhagwat, S 2018, ‘Determinants of Micronutrient Fortified Blended Food (Balbhog) Consumption among Children 6-35 Months of Age Provided through the Integrated Child Development Services Program in Gujarat, India’, Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive and Social Medicine, vol. 43, no. 2, pp. 97-101.
[11] Chaturvedi, S, Raven, J & Patwardhan, B 2017, ‘Addressing child under nutrition: can traditional practices offer a solution?’, Global Health Action, vol. 10, no. 1, 1-3, doi: 10.1080/16549716.2017.1327255.
[12] National Institute of Statistics of Rwanda (NISR) [Rwanda], Ministry of Health (MOH) [Rwanda] & ICF International 2015, Rwanda Demographic and Health Survey 2014-15, Rockville, Maryland, USA.
[13] Bundesministerium für Nachhaltigkeit und Tourismus 2014, Die Ernährungsgewohnheiten der Österreicher, Bundesministerium für Nachhaltigkeit und Tourismus, <https://www.bmnt.gv.at/land/lebensmittel/qs-lebensmittel/lebensmittelkonsum/ernaehrung_habits.html>.
[14] Rust, P., Hasenegger, V., König, J. (2017). Österreichischer Ernährungsbericht 2017. Department für Ernährungswissenschaften Universität Wien m Auftrag von Bundesministerium für Gesundheit und Frauen.
[15] Crane, R, Jones, K & Berkley, J 2015, ‘Environmental enteric dysfunction: An overview’, Food and Nutrition Bulletin, vol. 36, no. 10, pp. 76-87, doi:10.1177/2F15648265150361S113.
[16] Iannoti, L, Lutter, C, Bunn, D & Stewart, C 2014, ‘Eggs: The uncracked potential for improving maternal and young child nutrition among the world’s poor’, Nutrition Reviews, vol. 7, no. 26, pp. 355-368.
[17] Iannoti, L et al. 2017, ‘Eggs in Early Complementary Feeding and Child Growth: A randomized Controlled Trial’, Paediatrics, vol. 140, no. 1, pp. 1-9.
[18] The Lancet, 2016, Advancing Early Childhood Development: from Science to Scale, The Lancet https://www.thelancet.com/series/ECD2016
[19] Grantham-McGregor, S, Powell, C, Walker, S & Himes, J 1991, The Lancet, vol. 338, no. 8758, pp. 1-5, doi:10.1016/0140-6736(91)90001-6.
[20] Madlala, S, & Kassier, S 2018, ‘Antenatal and postpartum depression: effects on infant and young child health and feeding practices’, South African Journal of Clinical Nutrition, vol. 31, no. 1, pp. 1-7, doi:10.1080/16070658.2017.1333753
[21] Tobi, E, Slieker, R, Luijk, R, Dekkers, K, Stein, A, Xu, K, Biobank-based Integrative Omics Studies Consortium, Slagboom, P, van Zwet, E, Lumey & Heijmans B 2018, ‘DNA methylation as a mediator of the association between prenatal adversity and risk factors for metabolic disease in adulthood’, Science Advances, vol 4, no. 1, pp. 1-10 doi:10.1126/sciadv.aao4364.
[22] Taylor, R, Gray, A, Heath, A, Galland B, Lawrence, J, Sayers, R, Healey, D, Tannock, G, Meredith-Jones, K, Hanna, M, Hatch, B & Taylor, B 2018, ‘Sleep, nutrition, and physicial activity interventions to prevent obesity in infancy: follow-up of the Prevention of Overweight in Infancy (POI) randomized controlled trial at ages 3.5 and 5 y’, The American Journal of Clinical Nutrition, vol 108, no. 2, pp. 228-236, doi: 10.1093/ajcn/nqy090.
[23] Paul, I, Savage, J, Anzman-Frasca, S, Marini, M, Beiler, J, Hess, L, Loken, E & Birch, L 2018, ‘Effect of a Responsive Parenting Educational Intervention on Childhood Weight Outcomes at 3 Years of Age: The INSIGHT Randomized Clinical Trial’, JAMA, vol 320, no. 5, pp. 461-468, doi: 10.1001/jama.2018.9432.