When you picture child malnutrition, what do you see? Twenty years ago, the image was arresting: a dangerously underweight child who wasn’t getting enough to eat.
Today, there are still millions of malnourished children, but the picture is changing. While the number of stunted children is falling in every continent except Africa, overweight and obesity are growing in every continent, including Africa, and at a much faster rate. Globally, at least half of all children under five suffer from hidden hunger: a lack of essential nutrients that often goes unnoticed until it’s too late.
One in three children is not growing well because of malnutrition.
In many countries, and even within households, these three forms of malnutrition – undernutrition, hidden hunger and overweight – co-exist. This means that a single country may face the challenge of addressing high rates of stunting, micronutrient deficiencies, and obesity. Or a family may have an overweight mother and a stunted child. These trends reflect what is known as the triple burden of malnutrition, a burden that threatens the survival, growth and development of children, economies and societies.
This burden is only expected to grow. Strikingly, not a single country has made progress in decreasing levels of overweight and obesity in the past 20 years.
We are left facing the question: why are so many children eating too little of what they need, while an increasing number of children are eating too much of what they don’t need?
Over the past several decades, societies have evolved. We are more connected than ever before through global trade markets. More people are moving from rural areas into densely populated cities. More women are thriving in the workforce, while still raising families. And climate change is putting increased pressure on how we live and use natural resources.
Our brave new world has had a profound impact on how food is produced, what food we have access to, and ultimately, what we eat.
Globalization has changed the way we eat. It has rapidly transformed the systems that bring our food from field to families, affecting everything from how food is harvested to how it is displayed in supermarkets. Communities around the world now have access to greater quantities and a wider variety of foods. But with globalization and trade has come an expanded market for junk food and fast foods – as well as extensive food marketing directed at children.
As supermarkets, convenience stores and fast food chains become ubiquitous, families and communities are leaving behind their traditional, often healthier diets, in favour of modern diets often full of processed foods high in saturated fat, sugar and sodium and low in essential nutrients and fibre.
“Everything has pretty pictures on it. Everything has sugar."
Today, more than half of the world’s population lives in cities. Urbanization has caused a rapid shift in diet and lifestyle, with more ultra-processed foods and less physical activity.
The result is a higher prevalence of overweight and obesity among city dwellers, as well as higher rates of diabetes, hypertension and cardiovascular disease. By 2050, 70 per cent of the world’s adolescents will live in cities, more exposed to the marketing of unhealthy foods and more vulnerable to diet-related diseases than ever before.
More and more women are joining the job market, making up nearly 40 per cent of the world’s formal labour force. Yet, almost everywhere, mothers remain responsible for most child feeding and care. They often receive little support from families, employers or society at large. This leaves too many mothers to face the impossible choice of feeding their children well or earning a steady income.
Extreme weather events like floods, storms, droughts and extreme heat have collectively doubled since 1990, and children are disproportionately affected. They are the most susceptible to waterborne diseases, which increase their risk of malnutrition and death.
Climate shocks disrupt food production and food access for rural families – with drought alone causing 80 per cent of damage and losses in agriculture. In areas where people rely on a single staple crop like maize, a shock to food production can wipe out the entire food supply.
Increasingly, the disruption from climate change is forcing families to abandon their farms and move to urban areas, where processed foods and sedentary lifestyles are commonplace. And because food systems account for almost a third of greenhouse gas emissions, our shift to industrial food production is only exacerbating global warming.
If children aren’t eating the right foods, why can’t parents, or even children themselves, simply choose to prepare and eat healthier foods?
The answer lies in understanding food environments.
When we look at a food environment, in other words all of the factors that influence a family’s food choice – from what is available in their area, to how much money they have, to what foods are convenient or familiar – we see that diets are far from being a matter of simple personal preference.
Families living in cities typically buy their food, so their income often determines what they eat. They are more likely to shop at supermarkets, where much of the food is packaged or ultra-processed. For the urban poor, access to healthy food is even scarcer, and many rely on street food laden with fat and salt.
Some families in urban areas live in ‘food deserts’, or neighbourhoods where fresh produce and healthy food markets are nowhere to be found. Others live in ‘food swamps’, where unhealthy choices like fast food and chain restaurants overwhelm and underprice the number of healthy options.
Time and convenience are also factors. A single parent may struggle to both work and put healthy food on the table. Rural women in particular are often forced to balance unpaid farm work with their role as primary caregivers. As children grow, the main influences on their diet shift gradually from parents and other caregivers in the early years to the staff of day-care centres or other care providers for young children. When children enter school, their peers and friends hold more influence.
“I come here because it is the closest store to my house. They sell kefir, cottage cheese, powdered milk, soda, chips, alcoholic drinks, cookies and cigarettes."
One important aspect of the food environment, and a major influence on a child’s diet, is food marketing. Advertisements, food packaging and digital campaigns targeted at children are building demand for junk food, fast food and sugary drinks. This rise in food marketing is directly linked to the increase of childhood obesity.
Children are exposed to a huge volume of marketing for unhealthy foods every day. A recent study conducted across 22 countries found that for every one advertisement for healthy foods, there were four promoting unhealthy foods. This disparity is even greater in high-income countries like the United States and the United Kingdom.
Lower income countries are also seeing a rapid rise in unhealthy food consumption. From 2011 to 2016, fast-food sales grew by 113 per cent in India, 83 per cent in Viet Nam and 64 per cent in Egypt.
In comparison to traditional television and print marketing, digital marketing poses a unique challenge. Globally, one in three internet users is estimated to be a child. With the rise of smartphones, food marketers have a direct channel for advertising that can precisely target children, and is available to them almost all of the time.
Without effective regulation, this constant stream of food marketing – on TV, in print, on digital channels – is impossible for children to escape. Government legislation appears to be the most effective way to reduce unhealthy food sales, and the World Health Organization urges governments to commit to ending childhood obesity by using proven approaches promote better nutrition and to regulate marketing of unhealthy food to children.
Most forms of malnutrition across all parts of the world – from rural plots to city blocks – are rooted in poverty and inequity.
Children who live in extreme poverty in low income countries, especially in remote areas, are more likely to be underfed and malnourished. They are least likely to have access to safe water, sanitation and healthcare. Because of their deprivation, they are less likely to finish school, more likely to get sick, and ultimately, more likely to remain in poverty.
“Others are eating fish, but I am able to provide only rice. I know it’s not good, but that’s all I can provide.”
Malnutrition disproportionately affects poorer, disadvantaged children in high income countries, too. In the United States, childhood obesity is more common in families with lower education and income levels. In England, rates of childhood overweight and obesity are more than twice as high in the poorest areas. These areas also have five times more fast food restaurants than the most affluent areas. In many cases, healthy foods are more expensive than unhealthy options.
The cycles of poverty and malnutrition span generations.
A mother who is underweight or anaemic is more likely to have a child who is stunted. Her child will be less likely to grow up strong and healthy, to excel in school, and to gain job and economic opportunities. As a result, that child is more likely to remain in poverty, more likely to be malnourished, and more likely to have stunted children, too.
Similarly, children born to overweight mothers face barriers to healthy growth. Studies from around the world have shown an association between mothers who are overweight and overweight children in the next generation. Children’s physical and psychosocial functioning in late adulthood has also been linked to overweight mothers. Today, being overweight is the most common risk factor of pregnancy.
But good nutrition can break the vicious cycle of poverty and malnutrition – in just one generation. With proper care and nutrition, children of malnourished parents can still grow to a healthy height. In order for that to happen, women and girls, especially adolescent mothers, need support and guidance on nutrition before pregnancy, both for their own well-being and to make sure their children get the nutrition they need in the crucial first 1,000 days of life.
Malnutrition can cause permanent, widespread damage to a child’s growth, development and well-being. Stunting in the first 1,000 days is associated with poorer performance in school, both because malnutrition affects brain development, and also because malnourished children are more likely to get sick and miss school. Hidden hunger can cause blindness (vitamin A deficiency), impair learning (iodine deficiency) and increase the risk of a mother dying in childbirth (iron deficiency). Overweight and obesity can lead to serious illnesses like type 2 diabetes and cardiovascular disease.
And this disruption to children’s physical and cognitive development stays with them into adulthood, compromising their economic prospects and putting their futures at risk.
Collectively, the loss of potential and productivity has huge implications for the broader socio-economic development of societies and nations. It undermines countries’ ability to develop ‘human capital’, or the overall levels of education, training, skills, and health in a population. And the loss is significant.
The average lifetime lost earnings associated with stunting is US$1,400 per child, but can be over US$30,000 in wealthier countries. Economic losses in low- and middle-income countries from diseases related to overweight and obesity, including heart disease, cancer, diabetes and chronic respiratory disease, will reach more than US$7 trillion over the period 2011–2025.
Cumulatively, the estimated impact on the global economy of different forms of malnutrition could be as high as US$3.5 trillion a year, or US$500 for each individual.
By contrast, there are numerous examples of how better nutrition is associated with improvements in children’s school performance. From China to Tanzania, from Guatemala to the United States, multiple studies have shown how better nutrition improved rates of school enrolment, attendance, and performance in areas like mathematics and reading.
The investment case for addressing malnutrition is a strong one. It would cost just an additional US$8.50 per child per year to meet global targets for eliminating stunting in children under five.
This investment is not only small in comparison to annual expenditure on advertising by food and restaurant multinational corporations, but it also has an impressive rate of return. Every dollar invested in reducing stunting generates estimated economic returns equivalent to about US$18 in high-burden countries.
Good food and nutrition are not only the foundation of children’s health and the development of society at large, they are also a child’s basic human right.
We as communities, parents, governments, food corporations, marketers and global citizens have a collective responsibility to put children’s needs at the heart of our food systems.