At least one in three children is not getting the nutrition they need to grow well, particularly in the crucial first 1,000 days – from conception to the child's second birthday – and often beyond. An increasing number of children and young people are surviving, but far too few are thriving because of malnutrition. To meet the challenges of the 21st century, we need to recognize the impact of forces like urbanization and globalization on nutrition, and focus increasingly on using local and global food systems to improve the diets of children, young people and women.
In the 21st century, children’s malnutrition has three key strands. The first is the continuing scourge of undernutrition. Despite declines in some parts of the world, undernutrition deprives far too many children of the energy and nutrients they need to grow well and is linked to just under half of all deaths of children aged under 5 each year.
The second strand is hidden hunger – deficiencies in essential vitamins and minerals such as vitamins A and B, and iron and zinc. Unseen, and all too often ignored, hidden hunger robs children of their health and vitality and even their lives.
The third strand is overweight and, in its more severe form, obesity. Once regarded as a condition of the rich, overweight now afflicts more and more children, even in some of the world’s least-developed countries. It is also fueling a rise in diet-related non-communicable diseases (NCDs) later in life, such as heart disease, which is the leading cause of death worldwide.2 All three strands of malnutrition – undernutrition, hidden hunger and overweight – are interwoven. They can affect children, families and communities simultaneously and over the course of a single lifetime.
The consequences are profound, not just for the child’s own prospects – in childhood itself and on into adulthood. These forms of malnutrition also share many common causes. These begin with the diets of children and mothers, and stretch out to the ways in which access, affordability and decision-making power are distributed across our societies. Increasingly, we cannot think about the roots of these three strands of malnutrition without talking about food systems – everything that happens to bring food ‘from farm to mouth’. Children’s malnutrition in the 21st century increasingly reflects the reality that too many food systems provide children with too little of the food they do need, and too much of the food they don’t need.
At least 1 in 3 children under 5 is undernourished or overweight and 1 in 2 suffers from hidden hunger, undermining the capacity of millions of children to grow and develop to their full potential.
Globally, at least 1 in 3 children under 5 is not growing well due to malnutrition in its more visible forms: stunting, wasting and overweight.
Globally, at least 1 in 2 children under 5 suffers from hidden hunger due to deficiencies in vitamins and other essential nutrients. Undernutrition continues to exert a heavy toll. In 2018, almost 200 million children under 5 suffered from stunting or wasting while at least 340 million suffered from hidden hunger.
Overweight and obesity continue to rise. From 2000–2016, the proportion of overweight children (5 to 19 years old) rose from 1 in 10 to almost 1 in 5.
The number of stunted children has declined in all continents, except in Africa while the number of overweight children has increased in all continents, including in Africa.
The Triple Burden of Malnutrition
The triple burden of malnutrition – undernutrition, hidden hunger and overweight – threatens the survival, growth and development of children, young people, economies and nations.
Stunting – a clear sign that children in a country are not developing well – is both a symptom of past deprivation and a predictor of future poverty.
Wasting can be lethal for children, particularly in its most severe forms. Contrary to common belief, most wasted children around the world live in Asia and not in emergency settings.
Hidden hunger harms children and women. Iron deficiency reduces children’s ability to learn and iron deficiency anaemia increases women’s risk of death during or shortly after childbirth.
Child overweight can lead to early onset of type-2 diabetes, stigmatization and depression, and is a strong predictor of adult obesity, with serious health and economic consequences.
The greatest burden of all forms of malnutrition is shouldered by children and young people from the poorest and most marginalized communities, perpetuating poverty across generations
The triple burden of malnutrition is driven by the poor quality of children’s diets: 2 in 3 children are not fed the minimum recommended diverse diet for healthy growth and development.
Only 2 in 5 infants under six months of age are exclusively breastfed, as recommended. Breastfeeding could save the lives of 820,000 children annually worldwide.
Use of breastmilk substitutes is of concern. Sales of milk-based formula grew by 41 per cent globally and by 72 per cent in upper middle-income countries such as Brazil, China and Turkey from 2008–2013.
Poor diets drive malnutrition in early childhood: 44 per cent of children aged 6 to 23 months are not fed fruits or vegetables and 59 per cent are not fed eggs, dairy, fish or meat.
Only 1 in 5 children aged 6 to 23 months from the poorest households and rural areas is fed the minimum recommended diverse diet for healthy growth and brain development.
Many school-going adolescents consume highly processed foods: 42 per cent drink carbonated soft drinks at least once a day and 46 per cent eat fast food at least once a week.
The Global changes
Globalization, urbanization, inequities, humanitarian crises and climate shocks are driving unprecedented negative changes in the nutrition situation of children around the world.
Globalization is shaping food options and choices: 77 per cent of processed food sales worldwide are controlled by just 100 large firms. In cities, many poor children live in ‘food deserts’, facing an absence of healthy food options, or in ‘food swamps’, confronted with an abundance of high-calorie, low-nutrient, processed foods.
Poor families tend to select low-quality food that costs less. Because of poverty and exclusion, the most disadvantaged children face the greatest risk of all forms of malnutrition.
Climate shocks, loss of biodiversity, and damage to water, air and soil are worsening the nutritional prospects of millions of children and young people, especially among the poor.
UNICEF and its partners treated more than 3.4 million children with severe malnutrition in humanitarian settings in 2018, from Afghanistan and Yemen to Nigeria and South Sudan. Improving children’s nutrition requires food systems to deliver nutritious, safe, affordable and sustainable diets for all children.
Millions of children are eating too little of what they need, and millions are eating too much of what they don’t need: poor diets are now the main risk factor for the global burden of disease.
National food systems must put children’s nutrition at the heart of their work because their nutritional needs are unique and meeting them is critical for sustainable development.
Financial incentives should be used to reward actors who increase the availability of healthy and affordable foods in markets and other points of sale especially in low-income communities.
Financial disincentives on unhealthy foods can improve children’s diets. For example, taxes on sugary foods and beverages can reduce their consumption by children and adolescents.
Fortification of complementary foods and staple foods with micronutrients can be a cost-effective intervention to combat hidden hunger in children, young people and women.
The Food Environment
Food environments are crucial. When healthy options are affordable, convenient and desirable, children and families make better food choices.
Children, adolescents, young people, parents and families need support to demand nutritious foods, but food environments need to promote and support healthy diets.
Innovative, fun, memorable and engaging communication strategies to promote healthy eating can leverage the cultural and social aspirations of children, adolescents and families.
Legislation plays a key role in promoting good diets for children, such as by regulating the marketing of breastmilk substitutes to mothers and families, and of unhealthy food to children.
The marketing of unhealthy foods and sugar
sweetened beverages is directly linked to growing overweight and obesity in children.
Front of package labelling – visible, accurate and easy to understand – helps children, young people and families make healthier food choices and incentivizes suppliers to deliver healthy food.
Governments need to promote healthy food environments in schools, including healthy meals and limiting the sale and advertising of ‘junk food’ in proximity to schools and playgrounds.
The health, water and sanitation, education and social protection systems also have crucial roles to play in promoting and supporting good nutrition for children, adolescents and women. Investing in nutrition for children and young people is a cornerstone investment if the world is to achieve the Sustainable Development Goals by 2030.
Investing in child nutrition is key to human capital formation because nutrition is central to children’s growth, cognitive development, school performance and future productivity.
A large and young labour force – with a great creativity and productivity potential – is emerging in Africa and Asia. However, malnutrition risks limiting this demographic dividend.
Returns from investment in nutrition are high. For example, every dollar invested in reducing stunting generates an economic return equivalent to about US$18 in high-burden countries.
The Triple Burden of Malnutrition
The children who are not growing well are the victims of the three strands of the triple burden of malnutrition that is rapidly emerging in communities around the world, including in some of the world’s poorest countries. The first strand is undernutrition. Despite some declines, undernutrition continues to affect tens of millions of children. Its presence is visible in the stunted bodies of children deprived of adequate nutrition in the crucial first 1,000 days – from conception to the child’s second birthday – and often beyond. These children may carry the burden of early stunting for the rest of their lives and may never meet their full physical and intellectual potential. Undernutrition is also evident in the wasted bodies of children at any stage of life when circumstances such as food shortages, poor feeding practices and infection, often compounded by poverty, humanitarian crises and conflict, deprive them of adequate nutrition and, in far too many cases, result in death. In 2018, 149 million children under 5 were stunted and almost 50 million were wasted.
The second strand of malnutrition is hidden hunger. Deficiencies of essential vitamins and minerals – often referred to as micronutrients – rob children of their vitality at every stage of life and undermine the health and well-being of children, young people and women. This heavy toll is made all the more insidious by the fact that hidden hunger is rarely noticed until it is too late to do anything. The numbers of children affected by hidden hunger are striking. Based on the most recent data available, UNICEF estimates that at least 340 million children under 5 suffer from micronutrient deficiencies.
The third strand is overweight and, in its more severe form, obesity. The numbers of obese girls and boys between the ages of 5 and 19 have soared since the mid-1970s, rising by between 10- and 12- fold globally. Overweight, long thought of as a condition of the wealthy, is now increasingly a condition of the poor, reflecting the greater availability of ‘cheap calories’ from fatty and sugary foods in almost every country in the world. It brings with it a heightened risk of non-communicable diseases, such as type 2 diabetes and coronary heart disease. Analysis carried out as part of the Global Burden of Disease study suggests that diets lacking adequate nutrition are now the leading cause of death worldwide. Behind all these numbers are the real lives of the children and women.
Surviving, not Thriving
The state of children’s malnutrition in the 21st century can be summed up like this: more children and young people are surviving, but far too few are thriving. They are not thriving in the crucial first 1,000 days, when the foundations for healthy, lifelong physical growth and mental development are laid. And they are not thriving at other crucial development stages of life across childhood and into adolescence. Malnutrition has many causes. A mother’s nutritional status, for example, profoundly affects her child’s survival, growth and development, as does the child’s feeding in the first hours and days of life. For far too many children, the causes of malnutrition also include poor access to essential health services and to clean water and adequate sanitation, which can lead to illnesses that prevent the child from absorbing nutrients.
But to understand malnutrition, there is an increasing need to focus on food and diet, and at every stage of the child’s and young person’s life. The picture that emerges is a troubling one: far too many children and young people are eating too little healthy food and too much unhealthy food. These problems start early on. In their first six months, only two out of five children are being exclusively breastfed, depriving them of the best food a baby can get. When it comes to the ‘first foods’ (or complementary foods) that infants should start consuming at around the age of 6 months, these too are, in far too many cases, not meeting children’s needs. Fewer than one in three children between 6 and 23 months is eating the diverse diet that can support their rapidly growing bodies and brains.
For the poorest children, the proportion falls to only one in five. Among older children, low consumption of fruits and vegetables is widespread. This is true, too, of many adolescents, many of whom also regularly miss or skip breakfast and consume soft drinks and fast food.5 The diets of children today increasingly reflect the global ‘nutrition transition’, which is seeing communities leave behind often more healthy, traditional diets in favour of modern diets.
For many families, especially poorer families, this means an increasing reliance on highly processed foods, which can be high in saturated fat, sugar and sodium and low in essential nutrients and fibre, as well as on ‘ultra-processed’ foods, which have been characterized as formulations containing little or no whole food and which are extremely palatable, highly energy dense, and low in essential nutrients. Often missing from these diets are whole grains, fruit, nuts and seeds, vegetables, and omega-3 fatty acids.8 There is increasing concern about the impact of these diets on human health. Much of the focus is on rising overweight and obesity, but modern diets are also implicated in undernutrition. In Nepal, a recent study suggested that children under 2 may be getting on average a quarter of their energy intake from items such as biscuits, instant noodles and juice drinks, which is lowering their intake of essential vitamins and minerals. Children eating the most of these sorts of snacks and beverages were shorter than their peers.
Making food systems work for children Thirty years ago, the Convention on the Rights of the Child spoke of the need to provide children with “adequate nutritious foods” to combat malnutrition and disease. That goal has not changed. What has changed are the contexts in which this needs to happen, and the realization that food systems are a key – and underappreciated – part of the puzzle.
To make food systems work better for children, we need to understand the unique nutritional needs of children at every stage of life, particularly in the first 1,000 days – but also on day 1,001, and then on through the school years, when a well-nourished child can focus better and learn more in the classroom, and throughout the vital years of adolescence, when physical and mental development again speeds up and when lifelong eating habits are established. To make food systems work better for children, we need to understand the rapidly evolving contexts that are shaping and reshaping children’s diets. Climate change, urbanization and globalization are profoundly altering how and what children eat, as well as the social and cultural values we attach to food.
To make food systems work better for children, we need to respond to the challenges children, young people, women and families are facing around the world – food deserts, the high cost of healthy foods, time pressures, the limited availability of nutrient-rich foods, including fruits and vegetables – and the pressure many children, adolescents and families feel from marketing and advertising. To make food systems work better for children, we need to address the scandal of child labour in agriculture and food production, much of which is hazardous.
In 2016, 108 million children aged between 5 and 17 were engaged in agricultural labour, accounting for 71 per cent of all child labour.15 And to make food systems work better for children, we need to ensure food systems work with, and are not undermined by, all the other systems that affect children’s lives. The health, water and sanitation, education and social protection systems must all work together to provide children and their families with the knowledge, support and services they need to ensure that nutritious diets translate into better growth and development.
When food systems work better for children, we all benefit. Good nutrition can break the vicious intergenerational cycles through which malnutrition perpetuates poverty, and poverty perpetuates malnutrition. Children who are well nourished have a firm foundation from which they can develop to their full potential. When children do that, societies and economies develop better, too. Our goal must be to give children diets that are nutritious, safe, affordable and sustainable.
The World Health Organization recommends that babies be exclusively breastfed for their first 6 months of life, and then introduced to first (or complementary) foods, which gradually replace breastmilk between the ages of 6 and 23 months. Results from the workshop suggest that feeding practices in many instances are not optimal. Almost all of the women breastfed either from birth or within the first 10 days after birth.116 However, around two out of five mothers introduced breastmilk substitutes (BMS) by the time their baby was 8 weeks old, and most were combining breastmilk and BMS (and, often, other liquids) before their baby reached 6 months of age. Most mothers introduced first foods at 6 months of age, but a fifth started before their baby was 5 months old. Some waited until the baby was between 7 and 9 months.
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