Addressing micronutrient deficiencies associated with the double burden of childhood malnutrition in China, a combined food system framework

The double burden of malnutrition (DBM) is a concept that describes the increasing prevalence of both undernutrition and overnutrition within the same communities, especially in low- and middle-income countries (LMICs). Both of these elements of malnutrition contribute to the burden of disease. Common to both are deficiencies in micronutrients (MND) such as iron, zinc, and vitamins, all of which are needed for healthy growth and development as well as maintaining general health and productivity. In China, despite rapid economic development, tens of millions living in rural poor communities lack food diversity and are frequently nutrient deficient, whilst urban populations show a rapid rise of obesity owing to unhealthy diets and imbalanced energy intake. Such micronutrient deficiencies (MND) associated with DBM are particularly problematic in children.

Within the "Nutrition First" program under the "Healthy China 2030" national development strategies, interventions such as Ying Yang Bao (YYB), a soybean-based micronutrient supplementation package targeted at children, and biofortified crops with enriched micronutrients iron, zinc, and vitamin A etc., together with nutrition education and food diversity have been developed. These have been shown to be effective at improving nutrition in children affected by malnutrition/MND. However, outside of nutrition trials there is a challenge to promote uptake of these interventions. Combining expertise from the UK and China on nutrition and food systems, the focus of the current research is to determine the barriers to uptake of such interventions and to explore novel approaches to promoting their uptake, with the overall aim of improving child nutrition and health.

Food is a key part of Chinese culture. Some foods that are considered to be healthful, such as sweet potato, millet, etc., have gone out of fashion and are seen as food for the poor. On the other hand, there may be an inherent resistance to unfamiliar food items for children such as YYB, and concerns about safety of food and biofortification. We will test the acceptance of context specific interventions in children in different age groups. In children from deprived areas, the benefits of early exposure to YYB for enhanced acceptance will be tested in children aged 6 months to 2 years old. Acceptance of biofortified foods (zinc+/iron+ wheat and b-carotene+ sweet potato) will be tested in nursery and school children based on the early exposure and uptake hypothesis. For urban school children at risk of obesity, the intervention will focus on increasing the diversity and optimising the nutrient content of the diet. Feasibility testing of an enhanced diet diversity, food supplementation and biofortification, and nutritional knowledge education will be studied using a survey method at school, family and community levels.

Our research will engage with local communities, families and particularly mothers, to explore the determinants of malnutrition and MND, and the social and cultural barriers to uptake of nutrition interventions. When barriers to and drivers of uptake have been identified, photographic exhibitions using a story-telling approach to highlight positive messages will be used to promote the interventions in local communities, with social media campaigns to spread the word and promote engagement. We will develop a scalable food system-based intervention package for malnutrition/MND, and build this into the national food and health policies and guidelines. We will broaden the potential beneficiaries of the nutrition interventions by engaging with experts in Vietnam through communication and capacity-building activities.

Micronutrient deficiency (MND) associated with undernutrition and overnutrition is a global epidemic and huge health burden to the low- middle-income countries (LMICs). The rapid economic development in China has seen a 5-fold increase in obesity between 1995 and 2014 and yet tens of millions of people continue to live in poverty in the western rural areas and suffer from a high prevalence of micronutrient deficiency, especially children. This poses a particularly critical challenge for current and future health in China.
Co-designed and co-produced with our partners across the UK, China and in industry, this project will identify effective ways to scale-up food system based nutritional intervention strategies, and build these into national nutrition policy for the reduction of DBM.
Directly working with these policy-influencing organisations, we will ensure that our research is translated into real-world impact across several areas of society, initially in China but then in Vietnam and in future projects, to other LMICs. Millions of people, especially children, are affected by MND and the DBM. Identifying the best approaches to promoting uptake of effective interventions to reduce MND and the impact of DBM can therefore impact on health and development of millions of children, when adopted as part of national policy. This will be the case for this project as it will feed into the China government's "Nutrition First" strategy, which focuses on improving nutritional status by promoting and encouraging consumption of a healthy, nutritious, and safe diet. This is part of the "Healthy China 2030" national development strategy.
Impacts will include: (1) Improved health in rural and urban poor communities; (2) Improved child development and education; (3) A healthier future society with more productive adults bringing economic gains; (4) Reduced burden on resources of health systems; (5) Greater implementation of sustainable and diverse nutritious food crops; (6) Reduced burden of MND and DBM across LMICs in Asia.
Beneficiaries will include the children and families who receive improved nutrition. The outcome of the project will lead directly to improved health and better development, which will result in more productive adults in the future, bringing wider societal and economic benefits. This will particularly improve the health and economic conditions of poor rural communities, but will also improve health in more affluent communities where childhood obesity is linked to MND. The nurseries and schools will gain knowledge in the promotion of healthful diet to children and students. This not only impact on child health but also improve their cognitive function and student performance. Overall, this will contribute to the health and wellbeing of the society (lifetime of the project to over the coming decades). Further a sustainable and culturally sensitive nutritional intervention guidance into policy to protect against DBM in children will have huge impact on the public health and well-being of local communities and the Chinese population. In a wider context, health care agencies and policy planners will see economic benefits as a result of a reduced need for spending on treatment of diseases linked to MND and DBM. Instead, resources will be freed up for other public health challenges. A healthier population will also lead to improved economic performance that will benefit society as a whole. It is important to note that these benefits will be extended beyond China, with the lessons learned being disseminated to policy makers in Vietnam as the first step in spreading the impact of improved uptake of successful nutrition interventions.
The improved uptake of nutrition supplements and acceptance of biofortified foods will also benefit the agri-food industry by promoting increased variety of food and by providing impetus for development of new biofortified food crops.