Vitamin A, iodine, iron, zinc and folate deficiencies affect billions of children. How can the quality of food be improved?
Vitamins and minerals needed by the body in very small amounts - also known as micronutrients - are vital to human health, advancing physical and intellectual development in many important ways.
Around the world, billions of people live with at least one micronutrient deficiency such as vitamin A, iodine, iron, zinc or folate. The facts speak for themselves. Approximately one third of the developing world's children under the age of five are vitamin A-deficient, leaving them with weakened immune systems and vulnerable to diseases. Iodine deficiency is one of the main causes of mental impairment in children. And 500 million women aged 15 to 49 have anaemia mainly due to iron deficiency, which reduces their productivity, economic potential and reproductive outcomes health. We call this hidden hunger because the deficiencies are not visible.
The causes of micronutrient deficiencies are multiple and interconnected. At the most basic level, the problem is related to an inadequate diet, either in quantity (easy to detect) or quality (not so easy to detect until damage has been done). Throughout the world, people living in poverty do not consume sufficient amounts and variety of nutrient-rich foods, such as meat, eggs, fish, legumes and vegetables, to cover their daily needs, which increase in periods of growth, pregnancy or lactation. And it is not a problem only for the poorest. Micronutrient deficiencies are also frequent in emerging and high-income economies, where overweight and obesity rates are rising, multiplying the burden of disease and disability.
Approaches to dealing with hidden hunger require supply and demand as well as strong political commitment. All are needed for success. On the supply side, finding the right proven interventions for a population and ensuring their availability is essential, especially for the most vulnerable. Supplementation (iron and folic acid tablets during pregnancy), industrial fortification (salt iodisation), point-of-use fortification (micronutrient powders), biofortification (high-iron rice) and homestead gardening (raising chickens, growing vegetables) are some of them.
On the demand side, awareness and action are key. Families, caregivers, policymakers, and healthcare providers from the public and private sectors can all demand action and access to supplies. For farmers, biofortified crops need to be profitable enough for smallholder farmers to adopt and to grow, at minimal risk. Private sector and governments need to provide incentives to support micronutrient interventions and slant food systems towards healthy foods.
When we have so many options for dealing with micronutrient malnutrition, why does it persist? Reasons include:
- Despite our best efforts, hidden hunger remains exactly that - hidden for the vast majority. What is not seen tends to be ignored.
- Fragmentation of effort between different competing "solutions". Each country needs a unique combination of approaches, but each approach has its own champions. Very few organisations have the vision, credibility and authority to get different champions to talk to and work with each other.
- Macro-level policy decisions do not take micronutrients and dietary diversity into account. Small changes in policy could have large consequences for nutrition.
To make real progress on a better quality of nutritious food all over the world we need political commitment. How can we encourage it?
- Generate more data on micronutrient status and dietary intake to help guide programme and policy decisions. This involves the collection and analysis of dietary data and biological samples - a task that new technology has made much easier.
- Expose policymakers to the risks of inaction. The economic arguments are already powerful, but we should also appeal to aspirations for their country's future.
- More tools to help countries decide which combination of approaches are best for them. Governments cannot and do not need to do everything; they need support to ensure impact, safety, and the most efficient use of resources.
- More ways of building bridges within the field, including organisational (stronger collaboration within governments and the United Nations), financial (tenders incentivise different groups to work together) and relational (common training programmes, work exchange initiatives, and interacting with the private sector).
Finally, and just for a moment, we can take a pause and celebrate successful stories in public health nutrition. The success of vitamin A supplementation and salt iodization prove that continued commitment, funding, multi-sectoral integration, collaboration, modernisation and rigorous academic scrutiny can lead to measurable improvements in coverage and, ultimately, to more benefits for the most vulnerable.
Hidden hunger can be overcome, but it means uncovering the problem and joining up efforts. The health and well-being of billions of people depend on it.
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Nutrient-rich foods are missing from diets of people living in poverty, which leads to deficiencies. Photograph: Alamy