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

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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.