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Half of adolescents in some low-income countries are stunted from malnutrition, while school-age children in many of these same countries face a growing problem of excess body weight.

How do the conditions that influence food choices in these countries affect the health of school-age children? We don’t know.

Zulfiqar Bhutta, a professor at the University of Toronto's Faculty of Medicine and a co-director of the Centre for Global Child Health at the Hospital for Sick Children, and his team are trying to answer that question.

They're trying to define the “food environment” in Brazil, India, Ethiopia and other low- and middle-income countries and link it to the health outcomes of school-age children and adolescents.

Bhutta spoke with writer Jim Oldfield about what his research could mean for food policy, child nutrition and global health.

“My hope is that our research helps provide a starting point for the world to achieve the Sustainable Development Goal for nutrition, which is zero hunger by 2030,” he says. “We can’t get there without filling some key knowledge gaps.”

What will this project do?

There is a paucity of evidence on how food systems affect child health in low- and middle-income countries. This research will help us better understand the relationships between these systems and diet-related health outcomes among school-age children. Secondarily, it will enable us to develop a set of indicators to assess and monitor these food environments. We can then test the predictive validity of those indicators in country-specific case studies, with an eye to creating national recommendations to inform programmatic interventions and nutrition policies.

Why is there such a strong need for this data?

The health and nutritional status of young children has improved dramatically over the past 50 years, but we’ve seen much less improvement among adolescents. The Lancet published of papers on maternal and child nutrition in 2013, and although it was clear there has been a productive focus on children under age five, it was also clear that data on adolescence was patchy. It looked as though it would take another 15 to 20 years compile solid data – which was basically the time frame of the United Nations s. Some of us felt that was just too long to wait, and that we could shorten the timeline by synthesizing existing data and developing ways to measure these food systems and more specifically the food environment.

What kind of specifics do you hope to uncover?

Given the World Health Organization’s effort to minimize mass media, marketing and promotion of unhealthy food to children, we know that these aspects of the food environment do influence dietary intake. But to what extent?

Moreover, what about the physical and economic access to food for school-age children and adolescents? These other dimensions, what is termed food availability, food accessibility and food affordability, have been less commonly quantified and associated to diet-related health outcomes in school-age children and adolescents. These are potential environmental entry points for interventions, and there is a dire need for evidence to guide those strategies.    

What stage are you at with this project?

At this point, we have reviewed nearly 25,000 articles and have narrowed it down to 700 that relate to the food environment in low- and middle-income countries – at the household, community and school level. We have divided our efforts into two systematic reviews of literature on school-age children and adolescents; one that will synthesize the impact of food environment interventions on children and diet-related health, and another that will synthesize observational associations between the food environment and diet-related health. We hope to have results for these reviews by the end of the summer.

What are your next steps?

From these reviews, we hope to identify a pool of indicators on which we will seek stakeholder feedback, then test their predictability through a series of country case studies.

What are your long-term hopes for this work?

We’ve witnessed a huge drop in the number of undernourished people globally over the last 20 years, and great progress on maternal and early child mortality. And we’ve seen successful efforts to confront specific nutrient deficiencies. Iodine deficiency is a good example – salt fortification has limited this problem in many parts of the world. Folate deficiency is well-controlled in high-income settings.

But we need more successes like these. My hope is that our research helps provide a starting point for the world to achieve the Sustainable Development Goal for nutrition, which is zero hunger by 2030. We can’t get there without filling some key knowledge gaps.

And you know, this work will be just as important for Canada as for the rest of the world. There are many second-generation immigrants here who come from other places to overcome health issues related to malnutrition. As well, our knowledge of food environments and Indigenous populations is extremely limited. So as our work points out disparities abroad, it should help us fix them at home.

The research is funded by a Public Policy and Child Nutrition Collaborative Grant from the Joannah & Brian Lawson Centre for Child Nutrition.