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

Co-investigators

• Professor Louise Dye, School of Psychology
• Dr PuiYee Tan, School of Food Science and Nutrition
• Ms Ling Bai, School of Food Science and Nutrition

External co-investigators

• Dr Wes Lin, University of York;
• Dr Samantha Caton, University of Sheffield;
• 孙静 Professor Jing Sun, NINH, China CDC;  
• 黄建 Professor Jian Huang, NINH, China CDC;  
• 张倩 Professor Qian Zhang, NINH, China CDC;  
• 刘爱玲 Professor Ailing Liu, NINH, China CDC;  
• 王志宏 Professor Zhihong Wang, NINH, China CDC;  
• 杨振宇 Professor Zhenyu Yang, NINH, China CDC;
• Professor You Mao, The China National Health Development Research Center (CNHDR), Beijing, China

Postgraduate researchers

• JianLin Xu
• Rui Ma
• XiaoMian Tan

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 and improved food choice behaviour have been developed. These have been shown to be effective at improving nutrition in children affected by DBM/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 the 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 ß-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 food choice and 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. In the meantime, we will broaden the potential beneficiaries of the nutrition interventions by engaging with experts in Vietnam through communication and capacity-building activities.

In summary, the 3-year BBSRC funded project will assess the increasing double burden of malnutrition (DBM) including under- and over-nutrition, and the micronutrient deficiencies (MND) in infants, nursery and primary school-age children from economically diverse regions in China (Shanxi, Shanxi Beijing, Hebei and Shandong provinces).

We will identify the barriers and drivers for promoting effective uptake and scaling-up of existing food system-based interventions to reduce DBM, including nutrition supplementation, promotion of biofortification, increase diet diversity, and as well as nutrition education to promote for healthy food choice and diet behaviour.

The project has 6 objectives and will be delivered via 6 work packages.

Objectives and Work Packages:

1. To comprehensively assess the extent and determinants of MND within the context of the DBM in multiple rural and urban areas in China (WP1)

2. To analyse the barriers to and drivers of uptake of the nutritional intervention strategies (WP2)

3. To develop acceptable and effective methods to encourage public uptake of the intervention strategy to inform scaling up strategies (WP3)
4. To build an effective and scalable food system-based package into national nutrition health policies and guidelines to tackle DBM (WP4)
5. To encourage knowledge transfer of effective nutritional intervention strategies to the Vietnamese context through partnership building (WP5)
6. The project management (WP6)

Figure 1. The work packages flow chart

The collaborative team

Impact

We anticipate that this project will provide essential policy recommendations to China government for tackling the increasing challenge of DBM. The work will directly contribute to the reduction of DBM in China, also it is our aim to transfer the intervention strategies and knowledge to Vietnam and other developing countries by involving nutrition researchers and policy makers from these countries in this work.

This ambitious project will be delivered through a close partnership with the University of York, University of Sheffield, the China CDC’s National Institute of Nutrition and Health, the China National Health Development Research Center, and outside China, the National Institute of Nutrition in Vietnam and The ILSI South East Asia Region.

The strength of this project is the wide participation from researchers, government policymakers, stakeholders and health managers, public and consumers; the strong partnership between UK and Chinese researchers in a multidisciplinary team spanning nutritional epidemiology, psychology and sociology and public health.

Long term Impacts will include:

• Improved health in rural and urban poor communities;
• Improved child development and education;
• A healthier future society with more productive adults bringing economic gains;
• Reduced burden on resources of health systems;
• Greater implementation of sustainable and diverse nutritious food crops;
• Reduced burden of MND and DBM across LMICs in Asia.

Grant

UKRI GCRF Combined Food Systems Approach to Scaling-up Interventions to Address the Double Burden of Malnutrition Call: grant number BB/T008989/1