Dalla Lana School of Public Health

Rising rates of food insecurity, with deteriorations in diet quality, micronutrient deficiencies, and other forms of malnutrition, in part stem from fundamental, complex, and dynamic changes in food systems¹²³. Current food systems perpetuate interactions with suboptimal food environments historically shaped by deeply rooted structural, social and environmental inequities, prohibiting equitable access to nutritious and safe foods, and that almost everywhere favour exposure to inexpensive, nutrient-poor, fast-food, convenience foods high in fat, sugar and/or salt, and sugar-sweetened beverages⁴⁵⁶. For children and adolescents, this environmental exposure leads to an increased reliance and greater preference for these types of foods, as well as poorer eating patterns such as increased snacking and eating-away-from-home⁷. Together, this has contributed to the rising nutrition transition and double burden of malnutrition (DBM), especially in LMICs⁸.

Alignment of co-benefits at the intersection of Health and Environments

Through a series of country case studies, this project aims to generate a holistic narrative of change to food systems by conducting in-depth analyses of food system drivers and determinants on the DBM in children and adolescents (0-19 years) in LMICs. Countries will be selected based on optimal (positive outliers) or suboptimal (negative outliers) progress in reducing the DBM in children and adolescents.

Drawing on interdisciplinary and intersectoral expertise, this proposal will leverage effective research partnerships and engagement with experts at all stages, to triangulate and corroborate data through local knowledge generation and dissemination. Further, this project seeks to develop a composite score to monitor performance across the global food system and related systems (health, macroeconomic and geopolitical, environment and climate, social protection, education and water, and sanitation and hygiene systems) to help identify potential synergies and to reveal trade-offs between economic, environmental and social sustainability. As there are no one-size-fits-all solutions, country-level experiences provide illustrative examples of what it takes – in very practical and innovative ways – to transform food systems to reduce the DBM. Findings from each case study will allow for the development of comprehensive policies aimed at both the food and natural environments, resulting in a more coordinated governance of food and co-benefits to human health and the environment.

Relevant conceptual theories, methodological tools, frameworks, approaches, gender and equity considerations

Spotlight on references:

High Level Panel of Experts on Food Security and Nutrition, Nutrition of the Committee on World Food Security. Nutrition and Food systems. Rome: FAO; 2017 [cited 2021 09 01]. Available from: https://www.fao.org/policy-support/tools-and-publications/resources-details/en/c/1155796/

Carter A et al. A framework for identifying and learning from countries that demonstrated exemplary performance in improving health outcomes and systems. BMJ Glob Health 2020;  5(12)

Conceptually: the High Level Panel of Experts Food Security and Nutrition Framework will be used as guidance for both phases of work⁹. This framework illustrates the influence of food system drivers (structural factors including demographic change, political and economic environment, technological advances, natural resource management and social and cultural norms), determinants (processes and conditions including food supply chains and food environments), influencers (individual factors including behaviours) and interactions (dynamic feedback loops) on the diets of children and adolescents. 

Methodologically: the Exemplars in Global Health approach, developed by Gates Ventures¹⁰ is an evidence-based framework which identifies exemplar countries or ‘positive outliers’ (i.e., those that reduced a specific health outcome prevalence beyond the projected gains associated with general economic growth). This approach employs diverse and exhaustive methodologies (descriptive and causal quantitative analyses of survey datasets, administrative data and ecological variables; qualitative data collection and analyses; policy and program analyses; and systematic literature reviews)¹¹¹². Taken together, these tools will provide the opportunity to re-evaluate how to measure food system drivers, which drivers/indicators are most important and deduce feedback loops that can create compounding impacts on malnutrition.

Given the systemic inequities within food systems, this project will consider a diverse range of LMICs in country case study selection, which represent vulnerable and marginalized populations (e.g., migrant, internally displaced, refugee, and urban slum child and adolescents) in order to create meaningful impact in reducing the DBM. Women tend to be overrepresented among the poorest and constitute a large proportion of the informal food sector labor force with food systems¹³. Furthermore, women, young children and adolescents are also the most nutritionally vulnerable segments of the population given their higher nutrient needs, which puts them particularly at risk of under- and over-nutrition in times of crises. Therefore, we will conduct gender-specific descriptive and causal analyses, while ensuring adequate representation of women in qualitative interviews and stakeholder consultations in country-level activities.

Measurement of impact

 
This methodologically rigorous study will fill a global evidence gap in the current understanding of food systems in various ethnically diverse and dynamic LMICs, and how it is interlinked to the double burden of malnutrition in children and adolescents, mediated by diet. Measuring impact will entail:

• Identifying synergies and trade-offs within food systems and public health nutrition, as well as related systems within each country.
• Facilitating an adaptive process of system changes, aligned with national strategies and combined with contextual policy innovations. This process needs to be inclusive, with particular attention paid to vulnerable groups such as women, who make up a large proportion of the informal food sector labor force.
• Tracking a set of core national and subnational food system and related system indicators to benchmark progress over time to inform decision-making of policymakers, implementers and funders. 

Challenges/barriers and knowledge gaps impeding shifts towards healthier and sustainable food systems

As this proposal relies on both primary and secondary food systems data, various limitations exist. Often, secondary data are not always available or as robust as the methodology and technical advisors dictate. In cases of missing or low-quality data, we will rely on proxies whenever possible. Furthermore, there are ethical considerations in conducting primary data (i.e., multifaceted interviews and narratives) to produce a description of experiences¹⁴. This is particularly true when highly sensitive issues are concerned such as food accessibility and affordability in vulnerable populations. Thus, building trust and confidentiality with the in-country partners and the communities, knowing the local culture and micropolitics, and detecting our own biases as we engage in the research process, will be important steps in collecting valid and reliable data¹⁵. Furthermore, there are potential challenges in stakeholder uptake and coordination. To mitigate this, we will convene a technical advisory group (TAG) at the outset of the project. Their role is critical to ensure rigour, offer new ideas and avenues for exploration, and facilitate connections with in-country research partners and dissemination partners. TAG members are identified by project teams through self-nomination or through snowball sampling approaches, whereby experts are recommended by others in the field. The TAG is continuously engaged through all aspects of the project, including methods and inferences, strengths and limitations, prior knowledge, discourse on dissemination and partnerships.