Conceptual framework of food systems for children and adolescents

Drivers of food acquisition practices among adolescents in suburban food environments of Lao People's Democratic Republic

BACKGROUND

Dietary shifts among adolescents in low- and middle-income countries are exacerbating the double burden of malnutrition. Understanding the drivers of adolescent food acquisition and consumption practices and their lived experiences of the food environment is crucial for the effective development of targeted interventions and policies.

OBJECTIVE

To explore drivers of food acquisition and consumption practices among adolescents from two suburban schools in the food environments of Phonhong District, Lao People's Democratic Republic.

METHODS

We implemented a Qualitative-Geographical Information System methodology, featuring participatory photography, follow-up photo-elicitation interviews and focus group discussions with 30 adolescents from April to July 2022. Thematic analysis triangulated key themes from photos, maps, and transcripts.

RESULTS

Drivers of food acquisition and consumption included interactions across external, interpersonal, and intrapersonal domains. The six key themes were food availability and accessibility, product properties and convenience, peers and social media, caregivers and household practices, affordability, desirability, and autonomy, and perceptions, beliefs, and social norms. Consumption of ultra-processed foods was driven by the availability and accessibility of these affordable products in schools. By contrast, consumption of fruits and vegetables was driven by parental food practices at home.

CONCLUSION

A comprehensive multi-scalar approach is required to improve adolescent diets and nutrition in the suburban food environment of Lao PDR. This includes restricting the sale of ultra-processed foods in schools, promoting home gardening, increasing caregivers' awareness and engagement with adolescents about the benefits of healthy food choices, and leveraging social media to encourage healthy eating behaviors.

Empowering Healthy Adolescents: A Dietary Adherence Tool Incorporating Environmental Factors Based on Korean Guidelines

Background: Adolescence is a critical period for adopting lifestyle behaviors that influence long-term health. While dietary habits are well-documented, the broader socio-cultural and environmental factors impacting these behaviors are underexplored. This study aimed to develop a dietary adherence tool for adolescents that aligns with the Dietary Guidelines for Koreans, incorporating individual and environmental factors for a comprehensive understanding of dietary behaviors. Methods: A nationwide survey was conducted with 1010 adolescents in Korea to develop and validate a dietary adherence tool based on the Dietary Guidelines for Koreans. Factor analyses and structural equation modeling confirmed the construct validity of the tool, and a grading system was established to evaluate adherence based on survey responses. Results: The survey included participants from 17 regions across South Korea. The original 22 candidate items were revised through factor analysis, resulting in the deletion of 4 items and the addition of 6 new items, leading to a final 24-item tool encompassing three domains: food intake, dietary and physical activity behaviors, and dietary culture. The validity of the revised tool remained intact. The mean dietary guideline adherence score of the participants was 54.5 (SD = 12.1), with domain scores of 39.1 (SD = 14.4) for food intake, 51.6 (SD = 16.6) for dietary and physical activity behaviors, and 66.8 (SD = 15.4) for dietary culture. Conclusions: The dietary adherence tool offers a comprehensive framework for assessing adolescent dietary behaviors by integrating food intake, dietary and physical activity behaviors, and environmental factors. By considering sustainability and family support, it promotes healthier and more sustainable eating patterns among adolescents.

Investigating the Consumer Choices of Gen Z: A Sustainable Food System Perspective

Background/Objectives: Developing nutrition-oriented and more responsible consumer behaviors is crucial for the well-being of current and future generations. Food choice determinants and concerns of Gen Zs-also referred to as Post-Millennials, or Zoomers-were explored from a sustainable food system perspective to identify factors encouraging young people to be on the front line of this much-needed transformation. Methods: Quantitative data were collected with the use of the CAWI method from 650 adults representing Generation Z living in Polish cities. Statistical analysis identified three consumer segments, and cluster (CL) means were statistically contrasted using a one-way ANOVA with Scheffé tests for post hoc comparisons. Results: The research results indicate that the key considerations of food choice in the studied Gen Z sample are taste, price, and health. External factors, such as social media influencers and consumer trends, play a relatively minor role in decision-making. Gen Zs were more aware of the link between their eating patterns and health than the link between their eating habits and the natural environment. Members of the biggest cluster (CL3), constituting 48.3% of the total sample, declared the highest level of agreement with statements referring to links between diet, environment, and health from the food system perspective. This most allo-centered (community-oriented, altruistic) consumer segment, differing significantly with gender to other CLs was more concerned about climate change and protecting the natural environment and open to changing its dietary habits. Conclusions: Implementing research-based policy measures focusing on Generation Z, especially young women, as potential leaders and drivers of food system change is recommended.

From preschool to policy: A scoping review of recommended interventions for a systems approach to improve dietary intake in early childhood

Early childhood is a key opportunity to establish healthy eating behaviors and prevent future non-communicable diseases associated with poor diets. How to effectively intervene in the system of the many determinants influencing children's dietary intake remains unclear. This scoping review aimed to map the determinants of nutrition and eating that have been addressed in early childhood nutrition interventions and identify which of these improve dietary intake. We searched six electronic databases to identify eligible studies published from January 2000 to January 2024. We included studies of any interventions reporting dietary intake among children aged between two and five years. A total of 193 eligible studies were identified and mapped to the Determinants of Nutrition and Eating (DONE) Framework. Parent (n = 97) and child (n = 76) food knowledge and skills were most frequently addressed. Most studies addressing parent (67%) and child (66%) food knowledge and skills reported improvements in dietary intake. Government regulations such as healthy food subsidies, and food advertising and labeling interventions showed promised, with 82% of studies reporting improvements in dietary intake. However, these interventions were predominantly implemented in the United States and Chile. This review provides a comprehensive and systematic map of a range of interventions that positively influence nutritional outcomes in preschool-aged children but recommends further policy-level action globally.

Interpersonal determinants of diet quality and eating behaviors in people aged 13-30 years: A systematic scoping review

Adolescence is an important period of increasing independence, when adolescents experience changing influences of family and friends on their diets as they transition into adulthood. We conducted a scoping review to map the literature on interpersonal determinants of diet quality and eating behaviors among individuals aged 13-30 years. We searched seven literature databases, and following screening, 329 papers were included. Determinants were grouped according to sub-categories of the Determinants of Nutrition and Eating framework: family structure (n = 122), social influences (n = 121), parental behaviors (n = 90), family food culture (n = 83), social support (n = 69), parental feeding styles (n = 24), parental attitudes/beliefs (n = 8), and parental resources/risk factors (n = 6), and we added two new sub-categories: parenting style (n = 74) and partner behaviors (n = 6). Fruit/vegetable (n = 143) and sugar-sweetened beverage (n = 102) intake were the most commonly measured diet outcomes, and breakfast consumption (n = 41) and fast food/takeaway intake (n = 39) the most commonly examined eating behaviors. This review highlights the gaps in the literature, both across the determinant sub-categories and also the relative paucity of longitudinal evidence and lack of evidence in emerging adults, particularly outside of university settings. Future research should focus on these areas to provide stronger evidence to support better design of interventions for this age group.

Bringing down barriers to children's healthy eating: a critical review of opportunities, within a complex food system

This narrative review revises the scientific evidence of recent years on healthy eating in children and adolescents, making sense of promising avenues of action, from a food system perspective. A conceptual framework is provided to better understand how eating habits of children and adolescents are shaped to identify key multisectoral approaches that should be implemented to promote healthier diets. The following influencing factors are discussed: individual factors (physiological and psychological factors, food preferences and food literacy competencies), factors within the personal and socio-cultural food environments, external food environments, and the supply chain. In each section, the main barriers to healthy eating are briefly discussed focussing on how to overcome them. Finally, a discussion with recommendations of actions is provided, anchored in scientific knowledge, and transferable to the general public, industry, and policymakers. We highlight that multidisciplinary approaches are not enough, a systems approach, with a truly holistic view, is needed. Apart from introducing systemic changes, a variety of interventions can be implemented at different levels to foster healthier diets in children through fostering healthier and more sustainable food environments, facilitating pleasurable sensory experiences, increasing their food literacy, and enhancing their agency by empowering them to make better food related decisions. Acknowledging children as unique individuals is required, through interpersonal interactions, as well as their role in their environments. Actions should aim to enable children and adolescents as active participants within sustainable food systems, to support healthier dietary behaviours that can be sustained throughout life, impacting health at a societal level.

A systems thinking framework for understanding rising childhood obesity in the Caribbean

OBJECTIVE

The aim of this study is to develop a systems thinking framework to describe the common complexities of childhood obesity in the Caribbean region and identify potential areas of intervention.

METHODS

Group model building (GMB) is a form of systems science. Trained GMB facilitators in Puerto Rico, the US Virgin Islands, Barbados, and Trinidad and Tobago convened a group of multi-disciplinary stakeholders in a series of virtual meetings in 2021 to elaborate a hypothesis of the system driving childhood obesity represented by causal loop diagrams (CLD). Commonalities and differences between the CLDs from each island were identified and reconciled to create a synthesized CLD.

RESULTS

A single explanatory CLD across the islands was developed and includes nine reinforcing loops. These loops addressed the interconnected role of schools, policy, commercial determinants, community and the personal experience of the child in rising childhood obesity rates.

CONCLUSIONS

Despite differences across settings, there is a core system driving childhood obesity in the Caribbean, as described by stakeholders in GMB workshops. Policy solutions to the problem must be multi-faceted and multi-level to address the interlinked reinforcing loops of the complex system and reduce rates of childhood obesity.

The influence of adolescents' nutrition knowledge and school food environment on adolescents' dietary behaviors in urban Ethiopia: A qualitative study

Adolescence is a critical period of physical, cognitive, and social development that needs to be supported with healthy diets. Dietary behaviours of adolescents can be shaped by their nutrition-literacy and their interaction with parents and peers as well as their school food environment. Therefore, the present study aimed to assess factors that influence dietary behaviours of adolescents in urban Ethiopia. Sex-disaggregated, focused group discussions (n = 70) were conducted in 36 private and government schools (n = 12/city) among adolescents (n = 432) 15-19 years of age in Addis Ababa, Bahir Dar, and Dire Dawa. Photovoice was applied in a subgroup of participants (n = 216) to gain further insights into adolescents' perception of their school food environment. Key informant interviews were conducted among school principals (n = 36). Adolescents had a relatively good nutrition knowledge and recognised the importance of diverse diets, but misperceptions also existed. They identified fruit and vegetables as healthy foods, but their consumption was deterred by food safety concerns. The adolescents identified foods high in salt, fat, and sugar, including processed/packaged foods as unhealthy, but still consumed them frequently due to their taste, affordability, availability and accessibility in and around schools. Both undernutrition and overweight/obesity were linked to social exclusion and bullying in school. Effective behavioural change communication is required to address common misperceptions. School nutrition programs should integrate water, sanitation and hygiene programs to ensure food safety. Regulations promoting healthy eating while discouraging unhealthy dietary behaviours are vital. Interventions to make nutrient-dense and healthy foods available, accessible, and affordable are urgently needed to improve the nutrition and health outcome of adolescents.

Environmental Sustainability of Food Environments: Development and Application of a Framework in 4 cities in South Asia

Background

Food environments, where people directly engage with broader food systems, may be an important contributor to the environmental sustainability of food systems.

Objectives

The primary objectives of this study were to establish a new food environment framework that considers environmental indicators and to assess data availability and gaps using data previously collected as part of a food systems survey in 4 South Asian cities.

Methods

The framework was developed by conducting a structured literature review of previous food environment frameworks and in-depth interviews with content experts (n = 6). The framework and indicators were then mapped to data collected by consumer and vendor surveys using the Urban Food Systems Assessment Tool (UFSAT) in Ahmedabad (India), Pune (India), Kathmandu (Nepal), and Pokhara (Nepal).

Results

We have expanded the sustainability domain within food environments to include consumer travel to food vendors, the presence of food delivery services, policies related to sustainability, vendor food waste, vendor plastic use, vendor utility usage, vendor recycling and waste management practices, and food packaging. Mapping the framework to existing data from 4 cities in South Asia, we found variations in food environment sustainability indicators, particularly regarding consumer transportation to food vendors, the presence of delivery services, and food waste.

Conclusions

Although the majority of food environment research focuses on the availability and affordability of healthy foods, there is an urgent need to understand better how aspects of food environments contribute to environmental goals. When mapping the framework to existing food systems data, we found gaps in data on environmental sustainability in food environments and variation in indicators across settings.

Development of food literacy in children and adolescents: implications for the design of strategies to promote healthier and more sustainable diets

Food literacy has emerged as a key individual trait to promote the transformation of food systems toward healthy and sustainable diets. Childhood and adolescence are key periods for establishing the foundations of eating habits. Different food literacy competencies are acquired as children develop different cognitive abilities, skills, and experiences, contributing to the development of critical tools that allow them to navigate a complex food system. Thus, the design and implementation of programs to support the development of food literacy from early childhood can contribute to healthier and more sustainable eating habits. In this context, the aim of the present narrative review is to provide an in-depth description of how different food literacy competencies are developed in childhood and adolescence, integrating the extensive body of evidence on cognitive, social, and food-related development. Implications for the development of multisectoral strategies to target the multidimensional nature of food literacy and promote the development of the 3 types of competencies (relational, functional, and critical) are discussed.

How are intra-household dynamics, gender roles and time availability related to food access and children's diet quality during the Covid-19 lockdown?

The association between food access and children's diet quality has been documented mainly from its external dimension (e.g., availability, prices, food properties, and marketing). However, existing research has underscored that the external food environment cannot fully account for variations in children's diet quality, even amid the COVID-19 lockdown. It is increasingly evident that elements within the domestic food environment also play a crucial role in shaping this relationship. Specifically, gender roles influence how food is procured and consumed, along with challenges related to time constraints. This study explores the influence of the domestic time-gender axis and household dynamics in food access and children's dietary quality in 14 female-headed households in Santiago, Chile, during the COVID-19 lockdown. Employing a photo-elicitation exercise, we engaged with families residing in the same urban neighborhood but exhibiting varying levels of dietary quality among their children. Our analysis utilized a framework incorporating both socio-ecological food environment and gender theories. Our findings show that within these households, only one unit of "person-time" was available to address all food and caregiving tasks. Due to an unequal gender system, this limited time allocation was disproportionately absorbed by women, who were already burdened with multiple responsibilities. The lack of time favors the consumption of ultra-processed foods and hinders the intake of fresh foods. Other associated intrahousehold dynamics, such as children's fussiness and special diets, accentuates these time scarcity consequences. These difficulties were further exacerbated by strategies adopted in response to the COVID-19 lockdown, however, in families where food-related responsibilities were shared more equitably the lockdown was less disrupting. These results indicate that on top of external food environment policies, comprehensive gender-transformative policies that include food socialization processes are needed to promote healthier diets among all.

Global Food Security and Sustainability Issues: The Road to 2030 from Nutrition and Sustainable Healthy Diets to Food Systems Change

The accomplishment of food/nutrition security for all across sustainable food systems (SFS) is tied to the Sustainable Development Goals (SDGs). SFS is connected to all SDGs via the traditional framework of social inclusion, economic development, environmental safety, inclusivity, and the development of sustainable food systems. We suggest that, for the world to achieve sustainable development, a shift to SFS is necessary to guarantee food/nutrition security for all, while operating within planetary boundaries to protect ecosystems and adapt to and mitigate climate change. Therefore, there is a requirement for original approaches that implement systemic and more participatory methods to engage with a wider range of food system stakeholders. However, the lack of skills and tools regarding novel methodologies for food system transformation is a key obstacle to the deployment of such approaches in practice. In the first part of this review, a summary of some challenges that occur in the governance of food system transformation is given. Through a case study of plant-based proteins and their biological and chemical modification as diets shift towards alternative proteins, we demonstrate that resource-efficient food systems and food waste, through system transformation, are useful in understanding both (i) how food system transformation has ensued and (ii) how the required transformation is prohibited. Finally, we discuss the implications of food system transformation in terms of nutrition and sustainable healthy diets, which are needed to achieve changes in food safety systems in the future. The linkage of food and the environment is evident, focusing on nutrition and sustainable healthy diets. This cannot be accomplished without system change and research towards new foods and, more specifically, new proteins such as plant-based ones and their biological and chemical modification.

Fix my food: An urgent call to action from adolescents on how they experience and want to see change in their food systems

BACKGROUND

Global food systems are failing adolescents. Poor diet quality driving malnutrition among adolescents around the world and the quality of foods eaten by adolescents not only determines their health and development, but also is the foundation of thriving communities. The present study aimed to engage adolescents across low-income, middle-income and high-income countries to determine their lived experience of food, food systems and the challenges they face within their food systems.

METHODS

The study used the Distributed Data Generation method pioneered by the Young and Resilient Research Centre, at Western Sydney University, to conduct workshops with adolescents aged 10-19 years across the globe in collaboration with UNICEF. Participatory workshops were designed to capture qualitative data on adolescents lived experiences and perspectives of their food systems, food sustainability and food security, and how improvements can be made. Thematic analysis was undertaken to analyse qualitative data. Descriptive statistics were generated for demographic data captured.

RESULTS

Six hundred and forty adolescents across 18 countries participated. Three key themes emerged, which included experiences of food, challenges to food systems and strengthening food systems. Adolescents saw potential in empowering communities to create change and contribute to food system transformation. Adolescents called for inclusion in decision-making from local food practice to large global policy development.

CONCLUSIONS

The study results demonstrated how adolescents experience their food systems and want to see sustainable change, although they also want to be a part of the change. Adolescents described that there needs to be an active choice to work with them, listen to their lived experience and across all levels of society strengthen food systems. To achieve this, adolescents need to be involved in decision-making around their food systems for a sustainable future.

Process Evaluation of Food Game: A Gamified School-Based Intervention to Promote Healthier and More Sustainable Dietary Choices

Food Game is a gamified school-based intervention that aims to promote healthier dietary choices (i.e., adherence to the Mediterranean diet) and more sustainable behaviors among high school students in an urban area in Northern Italy. The program consists of an offline and online competition in which groups of students participate in peer-led activities to design and communicate products promoting health and sustainability. This study aimed to examine how the program works in practice, understand its mechanisms of change and assess any variation in student outcomes. A mixed methods process evaluation was conducted. Students completed a three-wave longitudinal survey and participated in focus groups. Program staff and teachers were also interviewed. Qualitative and quantitative data analyses indicate that Food Game?s gamification strategy was successful in engaging students, who felt stimulated by the game, its embedded competition and the self-organized group work. Although no significant change in adherence to the Mediterranean diet was found, pro-environmental behaviors, attitudes and perceived peer approval on healthy eating increased over time. Findings provide preliminary support for Food Game as an acceptable and engaging intervention though there is yet not sufficient evidence that it is also promotes healthier and more sustainable behaviors. The results contribute to the limited evidence base for offline gamified school-based interventions and offer insight into the applicability of the gamification approach as a key motivational strategy in other prevention settings and contexts. Suggestions on how to strengthen the program include dosage increase and addition of activities to promote change on relevant school and community factors.

Rapid review of factors influencing dietary behaviors in Fiji

Introduction

In Fiji, multiple burdens of malnutrition including undernutrition, overweight/obesity, and micronutrient deficiencies coexist at the individual, household, and population levels. The diets of children, adolescents, and adults are generally unhealthy. The objective of this review was to understand how the dietary behaviors of children, adolescents, and women in Fiji are influenced by individual, social, and food environment factors.

Methods

This rapid review was conducted to synthesize existing evidence, identify research gaps in the evidence base, and make recommendations for future research. The Cochrane Rapid Reviews Methods and the updated guideline for reporting systematic reviews were used. The search strategy for this rapid review was based on the Population Context Outcome [P(E)CO] framework, including search terms for population (children, adolescents, and adults), context (Fiji), and outcome (dietary behaviors). Searches were conducted in PubMed, Scopus, PsycINFO, and Google Scholar.

Results

The 22 studies included in this review identified different factors influencing dietary behaviors in Fiji. Individual preferences for processed and imported foods, especially of younger generations, and social dynamics, especially gender norms and social pressure, to serve meat and overeat appeared to be prominent in driving dietary habits. The ongoing nutrition transition has led to increasing availability and affordability of ultra-processed and fast foods, especially in urban areas. Concerns about food safety and contamination and climate change and its effect on local food production also appear to influence dietary choices.

Discussion

This review identified different dynamics influencing dietary behaviors, but also research gaps especially with regard to the food environment, calling for an integrated approach to address these factors more systemically.

Characteristics of food environments that influence food acquisition and diets of women in low- and middle-income countries: a scoping review protocol

OBJECTIVE

This scoping review aims to identify and map characteristics of food environments that influence food acquisition practices and dietary intake of women of reproductive age in low- and middle-income countries.

INTRODUCTION

Due to the disproportionate burden of malnutrition on women of reproductive age in low- and middle-income countries, accelerated progress in improving women's nutrition is required to achieve Sustainable Development Goal 2 "Zero hunger" by 2030. Food environments are increasingly recognized as the key interface between consumers and food systems; however, little is known about the characteristics that influence women's food acquisition and diets in low- and middle-income countries, especially during physiological stages of heightened nutritional requirement, such as pre-conception, pregnancy, and breastfeeding.

INCLUSION CRITERIA

This review will consider quantitative, qualitative, mixed methods, or review studies that report on the influence of food environment characteristics on food acquisition practices and dietary intake of women aged 15 to 49 years in any low- or middle-income country, as defined by the World Bank in 2021.

METHODS

Twenty-one databases across EBSCO, Web of Science Core Collection, and PubMed platforms will be searched. Screening, selection, and data extraction will be performed in duplicate by 2 members of the team, with any discrepancies resolved by group discussion. The patterns of food acquisition and dietary intake in relation to food environment characteristics will be charted, mapped, and summarized in tabular and graphical formats. Findings will inform the refinement of effective food environment conceptual frameworks for this nutritionally vulnerable group.

Resilience and vulnerabilities of urban food environments in the Asia-Pacific region

Rapid urbanisation in the Asia-Pacific region is associated with complex changes to urban food environments. The impact of changing food environments on food purchasing and consumption and the diets and nutritional status of vulnerable groups, especially women and young children, is not well researched in low- and middle-income country cities. This paper aimed to examine: the risks and opportunities for healthy diets for low income populations offered by modernising urban centres; the concept of food deserts in relation to urban food environments in the Asia-Pacific region and how these could be mitigated; and measures to strengthen the resilience of food environments in the region using a case study of the impact of COVID-19 on informal food vendors. Our findings indicate that the dynamic changes in urban food environments in the Asia- Pacific region need to be understood by examining not only modern retail food outlets but also wet markets and informal food outlets, including street foods. Efforts should be made to ensure both modern and traditional outlets provide complementary platforms for convenient, affordable and accessible nutritious foods for urban populations. The resilience of urban food environments to environmental, physical and socio-economic shocks can be strengthened by shortening food supply chains and maximising food production in cities. Support mechanisms targeting urban informal food outlets and street vendors can also strengthen resilience and improve food security. Further research is needed on the impact of urbanising food environments on consumer choices, preferences, diets and health outcomes.

Neighborhood obesogenic environment and cardiometabolic risk in Brazilian children: The mediation role of the mother's body mass index

OBJECTIVE

We aimed to evaluate the association of neighborhood obesogenic and leptogenic environments with cardiometabolic risk clustering among Brazilian schoolchildren, mediated by child's ultra-processed food consumption and the mother's body mass index (BMI).

METHODS

A total of 367 children aged 8-9 years, enrolled in urban schools of Viçosa, Minas Gerais, Brazil, were evaluated. Waist circumference, insulin resistance, blood pressure, high-density lipoprotein-cholesterol, and triglycerides concentrations were measured. The child's ultra-processed food consumption assessment was performed by applying three 24-hour dietary recall. The mother's weight and height values were used to calculate the BMI. The neighborhood income, walkability index, predominantly ultra-processed food stores, public spaces for leisure, and/or physical activities, traffic accidents, crime, and green spaces densities were assessed in four hundred road network buffers around households. From neighborhood and cardiometabolic risk variables, four latent variables were obtained from confirmatory factor analysis: neighborhood "obesogenic", and "leptogenic" environments; "high cardiometabolic risk," and "low atherogenic risk". A structural equation model was used to test the direct and indirect associations between neighborhood environment and cardiometabolic risk clusters.

RESULTS

The neighborhood obesogenic environment had a significant total association (Standardized Coefficient = 0.172, p = .011) and was indirectly associated with the child's "high cardiometabolic risk" cluster, mediated by the mother's body mass index (Standardized Coefficient = 0.066, p = .049).

CONCLUSIONS

Our results reinforce the role of the urban environment on maternal obesity and child's cardiometabolic risk and provide evidence for public health policies aimed to prevent such conditions.

Research priorities for nutrition of school-aged children and adolescents in low- and middle-income countries

PURPOSE

A lack of data, intervention studies, policies, and targets for nutrition in school-age children (SAC) and adolescents (5-19 years) is hampering progress towards tackling malnutrition. To stimulate and guide further research, this study generated a list of research priorities.

METHODS

Using the Child Health and Nutrition Research Initiative (CHNRI) method, a list of 48 research questions was compiled and questions were scored against defined criteria using a stakeholder survey. Questions covered all forms of malnutrition, including micronutrient deficiencies, thinness, stunting, overweight/obesity, and suboptimal dietary quality. The context was defined as research focused on SAC and adolescents, 5 to 19 years old, in low-and middle-income countries, that could achieve measurable results in reducing the prevalence of malnutrition in the next 10 years.

RESULTS

Between 85 and 101 stakeholders responded per question. Respondents covered a broad geographical distribution across 38 countries, with the largest proportion focusing on work in East and Southern Africa. Of the research questions ranked in the top ten, half focused on delivery strategies for reaching adolescents and half on improving existing interventions. There were few differences in the ranked order of questions between age groups but those related to in-school children and adolescents had higher expert agreement than those for out-of-school adolescents. The top ranked research question focused on tailoring antenatal and postnatal care for pregnant adolescent girls.

CONCLUSION

Nutrition programmes should incorporate implementation research to inform delivery of effective interventions to this age group, starting in schools. Academic research on the development and tailoring of existing nutrition interventions is also needed; specifically, on how to package multisectoral programmes and how to better reach vulnerable and underserved sub- groups, including those out of school.

A new dietary guideline balancing sustainability and nutrition for China's rural and urban residents

Diets have important but often complex implications for both environmental quality and nutrition. We establish a production-oriented life cycle model to quantify and compare the farm-to-gate environmental impacts and food nutritional qualities underlying rural and urban diets in China from 1980 to 2019, a period of rapid urbanization and socioeconomic changes. The environmental impacts of rural diets were generally higher than those of urban diets, but this gap reduced after 2000. Environmental and nutritional values varied considerably across the 31 Chinese provinces due to their different food intakes and dietary structures. Dietary changes coinciding with urbanization increased greenhouse gas emissions, eutrophication potential, and nutritional quality, but decreased energy consumption and acidification potential. Based on our results, we propose a new dietary guideline to mitigate environmental impacts and improve nutritional quality.

'I Knew I Should Stop, but I Couldn't Control Myself': a qualitative study to explore the factors influencing adolescents' consumption of sugar-sweetened beverages and sugary snacks from a socio-ecological perspective

OBJECTIVE

To explore the factors influencing Taiwanese adolescents' consumption of sugar-sweetened beverages (SSB) and sugary snacks from a socio-ecological perspective.

DESIGN

This study adopted a qualitative design by using face-to-face, in-depth interviews guided by a semistructured questionnaire.

SETTING

Eight junior high schools in New Taipei City and Changhua County, Taiwan, September to November 2018.

PARTICIPANTS

Fifty-nine participants aged 12-14 years participated in this study.

RESULTS

Reflexive thematic analysis was used to analyse the data. This study identified four themes to address the multifaceted factors that influence adolescents' consumption of SSB and sugary snacks. At the intrapersonal level, physiological factors, psychological factors, individual economic factors and taste preferences were mentioned in connection with people's consumption of SSB and sugary snacks. Positive or negative influences of parents, siblings, peers and teachers on SSB and sugary snack intake were identified at the interpersonal level. The availability of SSB and sugary snacks at home, their availability in vending machines or in school stores in the school environment and participants' access to convenience stores and hand-shaken drink shops in the broader community influenced SSB and sugary snack consumption. Additionally, food culture and food advertising were identified as influencing societal factors.

CONCLUSIONS

Overall, this qualitative study determined not only that the consumption of SSB and sugary snacks is influenced by intrapersonal factors but also that interpersonal, environmental and societal factors affect adolescents' increased sugar intake. The findings are helpful to broaden the options for designing and developing interventions to decrease SSB and sugary snack consumption by adolescents.

Evaluation of Dietary Intake and Anthropometric Status in 1–9-Year-old Children Living in Serbia: National Food Consumption Survey According to the EU Menu Methodology

The Serbian Food Consumption Survey among 1–9-year-old-children was conceptualized and conducted in compliance with the principles, established protocols, and guidelines of the EU Menu project between 2017 and 2021. Valid data were collected for 576 individuals (290 1–3-year-old toddlers and 276 3–9-year-old children). Regardless of age and gender category, the majority (68.80%) of children had normal weights according to the Body Mass Index-for-age classification system. The median daily energy intake was 1406.71 kcal with no differences between the settlement types. The overall median contributions of carbohydrates, protein, and fat to the total energy intake were 47.54%, 14.06%, and 37.88%, respectively. The proportions of the macronutrient intake deviated from the dietary reference values with compliance to the recommendations being particularly poor for fat and fiber. The consumption of energy-dense food groups such as meat and meat products, fat and oil, sugar, and confections was more pronounced among older children. The survey results provide a valuable insight into the nutritional status and dietary habits of toddlers and children 1–9 years old living in Serbia. They may serve as an evidence platform for public health programs, a valuable asset for decision-makers, and a reliable reference to guide nutritional policies, diet monitoring, and interventions targeting this population group in the future.

School and community drivers of child diets in two Arab cities: The SCALE protocol and innovative tools to assess children’s food environments

Background

In the context of the rapid nutrition transition experienced by middle-income countries of the Arab region, children and adolescent’s food choices and dietary behaviors are early risk factors for the development of non-communicable diseases. Assessment of factors influencing food choices among this age group is challenging and is usually based on self-reported data, which are prone to information and recall bias. As the popularity of technologies and video gaming platforms increases, opportunities arise to use these tools to collect data on variables that affect food choice, dietary intake, and associated outcomes. This protocol paper describes the SCALE study (School and community drivers of child diets in Arab cities; identifying levers for intervention) which aims to explore the environments at the level of households, schools and communities in which children’s food choices are made and consequently identify barriers and enablers to healthy food choices within these environments.

Methods

Field studies are being conducted in primary schools, among children aged 9–12 years, in Greater Beirut, Lebanon and Greater Tunis, Tunisia. A stratified random sample of 50 primary schools (public and private) are selected and 50 children are randomly selected from grades 4-5-6 in each school. The study includes surveys with children, parents/caregivers, school directors, teachers, and nutrition/health educators to assess individual diets and the contextual factors that influence children’s food choices. Innovative locally adapted tools and methods such as game-based choice experiments, wearable cameras and neighborhood mapping are used to describe the environments in which children’s food choices are made.

Discussion

The SCALE study will generate contextual knowledge on factors in school and neighborhood environments that influence child dietary behaviors and will inform multi-level interventions and policies to address childhood malnutrition (under-and over-nutrition). By integrating methods from various disciplines, including economics, data science, nutrition, and public health and by considering factors at various levels (home, school, and neighborhood), the study will identify levers for intervention with the potential to improve children’s dietary behaviors. This will help fill existing gaps in research on food systems and consequently guide positive change in Lebanon and Tunisia, with the potential for replicability in other contexts.

The contribution of breastfeeding to a healthy, secure and sustainable food system for infants and young children: monitoring mothers' milk production in the food surveillance system of Norway

OBJECTIVE

The mother-child breastfeeding dyad is a powerful force for achieving healthy, secure and sustainable food systems. However, food system reports exclude breastfeeding and mother's milk. To help correct this omission and give breastfeeding women greater visibility in food systems dialogue and action, we illustrate how to estimate mother's milk production and incorporate this into food surveillance systems, drawing on the pioneering experience of Norway to show the potential value of such analysis.

DESIGN

The estimates use data on the proportion of children who are breastfed at each month of age (0-24 months), annual number of live births and assumptions on daily human milk intake at each month. New indicators for temporal and cross-country comparisons are considered.

SETTING

It is assumed that a breastfeeding mother on average produces 306 l of milk during 24 months of lactation.

PARTICIPANTS

The annual number of live births is from Statistics Norway. Data for any breastfeeding at each month of age, between 0 and 24 months, are from official surveys in 1993, 1998-1999, 2006-2007, 2013 and 2018-2019.

RESULTS

Estimated total milk production by Norwegian mothers increased from 8·2 to 10·1 million l per year between 1993 and 2018-2019. Annual per capita production increased from 69 to 91 l per child aged 0-24 months.

CONCLUSIONS

This study shows it is feasible and useful to include human milk production in food surveillance systems as an indicator of infant and young child food security and dietary quality. It also demonstrates significant potential for greater milk production.

Transforming the German Food System: How to Make Start-Ups Great!

The food system represents a key industry for Europe and Germany in particular. However, it is also the single most significant contributor to climate and environmental change. A food system transformation is necessary to overcome the system’s major and constantly increasing challenges in the upcoming decades. One possible facilitator for this transformation are radical and disruptive innovations that start-ups develop. There are many challenges for start-ups in general and food start-ups in particular. Various support opportunities and resources are crucial to ensure the success of food start-ups. One aim of this study is to identify how the success of start-ups in the food system can be supported and further strengthened by actors in the innovation ecosystem in Germany. There is still room for improvement and collaboration toward a thriving innovation ecosystem. A successful innovation ecosystem is characterised by a well-organised, collaborative, and supportive environment with a vivid exchange between the members in the ecosystem. The interviewees confirmed this, and although the different actors are already cooperating, there is still room for improvement. The most common recommendation for improving cooperation is learning from other countries and bringing the best to Germany.

Examining the Environmental Impacts of the Dairy and Baby Food Industries: Are First-Food Systems a Crucial Missing Part of the Healthy and Sustainable Food Systems Agenda Now Underway?

Food systems are increasingly being understood as driving various health and ecological crises and their transformation is recognised as a key opportunity for planetary health. First-food systems represent an underexplored aspect of this transformation. Despite breastfeeding representing the optimal source of infant nutrition, use of commercial milk formula (CMF) is high and growing rapidly. In this review, we examine the impact of CMF use on planetary health, considering in particular its effects on climate change, water use and pollution and the consequences of these effects for human health. Milk is the main ingredient in the production of CMF, making the role of the dairy sector a key area of attention. We find that CMF use has twice the carbon footprint of breastfeeding, while 1 kg of CMF has a blue water footprint of 699 L; CMF has a significant and harmful environmental impact. Facilitation and protection of breastfeeding represents a key part of developing sustainable first-food systems and has huge potential benefits for maternal and child health.

Drivers of Food Choice among Children and Caregivers in Post-earthquake Nepal

Food systems in many countries are experiencing a shift from traditional foods toward processed foods high in sugar, fat and salt, but low in dietary fiber and micronutrients. There is an urgent need to better understand drivers of changing food behavior, particularly for lower-income countries. This study analyzes drivers of food choice among children and parents in rural Nepal. It uses qualitative data collected through key informant interviews and focus group discussions with school children, parents and teachers. The study reveals substantial changes in food behavior during the past decade with increased consumption of rice, meat, and highly processed snack foods while an increased consumption of fruit and vegetables is not evident. It identifies cash availability is the main driver of increased rice, meat and snack food consumption. The second driver is the 2015 Nepal earthquake, which accelerated the transition from homegrown food to purchased food as people got habituated to eating more meat and snack foods while reconstruction tripled local wages and changed the food environment. This shows how humanitarian assistance in the wake of extreme shocks can unintentionally contribute to unhealthy eating habits. An integrated school and home garden intervention appears to contribute to healthier diets.

Fish Acquisition and Consumption in the African Great Lakes Region through a Food Environment Lens: A Scoping Review

Effective actions for the fishery and aquaculture sectors to contribute toward improving nutrition rely on an understanding of the factors influencing fish intake, particularly amongst vulnerable populations. This scoping review synthesises evidence from 33 studies in the African Great Lakes Region to examine the influence of food environments on fish acquisition and consumption. We identified only two studies that explicitly applied a food environment framework and none that linked policy conditions with the contribution of fish to diets. Economic access to fish was represented in the largest number of included studies (21 studies), followed by preferences, acceptability and desirability of fish (17 studies) and availability and physical access (14 studies). Positive perceptions of taste and low cost, relative to other animal-source foods, were drivers of fish purchases in many settings; however, limited physical and economic access were frequently identified as preventing optimal intake. In lakeside communities, fish were increasingly directed toward external markets which reduced the availability and affordability of fish for local households. Few studies considered intra-household variations in fish access according to age, gender or physiological status, which represents an important knowledge gap. There is also scope for future research on seasonal influences on fish access and the design and rigorous evaluation of programmes and policies that address one or more constraints of availability, cost, convenience and preferences.

Listening to the voices of adolescents for the design of strategies to promote healthy eating: an exploratory study in a Latin American country

OBJECTIVE

To explore adolescents' views about the foods they consume and to identify their ideas about strategies to encourage healthier eating habits.

DESIGN

Individual questionnaires based on open-ended questions and group discussions (6-8 participants) were used to address the objectives. Data were analysed using content analysis based on deductive-inductive coding.

SETTING

Montevideo and its metropolitan area (Uruguay, Latin America).

PARTICIPANTS

Totally, 102 adolescents (aged between 11 and 15 years, 52 % female) recruited at two educational institutions.

RESULTS

Adolescents reported frequently consuming ultra-processed products and fast food although they were perceived as bad for their health, whereas they reported an infrequent consumption of fruits and vegetables. Multifaceted strategies to promote healthy eating habits emerged from adolescents' accounts, including public awareness campaigns, nutrition education programmes, nutrition label standards and regulations, and changes in food availability and affordability.

CONCLUSIONS

Results from the present work suggest that co-creation with adolescents may be an effective way to inform the development of strategies to promote healthier eating habits. The strategies suggested by adolescents were mainly focused on behaviour change communication, who emphasised the importance of social media and the involvement of celebrities and influencers. The need for educational and communication strategies to raise awareness of the social and environmental drivers of eating patterns among adolescents was identified.

Gaps and priorities in assessment of food environments for children and adolescents in low- and middle-income countries

School-aged children and adolescents have complex interactions with their food environments-the point of engagement of individuals with the food system-and are influenced by a diversity of individual, household and organizational factors. Although a wide range of methods have been proposed to define, monitor and evaluate food environments, few are tailored to school-aged children and adolescents. Here, we interrogate published literature on food metrics and methodologies for the characterization of food environments for school-aged children and adolescents living in low- and middle-income counties. We identify key priority actions and potential indicators for better monitoring and evaluation to galvanize policymaking to improve the healthiness of these interactions, which are so crucial to future adult well-being.