Children’s Diets in a Changing World
Ann Nutr Metab 2022;78(suppl 2):40–50 Received: January 21, 2022
DOI: 10.1159/000524328
The Changing Landscape of Children’s Diet and
Nutrition: New Threats, New Opportunities
José M. Saavedra
Johns Hopkins University School of Medicine, Baltimore, MD, USA
Key Messages
• Despite progress in child wasting and stunting these persist,
and micronutrient deficiencies remain high. Overweight and
obesity prevalence continue rising and will soon overtake
moderate underweight and wasting prevalence in children.
• The diets of most children in most countries are inadequate
and reflect global disparities.
• Most children with obesity, wasting, stunting, and
micronutrient deficiencies live in lower income countries and
in lower income communities within any country.
• Nutrition-related risks are the leading cause of global
mortality and disability.
• Climate change remains a major risk to food systems, while
food production remains the greatest contributor to climate
change.
• Major changes in food systems and participation of all sectors
will be needed to reverse these trends.
Keywords
Children · Nutrition · Malnutrition · Obesity · Diets · Climate
change · Pandemic
Abstract
Background: Over the last 30–40 years, we have seen an im-
provement in global child undernutrition, with major reduc-
tions in wasting and stunting. Meanwhile, childhood obesity
Karger@karger.com © 2022 S. Karger AG, Basel
www.karger.com/anm
Accepted: March 23, 2022
Published online: May 24, 2022
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has dramatically increased, initially in high-income popula-
tions and subsequently in the more economically vulnerable.
These trends are related to significant changes in diet and
external factors, including new environmental threats. Sum-
mary: Obesity rates first increased in older children, then
gradually in infants. And in the next couple of years, there will
be more overweight and obese than moderately or severely
underweight children in the world. The changes in childhood
nutritional landscape are a result of poor diets. Today, almost
50% of the world’s population consumes either too many or
too few calories. Dietary disparities between countries result
in disparities of under- and overnutrition and impact the
global health landscape. Most children with obesity, wasting,
and micronutrient deficiencies live in lower income countries
and in lower income families within any country. High ener-
gy-low nutrient diets are contributing to the increase in non-
communicable diseases, which will manifest later in this gen-
eration of children. In 1990, child wasting was the #1 leading
risk factor for mortality for all ages, and high BMI was #16;
today, they are #11 and #5, respectively. COVID-19 and cli-
mate change are new major threats to global nutrition. Cur-
rent and future efforts to improve the state of child nutrition
require multisectoral approaches to reprioritize actions which
address current trends and emerging threats.
© 2022 S. Karger AG, Basel
Correspondence to:
Jose M. Saavedra, jose @ saavedra.pe
Introduction
The nutrition of children is a major marker and determinant of
the health, wellbeing, and productivity of individuals and the
progress of society. The need for “early intervention” in child
nutrition gathered increasing attention in the last half-centu-
ry: first, with a focus on increasing child survival, then with
greater emphasis on correcting nutritional deficits, and only
in the last 3 decades, addressing both deficits and dietary ex-
cesses. This was partly driven by the increased scientific un-
derstanding that nutrition in early life is a determinant of long-
term adult health. Thus, the challenges, the needs, and the
focus have evolved with changing times. This paper reviews
the changes in the landscape of child nutrition over the last
several decades, the state and changes of their diets, the evo-
lution of the health consequences resulting from these
changes, as well as in the threats – old and new – hindering
our progress. Finally, it briefly discusses the opportunities we
have and the areas needing action or improvement to better
the health and nutrition of children.
The Changing Landscape of Child Nutrition
The survival and health of children have been a key marker
and driver of global development of human society for thou-
sands of years. In just the last 200 years, we have seen extraor-
dinary changes and accelera-
tions in these markers. Around
40–50% of children did not sur- Over the last 4 decades,
vive to age 5 years in the 1800s.
In 1900, this figure was 36%; in
obesity has increased in
2017, it is 4%. In many ways, it every country in the world,
can be argued now is the best
time for children to be alive [1, and may very soon overtake
2]. However, despite these im- undernutrition in prevalence
provements, this still means
that, on average, 15,000 chil-
dren younger than 5 years die each day [2]. Half of these
deaths are attributable to undernutrition, particularly wasting
or thinness, which has been the most persistent visible and
measurable underlying factor in this mortality [3].
Severe wasting is a marker of nutritional deficits, often as-
sociated with increased infectious morbidity and mortality.
Stunting is a marker of children’s poor somatic and cognitive
development, contributing to disabilities and low productivity.
These “anthropometrically-defined” forms of malnutrition are
frequently accompanied by micronutrient deficiencies, typi-
cally less visible, and harder to measure. These deficiencies,
termed by some “hidden hunger,” in themselves, may be a
Children’s Diets and Nutrition in a Changing World
greater contributor to disabilities than stunting or wasting
alone [4]. The prevalence of all these forms of undernutrition
has decreased significantly in the last few decades, and we
have seen the emergence of overnutrition: overweight and
obesity in children. Over the last 4 decades, obesity has in-
creased in every country in the world, and may very soon
overtake undernutrition in prevalence, and become the major
contributor to chronic disease and the global burden of dis-
ease [5]. The world simultaneously bears today a burden of
undernutrition (caused by lack of macro and/or micronutri-
ents) and overnutrition (primarily caused by an excess in en-
ergy intake vs. expended).
In addition, these nutritional disturbances are also chang-
ing in where they manifest. The distribution of different forms
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of malnutrition and their rate of change is also changing rap-
idly, leading to rapid situations of “transition” within given
populations and geographies, requiring rapid adaptation of
countries to address them. Not only is the prevalence of dif-
ferent forms of malnutrition changing, but it is doing so in the
same place. More than one form of malnutrition can coexist
within the same country, the same city or community, the
same household, and even the same child. For the purposes
of this review, we will adopt the more broad UNICEF definition
of “child” as “any person under the age of 18” found in https://
www.unicef.org/child-rights-convention/convention-text-
childrens-version. Examining the situation in some more de-
tail over the last few decades:
For Children under 5 Years of
Age
Globally, the prevalence of
stunting and wasting has mark-
edly declined to their lowest lev-
els ever. From 2000 to 2015, the
global prevalence of low birth
weight decreased at an average
rate of 1.23% annually, from
17.5% to 14.6% [6]. For children
under 5 years of age, from 1990 to 2010, the global estimated
prevalence of stunting decreased from 39.7% to 26.7%. From
2000 to 2020, the prevalence of stunting dropped from 33.1%
to 22% in children below 5 years of age. Today, 45.4 million
children under 5, or 6.7% have wasting [7], down from 52 mil-
lion children or 8% in 2011, and an estimated 58 million in
1990 [8]. While today’s prevalences are the lowest ever esti-
mated, this represents 149.2 million children under 5 years of
age who are stunted and 45.4 million who are wasted [9]. By
2025, the number of stunted children is estimated to be 131
million, while the prevalence of wasting will remain well above
5% [7].
Ann Nutr Metab 2022;78(suppl 2):40–50 41
DOI: 10.1159/000524328
 The change on the other end of the nutrition spectrum has
also been considerable. For children 2–4 years of age, be-
tween 1980 and 2015, the global prevalence of obesity almost
doubled, from 3.9% to 7.2% in boys and 3.7 to 6.4% in girls. It
was initially driven by increases in high-income countries,
where it has recently slowed down, while the rates have in-
creased in countries of lower incomes [10]. Looking at a more
recent timeframe, from 2000 to 2020, global obesity rates for
children under 5 years of age increased only slightly, from
5.4% to 5.7% or 33.3 to 38.9 million children, with the fastest
growing prevalence in Asia and Africa. Today, the global prev-
alence of wasting in children under 5 years of age stands at
6.7% and of overweight very close at 5.7% [9]. The Brookings
Institution estimates that by 2030, 90 million children aged
2–4 years, equal to 22% of the world’s total, will be overweight
[11].
For Children 5–19 Years of Age
We only recently have good global estimations of nutritional
status in this age-group. Regarding thinness, expressed as
body mass index over the last 30 years, mean BMI trends have
shown increases in almost every country, including most
countries in Africa. It is estimated that the absolute number of
underweight children (low weight for age) peaked around the
year 2000 and has since been decreasing [12]. Southeast Asia
and sub-Saharan Africa have the greatest persistent preva-
lence of children with low BMI. The trends are also improving
as related to age. In most countries, the prevalence of thin-
ness decreases as children enter adolescence, and in some
low- and middle-income countries (LMICs), it disappears by
the age of 19 years [13]. Looking at a more recent time frame,
from 2010 to 2020, the global prevalence of thinness among
children and adolescents has declined more modestly, from
12.8% to 10.9% in boys and 9.6% to 8.9% in girls (aged 5–9
years) and from 13.4% to 12.3% in male adolescents and from
8.1% to 7.9% in female adolescents (aged 10–19 years) [7].
Data on stunting in older children are more limited. Surveys
including children 12–15 years of age from 57 LMICs between
2003 and 2013 showed a global prevalence of stunting of 10%
[14]. Stunting in adolescent girls (15–19 years) in LMICs varies
significantly, from 52% in Guatemala and 44% in Bangladesh
to 6% in Brazil [15]. Nevertheless, in the last 30 years, there has
been a significant gain in height for boys and girls in most
countries. In the largest recent global studies, most countries
showed that height was at or above the WHO median for chil-
dren after 5 years of age, with girls doing better than boys [12,
13].
From 1975 to 2016, the global prevalence of obesity in 5-
to 19-year-olds increased eightfold, from 0.7% to 5.6% in girls,
and from 0.9% to 7.8% in boys [12]. This translates to an in-
42 Ann Nutr Metab 2022;78(suppl 2):40–50
DOI: 10.1159/000524328
crease from 5 to 50 million girls and from 6 million to 74 mil-
lion boys over this time. However, since about 2000, the rate
of increase has begun to slow down in high-income countries
and recently plateaued, especially in North America, north-
western Europe, and “high-income English-speaking” coun-
tries. Meanwhile, the increase has averaged 400% per decade
in southern African countries, albeit starting from a low base-
line. While prevalence remains higher in higher income coun-
tries, in absolute numbers, the great majority of overweight
and obese girls and boys are in LMICs [12]. In round terms,
from 2000 to 2016, the proportion of overweight 5- to
19-year-old children rose from 1 in 10 to almost 1 in 5 [9].
Given these trends, a 2017 estimate suggests that in just the
next couple of years, if post-2000 trends continue, the world
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may swing to having more obese than moderate and severe-
ly underweight children and adolescents [12]. The potential
effect of the coronavirus pandemic on these figures is yet to
be seen and is discussed below.
The state of micronutrient adequacy still suffers from an
even greater lack of adequate and reliable population-based
data on biomarkers of micronutrient status, hindering moni-
toring of micronutrient deficiencies. The information for most
micronutrient status biomarkers is scarce and often outdated.
Nevertheless, deficiencies of iron, vitamin A, vitamin D, zinc,
iodine, and folate remain very high globally. The World Health
Organization (WHO) estimates that 25% of school-age chil-
dren (around 305 million children) have anemia and that 50%
of it is primarily associated with iron deficiency. Prevalence of
anemia among girls and women of reproductive age remains
a major problem, with little or no progress in the last 10 years
[7].
Global Disparities
For all ages, and in all settings, all forms of malnutrition coex-
ist, increasing disparities between nations. It is common to
find under- and overnutrition coexisting in the same country,
the same community, the same household, even in the same
child. Micronutrient deficiencies are not uncommon in stunt-
ed or obese children. The trend changes mentioned above
have led to increasing disparities in the burden of malnutrition.
In 2020, 94% of children under 5 years of age with stunting,
97% of those with wasting, and 75% of those who are over-
weight lived in Asia and Africa [9]. Disparities are also evident
in high-income countries. For example, in the USA, 16.7% of
Hispanic 2- to 5-year-olds were obese, compared with a pop-
ulation average of 8.4% [16]. Thus, most LMICs confront all
forms of malnutrition, and independent of the country, most
children with all forms of malnutrition are from the most so-
cio-economically disadvantaged communities.
Saavedra
 These changes in children’s nutritional situation are not
only reflected in different prevalence but in the degree of the
differences of nutrition markers between countries. The dif-
ference in BMI between countries with the highest mean BMI
(e.g., Pacific Island countries, the USA, Chile, South Africa) and
lowest mean BMI (e.g., India, Bangladesh, Ethiopia, and Chad)
was 9–10 kg/m2; that is a difference of more than two stan-
dard deviations. The estimated difference in height of 19-year-
olds between countries with the tallest populations (e.g., the
Netherlands, Denmark) and the shortest (e.g., Timor-Leste,
Laos, Guatemala, Bangladesh) was 20 cm [12, 13].
In summary, the global nutritional landscape is changing
and changing faster than at any other documented time, par-
ticularly in children. Today, all forms of malnutrition coexist in
all countries and settings. The last 30 years alone show sig-
nificant decreases in wasting and stunting and rise of over-
weight and obesity, which increasingly affects younger chil-
dren. The rise in obesity has been dramatic and has gradually
shifted from higher to lower income countries and to lower
income groups within countries. If current trends continue, in
the next couple of years, there will be more overweight and
obese children than moderately or severe underweight chil-
dren [12]. But, already today, the gaps and disparities on the
burden of global malnutrition are very large. Most children
with obesity, wasting, stunting, and nutrient deficiencies live
in the most vulnerable countries or communities within a
country.
The Changing Diets of Children
Nutritional status is dependent on dietary intake, and today,
this intake is globally imbalanced. It is estimated that 48% of
the global population eats too many or too few calories, lead-
ing to global population rates of overweight (26%), obesity
(13%), and underweight (9%) [7].
The global dietary scenarios are also changing. Breast-
feeding, adequate complementary feeding, and eventually
the family diet are all part of the dietary determinants of the
nutritional status of children discussed above. In the first
months of life, exclusive breastfeeding remains the ideal diet
and form of feeding for infants. Here, there has also been
some progress. From 2000 to 2015, the global prevalence of
early exclusive breastfeeding increased from 36% to 43% [17].
Globally, estimates of exclusive breastfeeding showed some
progress, with 41.6% of infants under 6 months being exclu-
sively breastfed in 2018, compared with 37% in 2012 [18].
Breastfeeding duration is still shorter than desirable, particu-
larly in high-income countries. More importantly, more than
60% of infants in LMICs receive earlier than recommended
Children’s Diets and Nutrition in a Changing World
complementary feedings or inadequate breastmilk substi-
tutes, which, in unsanitary conditions contribute to undernu-
trition and disease [19]. Over the last 20 years, infant formula
consumption has increased in high- and middle-income
countries, while remaining low in low-income countries, par-
ticularly sub-Saharan Africa and South Asia. Animal milk con-
sumption under 6 months has also decreased significantly in
LMICs [20].
Fruit and vegetable intake
is still about 50% below the
recommended five servings
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per day
At a global level, for all ages, the Global Nutrition Report in
2021 indicates that diets are far from being healthy and have
not improved over the last decade. Assessing diets based on
WHO-UNICEF guidelines, fruit and vegetable intake is still
about 50% below the recommended five servings per day, and
legume and nuts intakes are each more than two-thirds below
recommended (two servings per day). On the other hand, red
and processed meat intake is on the rise, close to five times
the recommended high level (one serving per week). Simi-
larly, the intake of sugar-sweetened beverages is increasing
globally. The report concludes that despite variation between
regions, no region meets recommendations for healthy diets.
Only milk and fish intakes are within recommended ranges [7].
Dietary data for infants and young children have histori-
cally been sparse and difficult to obtain. Global and regional
complementary feeding is particularly scant. A recent UNICEF
report, based on a large number of representative dietary sur-
veys in 135 countries and territories, reported on the state and
progress of the diet in infants under 2 years of age in LMICs.
In this report, about two-thirds of children 12–23 months in
these LMICs were still being breastfed on a given day. Twenty-
seven percent of children aged 6–8 months were still not fed
any solid, semi-solid foods, although this was a small im-
provement from 33% in 2010. In children between 6 and 23
months, the progress over the last 10 years (2010–2020) has
been minimal. The percentage of children consuming eggs,
fish, and/or meat on a given day was 32% and 36% and veg-
etables and/or fruit 48% and 53% in 2010 and 2020, respec-
tively. The report also noted “unhealthy processed foods and
drinks are widely accessible and heavily marketed” in a select
group of countries studied [21].
The progress in trends has been marginal. The percentage
of children in LMICs fed the minimum recommended number
Ann Nutr Metab 2022;78(suppl 2):40–50 43
DOI: 10.1159/000524328
of meals or snacks throughout the day was 54%, a 3% increase
from 2010. Twenty-four percent of children are consuming a
minimally diverse diet (receiving 5 of 8 recommended food
groups) – compared to 21% 10 years ago. Of 50 countries as-
sessed, significant improvements in diet diversity were report-
ed in 21 countries, and 10 countries had a substantial drop in
the percentage of children consuming a minimally diverse
diet. In summary, the report concluded that diet quality in
LMICs had improved very marginally over the past 10 years.
More detailed global estimates of energy and specific nutrient
intake are still needed [21].
In higher income countries there have been few, but more
in-depth, nutrition surveys. In the USA, the Feeding Infants
and Toddlers Study, a large cross-sectional nationally repre-
sentative survey, finds patterns similarly replicated for other
higher income countries. It shows improvements in breast-
feeding initiation (above 80%) but low exclusivity and duration
(only 15% at 4–6 months of age). On a given day, more than
20% of infants below 2 years of age will not consume a serv-
ing of fruit or vegetables on a given day, while approximately
half consume fruit juice and one-quarter to one-third con-
sume sugar-sweetened beverages [22]. The mean reported
intake of energy for infants 0–6 and 6–12 months of age,
sexes combined, was about 25% higher than the estimated
energy requirements for the children in the 50th percentile for
these two age ranges. For 12- to 24-month-olds, it was 30%
higher [23].
On the other hand, except for persistent concerns of iron
adequacy, micronutrient intake in infants is largely adequate.
Preschoolers have a high intake of sodium and saturated fat
and lower than desired intakes of vitamins. High intakes of
retinol, zinc, and folic acid are common [22, 23]. Estimates in
Mexico, as an example, show that 50% of children 6–48
months of age did not consume fruits, and 80% did not con-
sume any vegetables on a given day. However, 80% con-
sumed sugar-sweetened beverages after 12 months. A total
of 61% of infants 6–12 months old did not meet the estimated
requirement for iron [24]. Surveys in urban China also show
low breastfeeding rates (47% after 6 months), with increasing
consumption of infant formulas and fortified milks. Similarly,
about 50% of infants did not consume any fruits or vegetables,
and 38% of toddlers did not consume any fruits on a given day
[25].
In summary, as expected, dietary changes over time have
correlated with changes in nutritional status. In low-income
scenarios, energy intake has improved, but high-quality pro-
tein and micronutrient intake improvement have been mar-
ginal. In middle-income groups, excesses in energy-dense
but nutrient-poor diets have increased. Diet gaps remain or
have widened. One-quarter of children in some poorer coun-
44 Ann Nutr Metab 2022;78(suppl 2):40–50
DOI: 10.1159/000524328
tries do not receive solid food at 6–8 months, while the aver-
age energy intake of infants is 25% higher than requirement in
some richer countries. Regardless of the region, diet diversity
remains low and with no improvements. Most children in the
world are not consuming fruits and vegetables most days [21–
23].
Thus, most countries are going through a rapid transition
phase, requiring rapid adaptation to deal with persistent un-
dernutrition and rising obesity. Such rapid changes and transi-
tions will require understanding and addressing multiple fac-
tors driving the change and their impacts. These include,
among many, economic and social changes, education, cul-
tural barriers, and especially changes in our food systems [26].
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The Changes in Health Consequences of Child
Nutrition
The nutritional consequences of inadequate diets in early life
are clear: undernutrition and overnutrition lead to specific
short-term effects on morbidity and mortality. However, the
impact of nutrition on child development has long-term
health consequences into adulthood and remains critical for
the well-being and development of individuals and society.
The changes in diet and nutritional landscape in children have
therefore also brought about changes in the health landscape
of the global population.
Both under- and
overnutrition in early life can
lead to permanent structural
and functional changes that
result in chronic disease
It is beyond the focus of this paper to discuss the growing
concept of the developmental origins of health and disease
and the many mechanisms of early nutrition programming of
health. But, suffice it to say that both under- and overnutrition
in early life can lead to permanent structural and functional
changes that result in chronic disease [27, 28]. The causes of
poor health and mortality of the past, particularly infectious
diseases, have been replaced by an epidemic of noncommu-
nicable diseases (NCDs). Cardiovascular diseases, diabetes,
cancer, and chronic respiratory diseases, leading to disabilities
and premature death, dramatically impact healthcare costs
and the economic burden of countries. NCDs are collective-
Saavedra
ly responsible for almost 70% of all deaths worldwide. Nearly
three-quarters of all NCD deaths occur in LMICs countries
[29]. The changes in diet and nutrition, particularly in early life,
are the most critical underlying and mechanistic factors for
the development of chronic NCDs. Therefore, early life, par-
ticularly gestation through the first 2 years (the first 1,000
days) and other periods of dynamic changes in growth and
development (such as the transition to middle childhood and
adolescence) are particular “windows of opportunity” in nutri-
tion that are relevant to long term health, productivity, and
well-being [30].
The Global Burden of Disease (GBD – a large global re-
search consortium that tracks worldwide death and disabil-
ity) reported in 2019 the ten
highest risks factors associated
with the highest number of Overnutrition is the highest
deaths worldwide. Of these, six
factors are nutrition-related:
contributor to disability, and
high plasma glucose, high high BMI is, by far, the
blood pressure, high BMI, high
LDL cholesterol, child and ma- fastest-growing risk for
ternal malnutrition, and “di- disability worldwide
etary risks” (e.g., low consump-
tion of fruit and vegetables,
high consumption of sugar-sweetened beverages, high salt
intake). The other four include tobacco and alcohol use, air
pollution, and kidney dysfunction. Comparing the GBD
mortality trends from 1990 to 2019, the most significant
declines in associated deaths were linked to improvements
in child growth failure, household air pollution, unsafe wa-
ter, and sanitation. The largest global increases in mortality
were associated with high fasting plasma glucose, and high
BMI. When assessing disabilities (measured in disability-ad-
justed life-years, DALYs), the GBD estimated that in 1990,
child wasting, low birth weight, and prematurity were the
number 1st, 2nd, and 3rd global causes of DALYs, consider-
ing all ages. Today, they are the 11th, 4th, and 6th, respec-
tively, in large part related to the significant reductions in
child mortality as a result of immunization, primary health
care and living standards since 1990. On the flipside, in
1990, high BMI, high fasting glucose, and high cholesterol
were the 16th, 11th, and 18th cause of disability. Today, they
rank 5th, 3rd, and 8th. So, today, considering all age-groups,
overnutrition is the highest contributor to disability, and
high BMI is, by far, the fastest-growing risk for disability
worldwide.
For children, however, despite improvements, malnutri-
tion persists. For children aged 0–9 years, the three leading
risk factors for attributable DALYs were all related to undernu-
trition, including child wasting and micronutrient deficiencies
Children’s Diets and Nutrition in a Changing World
[5]. In summary, malnutrition in all its forms, which includes
obesity, undernutrition, and dietary risks for NCDs, is already
the biggest cause by far of health loss globally.
The Emerging Threats to Child Nutrition
Diets and nutritional outcomes in children are determined by
parents’ and caregivers’ food choices and feeding practices
and eventually are determined by individual dietary behaviors.
These are influenced by multiple external factors that shape
these behaviors – not discussed here – but ultimately, they
require food security, access, and affordability of foods suf-
ficient to fulfill an adequate diet.
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Agriculture and production, dis-
tribution, processing, marketing,
retail sales, preparation, con-
sumption, and waste disposal or
recirculation are all critical envi-
ronmental components of food
systems – all of which have dra-
matically changed in recent
times – determine food security
and the ultimate intake of nutri-
ents [31]. Of the many threats which directly affect global nu-
trition and health, climate change and global pandemics are
today of particular relevance.
Food Systems and Climate Change
Climate change per se has direct effects on health, related to
extreme weather, and to the droughts and flooding which
impact food-borne and other infectious diseases. However,
the impact on food insecurity brought about by crop failures,
reduced food production, extreme weather events, and con-
sequent undernutrition are potentially devastating. In parallel,
countries transitioning transitions from lower to higher in-
comes are experiencing rapid urbanization and increased
motorized transportation, leading to lower physical activity
and greater obesity rates. The United Nations estimates that
in 2007, for the first time in human history, more people in the
world lived in urban rather than in rural areas. Today, over 55%
of humans live in cities. By 2050, it is projected that less than
one-third of the world will live in rural areas [32]. Conversely,
food systems are a major contributor to climate change. It is
estimated they account for one-third of all greenhouse gas
emissions. Livestock alone account for 12–19% of green-
house gas emissions. Different foods also have different ef-
fects. Meat and dairy products require more resources and
generate larger emissions than plant-based foods. Socioeco-
nomic improvements have led to dietary patterns of popula-
Ann Nutr Metab 2022;78(suppl 2):40–50 45
DOI: 10.1159/000524328
tions, which include increasing consumption of meat, dairy,
and other processed foods, whose production is associated
with high greenhouse-gas emissions. Preserved, frozen, and
transported fruits and vegetables increase greenhouse gas-
ses, and energy required for collection and management of
food waste compounds the problem [33, 34].
Through multiple simultaneous and interacting health
risks, climate change threatens to reverse years of progress in
public health and sustainable development. More critically, it
further increases the differences and disparities since LMICs
are likely to be more affected by climate change, while high-
income countries are greater contributors to greenhouse
emissions. Given the many interwoven drivers and multiple
components of food systems, better approaches to address
multiple sectors in society are needed [35–37].
In summary, nutrition, health, and climate change are inti-
mately linked in a complex interaction, recently termed “The
Global Syndemic” of obesity, undernutrition, and climate
change. The Lancet Commission publishing this report [33]
called for collective multisectoral actions to address this “syn-
demic” and “stimulate the reorientation of human systems to
promote health, equity, economic prosperity, and sustainabil-
ity” and offered specific broad recommendations to address
the drivers of this syndemic [33, 34, 36].
The COVID Pandemic
In November of 2019, after China reported the first cases of
the SARS-CoV-2 virus, which causes coronavirus disease
(COVID-19); the infection spread globally, causing more than
5 million deaths, and this count continues to rise in 2022. De-
spite extraordinary progress in biotechnology and vaccinol-
ogy, which developed effective vaccines and therapeutic ap-
proaches in record time, the unequal distribution of these and
the unequal pre-pandemic vulnerability of underserved pop-
ulations to disease and its consequences were put in evi-
dence. COVID-19 is having immediate and likely long-lasting
repercussions on global nutrition.
The pandemic has brought about a significant drop in ag-
ricultural production and supply chains. It is impacting food
processing, transportation, travel, supply chains and trade re-
strictions, loss of employment, reduced incomes, and higher
prices – all of which will affect the food availability and un-
doubtedly the nutrition of individuals, particularly children.
Estimates from The World Food Program suggest that the
number of people facing acute food insecurity was expected
to rise from 135 in 2019 to 265 million in 2020 [38]. UNICEF
estimated a 30% overall reduction in coverage of essential
nutrition services coverage, which could reach a 75–100%
reduction in some countries facing humanitarian crises. Esti-
mates in 2020 suggest there could be a 14% increase in the
46 Ann Nutr Metab 2022;78(suppl 2):40–50
DOI: 10.1159/000524328
prevalence of moderate or severe wasting among children
under 5 years of age, a major setback in the progress made
until recently [39, 40]. Exact figures will confirm these projec-
tions soon. The Global Nutrition Report in 2021 [7] stressed
that additional investments will be needed to meet the global
nutrition targets set by WHO for 2025 to overcome the effects
of the pandemic.
On the other hand, we may see the opposite effect in some
populations. Poor diet quality of children, with excess energy
and low nutrient density, may increase and be compounded
by decreased physical activity due to changes in schooling,
inactivity from lockdowns and quarantines, potentially in-
creasing obesity rates in middle-and high-income settings,
especially among their vulnerable groups [41]. Increases in
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intake of less nutrient-dense foods, increased snacking, and
greater inactivity have been reported in surveys in Europe [42]
and increased rates of weight gain among school-age chil-
dren in the USA [43]. The degree of infectivity of the virus has
fortunately been lower in children; however, it is clear the so-
cial and economic consequences of the pandemic will in-
crease their nutrition and other health-related risks, especial-
ly in the most vulnerable populations [44]. We will need to wait
to assess the full effect of the pandemic, but it is clear that, at
least in some populations, both undernutrition and overnutri-
tion will increase.
Taking Action
In the last 2 decades, the international community has in-
creased its commitment to nutrition. In 2012 the World Health
Assembly (WHA) endorsed a comprehensive plan for mater-
nal, infant, and young child nutrition, specifying nutrition tar-
gets for 2025 [45, 46]. In 2014, the Second International Con-
ference on Nutrition (ICN2), the Food and Agriculture Orga-
nization of the United Nations (FAO) endorsed documents
committing world leaders to establish national policies aimed
at “eliminating malnutrition in all its forms” and transforming
food systems to make nutritious diets available to all [47]. In
2015, the United Nations adopted the 2030 Agenda for Sus-
tainable Development and its sustainable development goals,
which included the commitment to “end hunger, achieve
food security and improved nutrition, and promote sustain-
able agriculture.” The UN proclaimed the years 2016–2025 as
the United Nations Decade of Action on Nutrition and called
for an effort by all relevant stakeholders and identified spe-
cific goals to address hunger, all forms of malnutrition, par-
ticularly in children under 5 years of age, and anemia in wom-
en and children and reduce the burden of diet-related NCDs
in all age-groups [48]. That same year, the WHA welcomed
Saavedra
the report of the Commission on Ending Childhood Obesity
and its six recommendations to address the obesogenic en-
vironment and critical periods in the life course to tackle
childhood obesity [49].
Undoubtedly, progress has been made with these and
many other initiatives, but the task is far from completed. In
2021, the Global Nutrition Report assessed that of 194 coun-
tries, 105 are on track to meet the target for childhood over-
weight, 27% are on track to meet stunting, and 29% to meet
wasting targets. The reduction of anemia in women of repro-
ductive age has hardly improved. Hardly any country is on
track to meet their targets for overall rates of obesity and
diabetes or reducing salt intake. Poor dietary intake world-
wide, driven by low consumption of fruits and vegetables,
and rising consumption of red meat and sugar-sweetened
beverages have not improved over the last decade. Finally, no
region in the world is on course to meet the sustainable de-
velopment goals set by the UN to limit the health and envi-
ronmental burdens related to diets and the food system. For
example, all regions have diets that, if globally adopted, cre-
ate impacts that are above levels necessary to limit global
warming [7].
All regions have diets that,
if globally adopted, create
impacts that are above levels
necessary to limit global
warming
As discussed previously, better integration of actions that
involve the multiple relevant systems and sectors related to
nutrition will be needed. In 2021, the UN Food Systems
Summit highlighted the need to accelerate the transforma-
tion of food systems to enable better diets and improve nu-
trition. Very recently, UNICEF published its “Nutrition Strat-
egy 2020–2030” [50]. This plan “intends to strengthen five
key systems – food, health, water and sanitation, education,
and social protection – to deliver nutritious diets, essential
nutrition services, and positive nutrition practices for chil-
dren, adolescents, and women” and is a clear step in the
right direction, to help countries better integrate their ef-
forts and priorities. However, this ambition requires re-
sources, which have been even more constrained due to the
COVID-19 pandemic. The same year, the Tokyo Nutrition
for Growth Summit [51] announced financial and policy
commitments to chart the path toward 2030. The summit
Children’s Diets and Nutrition in a Changing World
laid a roadmap and sought “encouraging governments,
business, donors, and other development partners to make
tangible data-driven financial, policy, programmatic, or im-
pact related commitments, to accelerate efforts toward
stronger nutrition action spanning food, health, and social
protection systems.”
Conclusions
In just the last 30–40 years of the modern era, we recog-
nized the importance of child nutrition and health as deter-
mining factors in the development of its communities,
countries, and society, and took action. The scientific un-
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derstanding of the effects and mechanisms of nutrition in
early life and long-term health has exploded. The econom-
ic argument for investing in children’s health and education
is irrefutable and is characterized by high benefit-cost ratios
[1, 30]. As stated in a recent World Bank report, as opposed
to other investment priorities, the returns on early life nutri-
tion are durable, inalienable, and portable. They are “durable
because investments made during the critical 1,000-day
window of opportunity last a lifetime without ever needing
to be replenished and inalienable and portable because they
belong to that child no matter what and wherever she or he
goes” [52].
During this time, remarkable progress has been made in
improving child survival and decreasing undernutrition. Si-
multaneously, we were faced with the need to continue to
improve undernutrition while countering the explosive rise of
overweight and obesity. This has led to the co-existence of
malnutrition of all types and its health consequences, includ-
ing the epidemic of chronic NCDs. All forms of malnutrition
and their health consequences are disproportionately im-
pacting – in prevalence and degree – the more vulnerable
populations and communities, independent of countries or
regions. Finally, new threats are hindering progress. Climate
change – partly the result of food systems that have positive-
ly increased agricultural production – is threatening global
health and the sustainability of these same food systems. The
threat of infectious pandemics such as COVID-19 will remain,
so it will be crucial to learn how to prevent and manage these
in the future. Diet and nutrition are the foundation for the
long-term health and well-being of societies. It will thus take
a whole of society approach and collaboration of all to adapt.
We need to correct course where needed, and to manage
threats as they arise, to create a virtuous circle where human
food production and consumption meet on a healthy, sus-
tainable plane.
Ann Nutr Metab 2022;78(suppl 2):40–50 47
DOI: 10.1159/000524328
Conflict of Interest Statement
J. Saavedra is the former Chief Medical Officer of Nestlé Nutrition and
Chairman of the board of the Nestlé Nutrition Institute and currently
is the Scientific Board Member for Scaled Microbiomics. The writing
of this article was supported by Nestlé Nutrition Institute.
Author Contributions
The content of this paper is the author’s sole responsibility. All relevant
sources are appropriately attributed.

Funding Sources
No funding was received for this paper.

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