Child Malnutrition & COVID-19 in the UK
Children’s right to safe, nutritious, and culturally appropriate food during the COVID-19 pandemic in the UK
By Marjorie Lima Do Vale, Helena Trigueiro, Kathy Martin, Shobhana Nagraj, Elaine Macaninch, Dominic Crocombe, Sumantra Ray
Last year, in the context of COVID-19, the UK Government published a policy paper entitled “Tackling obesity: empowering adults and children to live healthier lives”, which described several actions being considered by the Government to help people become healthier (1). The NNEdPro Global Centre, as an international and interdisciplinary global think-thank focussed on addressing inequalities and implementing effective solutions in nutrition and health, welcomed many of the actions proposed but advocated for more comprehensive language and actions that do not corroborate a reductionist view of nutrition that is centred on calories and weight (2).
This time, in face of several reports of inadequate and inefficient meal provision to school-aged children during the pandemic in the UK, particularly in England, NNEdPro responds to the UK Government actions in the school meal domain. In this advocacy paper, we outline current actions across the UK and make recommendations to improve the adequacy and efficiency of programmes being delivered with the overall goal to urgently protect children from rising food poverty and inequality.
The COVID-19 pandemic has posed several challenges to food, social and welfare systems, resulting in heightened vulnerability for many families, which are now facing an increased risk of food insecurity and malnutrition (3). Although the long-term impact of the pandemic on children’s nutrition and health is unknown, good nutrition is essential for children’s growth and development (4). Childhood is an essential period for developing healthy eating behaviours that might be carried into adolescence and adulthood (5,6) and therefore provides a window of opportunity to promote growth and development while also reducing the risk of non-communicable diseases later in life. Understanding the early impact of the COVID-19 pandemic on environments where children live, learn and play, and implementing timely and effective actions that promote food security and good nutrition in such unprecedented times is essential to minimise unnecessary risks and burden to individuals, society and future healthcare and social pressures.
The first motivating factor for this advocacy piece was the delayed response of the Government in England to secure access to food vouchers over summer and winter holidays by families entitled to receive free school meals. Despite this situation being “resolved” after pressure from third sector organisations along with celebrities in the UK, the food insecurity of children continues. More recently, the media has been inundated with pictures of inadequate food parcels being provided to families with third sector organisations and celebrities, now demanding a comprehensive review of free school meal systems across the UK. We are concerned that taking such a reactive approach, where actions are taken only when access to food is already disrupted, cannot continue any further. As such, we agree with others that free school meals systems must be reviewed and reinstated to prevent food insecurity from happening and not only mitigate its effects.
In line with our response to the UK Obesity Strategy (2), we want to prevent short-sighted approaches. Feeding children is not a simple task. Thinking otherwise can result in overlooking essential aspects of children’s food environments that have been disrupted and further wasting of public resources in actions that are inadequate and ineffective. Allocating necessary resources to support families in providing adequately nutritious foods for children needs immediate action and must be prioritised. Poor quality diets can manifest as undernutrition, obesity, or nutritional deficiencies with potentially lifelong consequences (7). We call for immediate commitment of UK Government leaders. Our recommendations are in line with and further build on those made in the National Food Strategy published in the summer of 2020 (8).
Support local districts in developing capacity and systems to comprehensively identify and monitor children and families eligible to expanded free school meals scheme or at increased risk of food insecurity and malnutrition.
Ensure access to safe and nutritionally balanced foods for all children who are normally in receipt of free school meals or otherwise identified as food insecure. This includes access to appropriate foods as well as cooking facilities for preparing and storing foods which can be accomplished via direct cash transfers or vouchers. Cash transfer and vouchers can be preferred options, considering that delivering food parcels that meet nutritional and cultural needs and potential food intolerances/allergies can be complex. However, the delivery of food parcels should not be excluded considering other factors that might prevent families from physically accessing foods.
In addition to the expansion of Holiday activities and Food programmes, we call for continued access to information on what and how to feed children from different age groups and for provision of support from nutrition/dietetics and healthcare professionals to parents and caregivers struggling to feed their children.
Support the collation of examples of innovation and good practice that are effective in improving equitable and sustainable access to adequate food (e.g., food banks, community kitchens, nutrition education programmes) across the UK and allocate funding to support replication of what works.
Importance of good nutrition during childhood
Undernutrition (when children have low weight and/or height for their age or gender), overweight or obesity (when children have high weight or body mass index for their age or gender) and micronutrient deficiencies are all part of the concept of malnutrition. In all its forms, malnutrition negatively influences child health in the short and long term (9).
Undernutrition and nutrient deficiencies are associated with children’s poor growth, cognition, school readiness and performance along with increased risk of infections and increased mortality. The other face of malnutrition, related to overweight and obesity, also pose risks to child health and have been associated with low self-esteem and increased risk of metabolic disorders (10).
Addressing childhood malnutrition by targeting and promoting healthy food environments in places where children live, learn and play, might be effective strategies to set the correct trajectory in the UK. Several studies have found associations between childhood environmental influences within children’s households (11,12,13,14), nurseries and schools (15,16, 17), and children’s eating behaviours, diets and nutrition outcomes.
Promotion of healthy food environments includes not only the provision of healthy foods but also, the provision of opportunities for children to interact with food in a positive way and to learn healthy eating behaviours that can potentially be carried into adolescent and adult life (5,6).
Background of childhood food insecurity and malnutrition in the UK
Food security is a concept closely related to malnutrition. Food security exists when individuals have stable access to foods that are safe, nutritious and culturally adequate—as such, being food secure can be considered a pre-requisite for a healthy dietary intake and nutritional status. The global food security report, 2020, highlighted that about 60k people in the UK could not afford an energy sufficient diet, about 130k could not afford a nutrient adequate diet and 200k could not afford a healthy diet, highlighting the alarmingly vast scale of those already food insecure and at risk of malnutrition. Furthermore, UNICEF reported that in 2014/15 about one in five children below the age of 15 in the UK lived in a food insecure household, which is the highest rate observed in Western Europe (19). Even more pertinent as UK has now exited the European Union and is navigating a number of economic uncertainties that lie ahead.
In terms of malnutrition, data from the Global Nutrition Report, including children aged 5 to 19 years, show that despite a small and steady decline in the prevalence of those underweight from 2000 to 2015, around 6.3% of girls and 9.8% boys are still underweight in the UK. In contrast, rates of overweight and obesity spiked within the same 15 years reference period, particularly in terms of obesity among boys (8.3 to 10.9%) (18). More recent data from the National Child Measurement Programme (NCMP) published in 2018/2019 show that the prevalence of children aged 4 years who were underweight was relatively low (1%). Significant variations existed across regions in England, Leicester has five times more undernourished children than Lincolnshire, for example. Rates of overweight, obesity and severe obesity among 4-year-olds reached 12.9%, 7.3% and 2.4% respectively, with important differences across regions. Among 10-11 year-olds, a higher prevalence of overweight (13.9%), obesity (15.4%) and severe obesity (4.3%) is observed (20). It is important to highlight that prevalence of obesity was consistently higher in the most deprived groups, suggesting an important role of socioeconomic deprivation in children's nutritional status (20).
For micronutrient adequacy, data from the Diet and Nutrition Survey of Infants and Young Children published in 2013 showed that 11 to 28% of children aged 12 to 18 months living in the UK, had intakes of iron below the lower reference nutrient intake (LRNI). Higher inadequacy was observed for South Asian children (28%) and children from parents that occupied routine and manual labour. Consumption of fruits and vegetables was also lower among South Asian children, and those from parents engaged in routine and manual labour. Intake of sodium was another area of concern, reaching a mean daily intake of 181% adequacy. For older children, aged 11 to 18 years, data from the NDNS show that mean intake of vitamin A, D, calcium, magnesium, potassium, selenium were below reference nutrient intake (RNI) in both sex groups. For girls, folate, iron and zinc were also below RNI. It was noted that for some micronutrients, such as vitamin A, folate and iodine, higher intake was associated with higher income levels. Similarly, consumption of fruits and vegetables and “5 A Day” also increased with income (21).
Altogether, this data suggests that childhood malnutrition in all its forms is a serious problem in the UK. Tackling childhood malnutrition is an important area for action to prevent growth and developmental delay, as well as the increased risk of metabolic diseases and non-communicable diseases later in life, particularly for children in lower sociodemographic groups (20).
Government role in addressing childhood food security and malnutrition
The right to food is a legal obligation anchored in international law proposed by the Committee on Economic, Social and Cultural Rights in 1999, and ratified by 170 State Parties, including the UK (22). It has been advocated that the UK Agriculture Bill 2017-2019 is amended to explicitly recognise the right to food, thus setting an appropriate legal and regulatory structure to guarantee its protection, respect and fulfilment. Also, the Parliament should publish a Right to Food Bill to ensure a comprehensive approach to the right to food, with the identification of principles, finalities, rights holders and duty bearers (23). In 2004, the FAO provided a set of guidelines to support state parties in promoting the right to food in the context of national food security. In the nutrition domain, examples of such actions included: taking measures to maintain or strengthen healthy eating habits and ensure that changes in availability and access to food supply do not negatively affect dietary composition and intake and disseminating information on the feeding of infants and young children that is consistent and in line with current scientific knowledge and internationally accepted practices (24).
Government actions in addressing childhood food security and malnutrition
Maintain and strengthen healthy eating habits and preventing disruptions
During the early stages of the pandemic, about 5.1 million people in households with children had already experienced one or more forms of food insecurity – with more than 200,000 children skipping meals because their family couldn’t financially or physically access sufficient food. The majority of households with children were unable to access food due to lack of food in shops (almost 3 million people) followed economic reasons (almost 1.5 million people) (25).
More recent reports from the Food Standards Agency show that concerns about food availability and access across households in the UK peaked during the first lockdown in April. After that, concerns with food availability and access fell steadily until September when it increased again, particularly among households with a child (26). A briefing paper produced on the use of food banks in the UK presented data showing that the Trussell Trust supplied 18% more “three-day emergency food parcels” in 2019-2020 than in the previous year, with one-third of these - more than half a million – being provided to children. Altogether, the available data indicates that households with children are particularly exposed to food insecurity in the context of the COVID-19 pandemic (27).
Governments across the UK have opted for different solutions to support school-aged children in accessing healthy food options, including cash transfers, food vouchers and delivery of food parcels, for example. In England, the continued provision of free school meals to eligible children was implemented via the adapted provision of meals by school canteens, delivery of food parcels or issuing of food vouchers. Since June, almost three months after the first lockdown, additional children were also made eligible to free school meals vouchers, and by August 2020, around 94% of state schools in England had registered for the voucher scheme (28). In Northern Ireland, direct payments were made to families of children entitled to free school meals. The “Eat Well, Live well” programme was also extended. Under this programme, anyone aged 4 to 25 years could access a five-day food box containing breakfast and lunch. In Scotland, replacement of school meals was mostly done through the provision of foods to families with only one-third of local authorities using direct cash transfers. In Wales, both vouchers and food delivery options were used. Local authorities were in charge of purchasing gift cards from retailers that operated in their local area. Food deliveries were used as an option for families that were shielding, and in collaboration with charities, aimed to address allergies and special diets, and contain recipe cards (29). Also, in the UK, two Government actions were taken to support food aid charities: the announcement of a £16 million package to support food charities and the opening of a Food Charities Grant Fund (27).
Despite increased support provided to food charities which might have enabled food banks to address the need of the emerging demand of families during the pandemic, food parcels provided by food banks do not necessarily meet individual’s nutritional requirements as they are often composed of tinned, long shelf-life products. For instance, one recent study with two food banks in Oxfordshire showed that food parcels distributed were high in sugar and carbohydrate. They also lacked vitamin A and vitamin D compared to the UK guidelines (30).
Despite Government efforts, implementation issues might have prohibited many children from getting access to proper foods. In England, schools and parents have reported difficulties in registering for the voucher scheme and obtaining support by telephone or email. Also, many vouchers were not effectively delivered due to wrong email addresses. There was also reported concerns regarding the limited number of grocery stores accepting vouchers and whether families, particularly those in rural areas, could physically access participating stores (28). Also, it has been reported that 45% of pregnant women and/or parents with children aged 0-3 years old were not aware of the Government’s Healthy Start scheme, yet 32% of them reported having a limited budget for food and struggling to afford fruits, vegetables, and milk (27). Also, issues related to the stigma associated with accessing Government benefits have been reported as a contributing factor to food insecurity during the pandemic in the UK (31). Food aid organisations, including food banks, have reported difficulties in supporting the emerging number of families in need, due to a limited number of donations, and facing staff shortages (32). Some of these constraints have been addressed by the Government following pressure from media, non-government organisations and civil society. For example, optimising the free school meals scheme processes and systems, and extending its coverage and duration in England and the announcement of the COVID-19 winter grant scheme focussed on vulnerable households with children. However, many opportunities were still missed, and families are still experiencing different levels of food insecurity. For instance, a recent report from the Food Foundation has shown that although food insecurity has improved since April, about 11% of families with children still experienced moderate to severe food insecurity in August, with 4% of children spending a whole day without eating any food (33,34).
Recommendations from the World Food Programme, FAO and UNICEF suggest when cash transfers and food vouchers are used, they should be of similar or enhanced value of the provided school meals, and also be accompanied by nutrition messages and education to better enable beneficiaries to maintain or strengthen diet diversity (35). Another review also conducted by UNICEF on the effectiveness of cash transfers in Africa further recommended that the value of cash transfer should consider inflation, spike in food prices, food availability and also be used as an entry point for other complementary healthy interventions, such as the provision of food supplements and information sessions that could enhance children’s nutritional outcomes (36).
When food parcels are the preferred option, parcels' content should provide fresh fruits and vegetables purchased from local food producers where possible. Also, food parcels must cater to children’s nutritional needs, allergies and cultural preferences. Irrespective of options provided, it is important to keep in mind whether parents or caregiver are equipped with the necessary knowledge, skills, time and resources to opt for nutritious meal options instead of relying on processed food that has high energy, low nutrient content.
Disseminating information on feeding infants and young children
Alongside providing nutritious food for families, advice on selecting and preparing foods to feed children can be crucial. The UK has published the UK Eatwell guide in 2016 following revisions of the previous Eatwell plate. However, these recommendations are only applicable to children aged 2 years and older. Guidance for pregnant women and parents on various aspects of infant’s health, including food and nutrition, is provided under the Start 4 Life information services, which was established in 2012 as a joint initiative by the NHS, Department of Health and Department of Education (37). Also, local councils in the UK have further compiled nutrition guidelines targeting children aged 2 to 5 years (38,39).
The Start 4 Life webpage has published specific guidance during the COVID-19 pandemic and UNICEF UK has released a guide for local authorities in terms of infant feeding during the coronavirus crisis in partnership with First Steps Nutrition trust (40). No specific guidance for feeding toddlers and preschoolers during the coronavirus outbreak has been released. Private initiatives led by large food retailers and third sector organisations have been launched with the overall goal to support parents on how to create healthy meals with £15 vouchers provided by the Government (41,42).
Providing guidance and support to parents is relevant, considering how the pandemic can disrupt children's food behaviours. Mothers’ increased anxiety and depression can translate in the mothers using more control over their child’s intake and less role modelling of healthy behaviours (43), which can contribute to less healthy eating behaviours in children during the pandemic. Parents have experienced challenges to feed their children during the lockdown, including uncertainties regarding what food to provide (44). A recent survey conducted by Public Health Scotland reported that 5 in 10 children had worse mood and behaviours during the pandemic, with every 3 in 10 also showing worse eating behaviours (45).
A recent effort in the UK towards the promotion of healthy eating habits in children included the release of the Child Feeding Guide, which aims to provide credible and freely accessible online support for parents, caregivers and healthcare workers in the form of advice and recommendations. A recent evaluation of the use and impact of this tool showed that it helped mothers to better understand their child’s eating behaviours and it has also influenced the way that mothers fed their children, yet more explorations of the impact of such tool on mothers and families from more diverse socioeconomic and educational background are still needed (46).
Also, interventions in the food environments where children live can help promote the healthy choice as the easiest choice. For example, making the healthy choice more visible, affordable and convenient. The recent UK Government Obesity Strategy proposed different actions to support a healthier food environment. This includes actions such as mandatory legislation to end promotions of high fat, sugar and salt options at the point of purchase, and the soon to be released ban on advertisement of high fat, sugar and salt products before 9 pm on TV and online (1). Although we acknowledge the importance of such actions, as we have previously described in our response to the UK Government Obesity Strategy (2), reducing promotions of unhealthy food options can effectively reduce intake of unhealthy food options, particularly among those from a low socioeconomic background (47), but might have an adverse impact on families’ food expenditure if healthy alternatives are not within families’ purchasing power. Promoting a common understanding and aligning efforts between the public and private sector towards healthy food options can optimise outcomes for children, their families and the environment (48).
This piece highlighted the importance of supporting parents and caregivers in accessing the resources they need to feed their children in such unprecedented times. Many gaps have been identified, which might have prevented vulnerable children in properly eating nutritious foods required for healthy growth and development. While we understand that the pandemic poses exceptional challenges for individuals, families, Government, non-government and private organisations, those who are hungry cannot wait. As such, timely action is needed.
The UK is now in its third lockdown. The right to food places a legal obligation on Governments to protect children from all forms of hunger (49). Many have called for an urgent and long-term fix in current free school meals policy and schemes (50). Multisectoral actions are needed to end children’s hunger in the UK once and for all. Considering that children should not eat just ‘any type of food’ provided in ‘any given way’, actions must also ensure that foods accessed are safe, nutritious and adequate and that feeding practices with accompanying education and enabling environments are supportive of long-term healthy food behaviours.
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