Published: 12th October 2020
Child stunting and supermarkets: a positive influence?
Inspired by “Supermarket food purchases and child nutrition in Kenya” by Debela
Diets are not only about nutrition. Multiple factors influence what people eat, and the market availability plays a crucial role. Especially in low- and middle-income countries (LMICs), the food shopping options close to people’s homes can profoundly change the nutrients and calorie intake of a household. Since these countries are also increasingly experiencing a double burden of malnutrition – undernutrition, as well as increasing overweight and diet-related non-communicable diseases (NCDs) – it is very important to understand how the two factors are related.
The food environment is the physical presence of food around an individual, defined as the distribution of store locations and food availability within those locations. Developing countries’ food environments are now experiencing a rapid rise of supermarkets at the expense of more traditional markets and shops. Supermarkets offer a particular range of food that includes a wider variety of goods, supplied in larger packs, and a wide selection of processed and ultra-processed foods.
How does this shift influence diet?
A recent study authored by Debela has investigated the role that supermarkets play in shaping the diet in three Kenyan settings.
Most studies that have investigated the relationship between the food environment and nutrition focus on the adult population. They associate the availability and consumption of supermarket food with an increased likelihood of overweight and a higher risk of non-communicable diseases. Supermarkets, in fact, offer a range of foods that are high in fat, sugar and salt.
Debela’s study aimed to fill a gap in research by focusing on child nutrition. The study surprisingly discovered that while supermarkets contribute to rising levels of obesity in adults, they can also ameliorate the height-for-age Z-score – the conventional way to measure stunting in children. In fact, “adults cannot grow in height anymore, so additional calories and nutrients from supermarket purchase will primarily lead to gains in body weight“. In children, however, it was noticed that the extra calories could contribute to gains in height. Moreover, given the lower rates of overweight among children, a moderate weight gain doesn’t necessarily lead to overweight. This pattern exclusively applies to low-income households: “many of the households are still moderately poor, and traditional diets are not highly diversified. In this context, the greater variety of foods offered by supermarkets at affordable prices can improve diets and nutrient intakes, even when most of the products purchased in supermarkets are in processed forms“. However, we can’t draw the same conclusions in more affluent settings, where we can still affirm that the consumption of ultra-processed food and the rise of supermarkets could contribute to child obesity (Umberger et al. 2015).
The UKRI GCRF Action Against Stunting Hub is researching stunting in low-income communities in Indonesia, India and Senegal. Considering the penetration of supermarkets in Asia, we asked our in-country researchers in India and Indonesia to analyse the food environment in their settings to understand how they are currently shaping food choices and nutrition.
The availability of supermarkets is rising quickly in developing countries, including in Indonesia. The food environment is going through rapid change: supermarkets are not only available in big cities, but also in suburbs and district areas. The number of small retail outlets such as mini markets and convenience stores, both in urban and rural areas, is increasing. In 2018, the growth was 6-9% – approximately 30.000 more outlets. Due to easier access, both supermarkets and small shops are becoming an alternative food option to traditional markets, and they contribute to shaping a new food system.
The food retail environments have a profound influence on food choices, dietary changes and nutritional outcomes, and they contribute both in positive and negative ways. On the one hand, supermarkets may lead to more diverse diets, lower food prices and increased food accessibility. On the other hand, they may contribute to “obesogenic” diet transition through higher consumption of energy-dense, ultra-processed foods, low nutrient density, and food and beverages that are high in salt and sugar, which contributes to rising rates of overweight and obesity.
Childhood obesity is a strong predictor of obesity in adulthood. The World Health Organization (WHO) noted that the consequences of childhood obesity include NCDs such as type 2 diabetes, cardiovascular diseases, metabolic syndrome, osteoarthritis and cancer in young adulthood. A study in Indonesia showed that supermarket shopping has a significant association with child overweight in high-income urban households, but not in low- and middle-income households. On average, children living in households that shop at supermarkets have 0.34 higher score for height indicator (height-for-age z-score) than children in families that obtain all their foods from traditional sources. The positive effects on child height are particularly welcome, as child stunting is still widespread and a significant health problem in developing countries. This positive effect is channelled through improvements in food variety and dietary diversity, such as fruits, meat, fish, and eggs, which are particularly rich in micronutrients.
Given the risks associated to changes in food environment, consumers need to have an adequate understanding of diet so they can choose healthier and more nutritious food for themselves and their family.
Telangana is the study site for the Hub in India. In this state, almost 61% of the population lives in rural areas. About 30% of the urban population resides in the state capital, Hyderabad.
The food environment in the state takes different forms, depending on the location and the formal or informal setting. To be categorised as an official food store, the shop has to be registered under the Department of Labour, Government of India. The formal markets include supermarkets, hypermarkets, wholesale and retail food stores, where mainly packaged food is sold. Informal markets are generally not registered, and they include open markets where foods are sold in unpacked forms. The informal markets include weekly fruits and vegetable stalls, mandis, mobile vendors, fresh fish and flesh food market, and farmers’ market. Generally, urban areas have many formal supermarkets and hypermarkets along with informal markets, while rural areas are characterised by informal markets.
The ongoing pandemic has had significant effects on food environments and food availability in India: the forms and shapes of supply chains and food markets have been further revamped. The changes in availability, accessibility and affordability of foods impact the nutritional status of individuals directly. In addition, the lockdown has had a multi-dimensional effect on the livelihood, dietary/psychological/behavioural health, public health system, and economy.
The scenario of food environment presents intricacies at a regional level. For instance, food prices of staples such as rice and wheat have not changed, but newspaper media reported that there is 10-20% surge in other food commodity prices in cities like Delhi, Mumbai and Patna due to limited stocks in wholesale and retail.
Covid-19 has enhanced existing disparity in food acquisition by different sectors of the population, which is reflected in the food eaten by individuals and more so among low-income families. Moreover, there is an additional problem of increased risk infection transmission in rural areas where the market spaces are generally congested, limiting the practice of physical distancing and indirectly increasing the overall burden.
The situation is not the same in Telangana State, wherein the state government has set up a high-level committee to monitor the prices of fruits and vegetables and support farmers by facilitating transport of food. The Government of Telangana launched a scheme for home delivery of fruit baskets (rythu bazars) with the double purpose of ensuring proper price to farmers and make fruits available at reasonable prices to consumers. The availability, affordability and accessibility of fruits and vegetables had been guaranteed in the area during the pandemic.
The perceptions of the consumers on the current Covid-19 also need to be understood.
Social media videos going viral on unhygienic handling of fruits and vegetables has triggered fear, decreasing the demand and purchase of perishables. A similar scenario of false impression is being observed for animal source foods such as poultry (40% reduction in chicken demand in Telangana state) wherein consumers presumed that consuming chicken would infect them with Covid-19. The wide circulation of fake news in concurrence with availability and access issues might prevent the consumers from purchasing and consuming a diverse diet.
The scenario might be different in interior areas, rural areas, red, orange and containment zones—the new normal needs further exploration in order to build a healthier India.
Many low- and middle- income countries are undergoing a nutrition transition that is accompanied by the rise of supermarkets at the expenses of more traditional ways of shopping. While this shift proved to coincide with rising rates of overweight among the adult population, it might have better effects on children’s diets, because it provides with a larger range of micronutrients and a higher calorie intake. The Hub is committed to understand the food environments and to develop tools and metrics to measure them at the community level.
The Covid-19 pandemic will also need to be taken into consideration given the impact it is having on food accessibility. The post-pandemic nutritional status will be assessed to understand how the lockdown reshaped diets and how it affected stunting. The study will reflect on the variables that recently emerged to define the multiples drivers of stunting and determine possible solutions.
This article was written with the contribution of
Dr Archana Konapur, Hub Researcher – ICMR-National Institute of Nutrition
Indriya Laras Pramesthi, Hub Researcher – SEAMEO Regional Center for Food and Nutrition