• Public Health

Malnutrition in its different forms is a significant public health issue for countries globally, and underpins persistent social and economic challenges. This includes both undernutrition (ie, micronutrient deficiencies, underweight and childhood stunting and wasting) as well as overweight, obesity and diet-related non-communicable diseases.1 Globally, more than 2 billion children and adults are estimated to be overweight and more than 150 million children are stunted.1 As with other areas of public health, a variety of actors are involved with the issue of malnutrition, rendering these issues open to conflicting framings, interests and attendant power struggles. This gives rise to different ‘schools of thought’ on how to address malnutrition, with different actors favouring different approaches.2

The international public health nutrition and food systems communities place considerable emphasis on addressing micronutrient malnutrition in low-income settings. As Jonsson (2010) and others describe, this focus on micronutrient malnutrition has indeed been a prominent paradigm in food and nutrition policy for a number of decades.2 3 It often manifests through a focus on addressing dietary diversity particularly in relation to low fruit and vegetable consumption, and high levels of ultra-processed food consumption, and through a focus on specific dietary micronutrient deficiencies.

More recently, some scholars have questioned this micronutrient malnutrition focus, suggesting need for something broader, with several suggesting a need for greater prioritisation of hunger and food adequacy.2 4 5 As described by Harris (2019),2 the food and nutrition policy focus of national governments in many low-income settings is often already on issues of hunger and food adequacy—at odds with the focus of many international actors.2 These findings raise important questions of international donor influence in shaping national policy.6 However, rather than being underpinned by empirical study, these discussions have largely been theoretical. In this regard, our recent empirical studies drawing on fieldwork in rural Malawi are somewhat novel.

First, our analyses drawing on a discrete choice experiment methodology suggest that if maize price lowers (eg, through policy targeting maize, the staple crop of Malawi), people in rural village communities would maintain a preference for more maize rather than other food products, despite also valuing these other products.7 8 Second, our survey analyses suggest that households diversify crop production only after achieving food security; and food-insecure households are unlikely to diversify crop production to include nutrient-rich crops.9 Third, our qualitative analyses based on focus group discussions with men and women in these rural communities found that people are aware of needing to consume a great variety of (healthy) foods, and yet due to the unaffordability of these diets, they are unable to do so.10

Particularly as shown from the focus group discussions, these findings are likely due to population characteristics, as severely resource-constrained households with low incomes tend to focus on alleviating hunger, not dietary diversification. Furthermore, the level of ultra-processed food consumption among our study participants was low by international standards. While a focus on addressing high levels of ultra-processed food consumption might be appropriate from a prevention perspective, it appears less of a priority in terms of addressing the immediate nutritional needs of people on the ground in settings such as ours. Our participants were from rural communities with relative proximity to cities such as Lilongwe and Blantyre, and high levels of poverty and food insecurity.

We are not disputing the importance of micronutrient malnutrition. Indeed, addressing micronutrient malnutrition is critical. We also wish to emphasise the attention needed to addressing the power and influence of corporate actors in food systems globally including in regard to ultra-processed food consumption.11 However, there may be important trade-offs and synergies between addressing hunger and the achievement of food adequacy aspects of food security, and addressing micronutrient nutrition. Caution may be needed with policy and programme interventions encouraging consumption of nutritious foods before addressing hunger and food adequacy—although ideally, they would be addressed together.