expert opinion

Hidden hunger in the developed world

November 15, 2013


Hans Konrad Biesalski, Head of the Department of Biological Chemistry and Nutrition, University of Hohenheim, and Associate Director of the Food Security Center in Stuttgart, Germany

“It is a popular misconception that most people who live in the developed countries of the world enjoy a nutritionally sound diet and are not prey to hidden hunger or chro- nic micronutrient malnutrition. The reality is, however, different. Micronutrient inade- quacies can be found in the developed as well as in the developing world, and their current rate of growth in the developed world gives cause for concern. Growing evid- ence from intake surveys in Western countries, such as the US, Canada, Germany, France, the UK and many others, indicates that a sufficient intake is not being achie- ved in the case of some micronutrients, according to recommendations using the Recommended Dietary Allowances (RDAs) as a reference (1, 2). This is especially the case for folic acid, vitamin D, vitamin E, iron and iodine. According to the United Nations Food and Agriculture Organization (FAO), micronutrient inadequacies may, in the long term, lead to a wide number of health problems, including impaired cognitive development, lower resistance to disease, and increased risks during childbirth for both mothers and children.

An increase in poverty in industrialized countries, with children primarily affected, is an issue that is often overlooked. Being poor means having a poor diet and little dietary diversity in many cases, which also me- ans that children who live in the land of plenty may also suffer from malnutrition. Cases of rickets, for ex- ample, have gone up fourfold in UK in the past 15 years because many pregnant women and young children are not getting enough vitamin D. Sadly, this fact seems to interest very few people. There is a polarization in dietary lifestyles in the developed world. While the more affluent and educated have the resources to support a healthier lifestyle and diet, those who are economically poor, who live in “food deserts” and do not possess a good knowledge of nutrition, often do not have the means to make the right choices. The more varied one’s diet is, the healthier one is. Normal body weight and growth can only be achieved if children take their food from several different sources. Dietary diversity depends upon certain factors, for instance, that different foods are available and affordable. This lack of diversity is responsible for malnutrition and all of its harmful consequences. There are districts in both urban environments and rural settings where shops do not stock the range of fresh and nutritious foods necessary for a balanced diet. These areas are usually characterized by convenience stores that stock only processed foods and by fast-food restaurants. Residents who are unable, for whatever reason, to travel further afield in search of a better diet therefore find them- selves in a situation where there is food to buy, but the nutritional value of that food is inadequate.

It should be pointed out that in all cultural and geographical settings, the question of access to healthy food has many dimensions, and that a variety of factors may combine to prevent an individual or a group of indi- viduals from enjoying a balanced diet. Some of these factors are, for instance, lack of mobility (lack of trans- port or lack of physical mobility due to illness or infirmity), lack of purchasing power, and a lack of under- standing of basic nutritional principles. Within the world’s most affluent societies, there are individuals – in hospitals, nursing homes or hospices, or living in sub-standard housing or sleeping on the street – who do not have access to that “simplest” thing: a healthy, balanced diet.

The long-term consequences of malnutrition and hidden hunger in the developed world are significant. For ex- ample, inadequate and suboptimal vitamin D status alone is known to be a risk factor for fractures, as well as some cancers, such as breast and prostate cancer, and several autoimmune diseases such as mult- iple sclerosis, rheumatoid arthritis and type-1 diabetes (3). Many people have a low level of serum vitamin D (measured as 25-hydroxy-vitamin D) owing to poor access to natural sources of vitamin D. This may be attributable, for instance, to factors such as an absence of cold-water ocean fish from the diet, living largely indoors and therefore getting insufficient exposure to sunlight, and inhabiting the high latitudes of the world. The reduction of the direct and indirect costs associated with the above-mentioned diseases has been calcul- ated based on randomized controlled trials using an intake of 200 to 800 IU vitamin D, which results in an adequate vitamin D status. Assessments by various research groups indicate that the financial burden on direct and indirect healthcare costs arising from inadequate micronutrient status in the developed world could be in the range of billions of euros (4, 5).

We have clear evidence that income is related to food security, and we have a range of data showing that a balanced diet is related to higher income and higher education. We need to evaluate food security, in parti- cular in females and youngchildren living in poverty, because inadequacy of micronutrient supply during the short period of the 1,000-day window may also have an impact on further development and, consequently, on the economic and health future of the child in developed countries. The 1,000 days between a woman’s pregnancy and her child’s 2nd birthday offer a unique window of opportunity to shape healthier and more prosperous futures. The right nutrition during this 1,000-day window can have a profound impact on a child’s ability to grow, learn, and rise out of poverty. It can also shape a society’s long-term health, stability and prosperity.

Perhaps the magnitude of this problem is overestimated in the developed world. Nevertheless, as long as we lack data of sufficient quality on this subject, this problem should concern us. Nutrition science is based on molecular biology on the one hand and on research related to obesity on the other. Both have an excellent, economically driven lobby. Malnutrition, however, is not in the focus of nutrition scientists, even though its impact is as serious as is that of overnutrition.”

Based on: Biesalski H.-K. Hidden Hunger in the Developed World. In: The Road to Good Nutrition. Karger Medical and Scientific Publishers. 2013.


1. Roman Viñas B. et al. Projected prevalence of inadequate nutrient intakes in Europe. Ann Nutr Metab. 2011; 59:84-95.

2. Fulgoni V. L. et al. Foods, fortificants, and supplements: where do Americans get their nutrients? J Nutr. 2011; 141:1847–1854.

3. Bischoff-Ferrari H. Health effects of vitamin D. Dermatol Ther. 2010; 23(1):23–30.

4. Grant W. B. et al. Estimated benefit of increased vitamin D status in reducing the economic burden of disease in Europe. Prog Biophys Mol Biol. 2009; 99:104–113.

5. Zittermann A. The estimated benefits of vitamin D for Germany. Mol Nutr Food Res. 2010; 54(8):1164–1171.