From feeding billions to nourishing billions: how do we get food systems to deliver higher quality diets?

It is a curious fact that while poor diet is the number one risk factor driving the world’s disease burden we don’t actually know much about the quality of our diets. We know that diets must be pretty poor because 800 million people do not have enough food to eat, 2 billion consume diets that are lacking in one or more minerals or vitamins and 1.9 billion people are overweight and obese. When you put those numbers together you can safely say that the diet of 1 in 3 people on the planet is inadequate. But we know very little about the specific components of the diet, how their consumption varies by country, income, rural/urban residence and age—nor how diets are changing over time.

As the very first Global Nutrition Report noted, and as the GODAN initiative reiterated last week, there needs to be a data revolution in the way we assess diets. With better diet data we can link the diet deficits to different components of food systems and make these food systems more supportive of high quality diets that are vital to end malnutrition by 2030, a goal which is in enshrined in Sustainable Development Goal number 2.

A new report from the Global Panel on Agriculture and Food Systems for Nutrition, released at FAO this week, aims to help policymakers make their food systems more supportive of high quality diets. The analysis in the report was produced by a lead expert group that I chaired and which benefitted significantly from the active participation of Corinna Hawkes, also a Global Nutrition Report co-chair.

The good news from the report is that there are plenty of opportunities in the food system to act to make it easier for consumers to access safe, diverse and nutritious foods that are affordable. The less good news is that these actions are not being taken.

What is the case for action? The trends in the report are scary. If current trends continue, by 2030 nearly half of the world’s adult population will be overweight or obese, up from one third today. Incredibly, over half of all Chinese adults will be overweight or obese by this date. And the poorest countries are not immune to these trends. For example, by 2030 Bangladesh will have more adults with diabetes than Mexico or Indonesia. And for undernutrition, the trends are deeply troubling too. For example, the world signed up to half anemia rates in women by 2025. At current rates of progress this will only be achieved by 2084.

These trends are unlikely to self-correct. Unlike with many development issues (although not climate or environment), income increases will not improve the situation. As the report notes, the consumption of foods that are part of a high quality diet (e.g. fruits) does increase with income, but the consumption of foods that are harmful to a high quality diet (e.g. processed meats) also increases with income. Nor can we rely on urbanization to get us out of this diet mess. In fact urbanization, as it currently occurs, is a driver of poor diets because it encourages the demand for and the supply of highly processed foods which require less preparation time and tend to be energy dense and high in salts, sugar and unhealthy fats. The globalisation of foreign direct investment and consumer preferences also contribute to diet changes, and the aging of populations makes these changes more likely to result in non-communicable diseases such as diabetes, hypertension and some forms of cancer, strokes and heart disease. On top of this is climate change, making the production and storage of fragile and resource intense--but also more nutritious--crops such as fruits and vegetables more challenging.

These trends have huge mortality and morbidity costs as suggested above, but they also have enormous economic costs—at the macro and micro levels. At the macro level the economic costs are estimated to be an annual loss of 10% global GDP—equivalent to a global financial crisis every year. At the family level, the costs are also substantial. For instance a recent high quality study on China, reported in the 2016 GNR, estimated a 16% household income loss from a member of a family being diagnosed with diabetes.

The food system goes well beyond the farm gate, and covers everything that governs the flow of food from farm to fork: production, storage, transport, trade, transformation, marketing and retailing. Actions in these parts of the food system shape the food environment that consumers face at the point of access. How safe, diverse, nutritious, affordable and acceptable are the foods that consumers are faced with? Healthy choices come down to personal responsibility and how easy it is to make the right choice. We find that it is becoming increasingly difficult for consumers to afford to make the healthy choices. To make food systems and the food environment more likely to generate affordable and attractive high quality diet choices the report identifies three types of intervention in each of these components of the food system:

• policies that are currently being tried to change diet quality;
• policies that are aimed at increasing the quantity of food available but which could also serve “double duty” to improve diet quality;
• and policy options from other sectors which might add value when applied to food systems.

We highlight some of the interventions, policies and actions that have been tried to improve diet quality, ranging from biofortification to increasing the micronutrient content of staple food crops, behavior change to increase the consumption of fruits and vegetables, taxes on the consumption of foods that are thought to be especially damaging, and regulations on the marketing of certain types of foods to children. While the evidence base on these interventions is not as strong as the evidence base on interventions to address undernutrition, this does not mean these interventions should not be piloted and, if successful, scaled.

But we also conclude there are many “quantity” interventions that could be geared more to quality. Why, for example is most of the productivity enhancing research and development in agriculture geared towards staple crops? Why do food price subsidies not favour more nutritious foods? Why can’t licenses to street food vendors reward the use of healthier cooking oils? Why can’t start up funding for SMEs be more favourable for those with a sustainable plan for processing food in healthier ways?

Then there are interventions that have proven successful in other sectors which could be tried within the food system. For instance, could tax breaks for private investments that focus on nutrition be trialled? One example is tax incentives to retailers who are shown to improve the consumer interface in ways specified by public health authorities. Could mobile phones be used to assess the percent of people in different communities that consume at least 5 fruits and vegetables a day?

While there are choices, frequently they are not shaped or driven by specific diet issues the country is facing. Too often diet problems are not diagnosed and then not linked to specific components in the food sector. This is a challenge for policymakers, so the report outlines a tool that can help them link diet issues to food system components, identify actions to change the components, then align these across food system components and finally find ways to make them more sustainable.

For example, if the diet goal is to increase the consumption of pulses which are rich in good quality protein, a number of actions could be taken. In the agricultural production sector more research and development could be allocated to increasing the productivity and profitability of these crops. In the transformation sector a fast cooking bean flour could be developed to make it cheaper to cook in terms of time and energy. In the storage, transport and trade sectors farmers are not using the best management practices to reduce insect damage. In the retail and provisioning sector where staple crops receive a public consumer subsidy, extend or shift to pulses.

Despite these options, there is not enough policy action, experimentation and evaluation in this space. At an absolute minimum policies around public sector food procurement should be guided strongly by nutrition concerns. What is this inaction driven by? A lack of knowledge about how poor diets really are? A lack of knowledge about the consequences of poor diets? A lack of clarity on what to do? An unwillingness to take on vested interests that are happy to maintain the status quo? Probably all of these, with each combination of factors being highly context specific. The report provides policymakers, and those who hold them accountable, with information and tools to overcome these obstacles.

As the report makes clear, making food systems promote rather than undermine high quality diets is a choice. Those in low and middle income countries have the chance to get food system choices working for improved diet at the first time of asking. They don’t have to go through the long and painful nutrition journey that high income countries have taken. The new report tries to make it easier for them to make these choices by bringing new data, tools and policy perspectives to bear. The report also tries to make it harder for them not to act, by making the trends and consequences of business as usual very clear.

Enhancing the ability of food systems to deliver high quality diets is a choice that is well within the grasp of policymakers. It is a choice that will help achieve the SDG goal of ending malnutrition in all its forms by 2030. It is a choice that will reap benefits for decades to come, for all people, in all countries. We must move beyond a mindset of feeding billions to one of nourishing billions.

Photo Credit: IFPRI