Achieving Optimal Nutrition: The Critical Role of Food Systems & Diets

Jessica Fanzo, PhD

Bloomberg Distinguished Associate Professor of Global Food & Agriculture Policy & Ethics

Director of the Global Food Policy & Ethics Program

For Our Discussion

• Map the components of a food system, food environments and their drivers .

• Describe the major global challenges and trade-offs of ensuring food security and healthy diets and their health, environment, economic and sociocultural consequences.

• Describe the exogenous drivers to the food system that will inhibit success if action is not taken.

• Understand the prevailing evidence in improving diets and nutrition.

Part 1: Food Systems and

Environments

Food systems for diets and nutrition

HLPE 2017 Food Systems and Nutrition Report

Barriers & opportunities for healthier eating

Mozafarrian 2016 Circulation; Afshin et al 2015

Part 2: Transitioning Diets

1. Too much

2. Poor quality

3. Not affordable

4. Not sustainable

1. Too Much

Ranganathan, J. et al. 2016. “Shifting Diets for a Sustainable Food Future.” Working Paper, Installment 11 of Creating a Sustainable Food Future. Washington, DC: World Resources Institute. Accessible at http://www.worldresourcesreport.org; Theresa M Marteau et al. BMJ 2015;351:bmj.h5863

2. Poor Quality

Micha et al 2015 BMJ; Harvard, Neel 2012; Global Panel on Agriculture and Food Systems for Nutrition. 2016. Food systems and diets: Facing the challenges of the 21st century. London, UK

Global sugar supply per calories/person/per day in 2008

Global Dietary Database, 2017

Some improvements over time, some not

Global Panel on Agriculture and Food Systems for Nutrition. 2016. Food systems and diets: Facing the challenges of the 21st century. London, UK

Dietary intake data from the Global Dietary Database (Tufts) comparing 1990 to 2013

Consumption of sugar sweetened beverages

Popkins and Hawkes Lancet Diabetes 2016

Global Dietary Database; Global Panel on Agriculture and Food Systems for Nutrition. 2016. Food systems and diets: Facing the challenges of the 21st century. London, UK.

Per capita sales volumes of non-alcoholic beverage types 2000-2015

Processed, packaged foods

Baker and Friel Globalization and Health (2016) 12:80

Distribution share (%) of processed foods through modern grocery retail channels, 1999–2013

Sales of ultra-processed food products and oils & fats, in selected Asian markets, 2000–2013 with projections to 2017

Global dietary patterns among men and women in 187 countries in 2010

Imamura et al Lancet Glob Health 2015; 3: e132–42

3. Not Affordable

Hallegatte, Stephane, Mook Bangalore, Laura Bonzanigo,Marianne Fay, Tamaro Kane, Ulf Narloch, Julie Rozenberg, David Treguer, and Adrien Vogt-Schilb. 2016. Shock Waves: Managing the Impacts of Climate Change on Poverty. Climate Change and Development Series. Washington, DC: World Bank; Semba, R. D. (2012). The historical evolution of thought regarding multiple micronutrient nutrition. The Journal of nutrition, 142(1), 143S-156S

0.0 2.0 4.0 6.0 8.0 10.0 12.0

USA

Singapore

United Kingdom

Switzerland

Canada

Ireland

Australia

Austria

Germany

Denmark

% Share of Consumer Expenditures on Food

Countries in which consumers spend less than 15% of income on food expenditures

0 10 20 30 40 50 60

Turkmenistan

Azerbaijan

Guatemala

Pakistan

Philippines

Algeria

Kazakhstan

Cameroon

Kenya

Nigeria

% Share of Consumer Expenditures on Food

Countries in which consumers spend more than 30% of income on food expenditures

Economic access to food

Global Dietary Database; Global Panel on Agriculture and Food Systems for Nutrition. 2016. Food systems and diets: Facing the challenges of the 21st century. London, UK.

% of monetary value of food consumed from different sources: Ethiopia 2004/2005, Uganda 2009/2010, Tanzania 2010/2011, Mozambique 2008/2009, Malawi 2001/2011, South Africa 2010

4. Not Sustainable

Ranganathan, J. et al. 2016. “Shifting Diets for a Sustainable Food Future.” Working Paper, Installment 11 of Creating a Sustainable Food Future. Washington, DC: World Resources Institute. Accessible at http://www.worldresourcesreport.org

Ruminants contribute ~50% of GHGe from ag productionAnimal based protein consumption is rising in many countries

Part 3: The Implications of Our “Choices”

• Health Consequences

• Environmental Consequences

• Social Inequity Consequences

1. Health Consequences

• 815 million undernourished (hungry)

• 155 million children under five stunted, or chronically undernourished

• 52 million children under five wasted, or acutely undernourished

• 2.1 billion adults overweight or obese (Of that, 603.7 million adults & 107.7 million children are obese)

• 41 million children under five overweight

• 2 billion people with some type of micronutrient deficiency

Global Nutrition Report, 2016; IHME GDB Group Lancet 2017; Joint Child Malnutrition Estimates 2017 GBD 2013 Risk Factors Collaborators; Lancet 2015; Global Panel on Agriculture and Food Systems for Nutrition. 2016. Food systems and diets: Facing the challenges of the 21st century. London, UK

Joint Malnutrition Estimates 2017

Stunting Burden

Joint Malnutrition Estimates 2017

Wasting Burden

Famines are back

Global Nutrition Report 2017

Joint Malnutrition Estimates 2017

Childhood Overweight Burden

Adult Obesity

NCD Risk Factor Collaboration, 2017. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128· 9 million children, adolescents, and adults. The Lancet.

Number of countries facing burdens of malnutrition

Global Nutrition Report, 2017

2. Environmental Consequences

Ranganathan, J. et al. 2016. “Shifting Diets for a Sustainable Food Future.” Working Paper, Installment 11 of Creating a Sustainable Food Future. Washington, DC: World Resources Institute. Accessible at http://www.worldresourcesreport.org; Downs, S. M., & Fanzo, J. (2015). Is a cardio-protective diet sustainable? A review of the synergies and tensions between foods that promote the health of the heart and the planet. Current nutrition reports, 4(4), 313.

0 5000 10000 15000 20000 25000 30000

fruit

dried fruit

vegetables

potatoes

bread

pasta

rice

fish

milk

cheese

yogurt

olive oil

nuts

beef

poultry

pork

cookies

sweets

alcoholic beverages

Fru

its

Veg

etab

le

sW

ho

le G

rain

s

Fish

and

shel

lfi

shD

airy

pro

du

cts

Veg

etab le oils

Nu

ts

Mea

t

Swee

tsan

db

aker

yfo

od

s

Alc

oh

oli

cb

ever

ag es

Foo

ds

to E

nco

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Dis

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rage

Carbon footprint (grams of C02/ litre or kg of food)Water footprint (litre of water/litre or kg of food)

Water footprint Carbon footprint

Cardio-protective diet’s on water and carbon footprintsAnimal-based foods are more resource intensive than plant-based foods

3. Social Inequity Consequences

• The NEED VS ACCESS: In the high- and middle-

income countries and among urban

populations in all income countries, meat

consumption is rising (exceptions). Whereas,

in many low-income countries, populations

cannot access or afford animal source foods

and these are of critical importance to growth,

development and wellbeing.

• CONSEQUENCES of DECISIONS: Those most

vulnerable and in low income countries will

suffer the most from high-income country

decisions regarding the environment, natural

resource depletion and climate change.

UNICEF Global databases 2016, based on MICS, DHS and other national surveys.

Part 4: Drivers of Food System Changes

1. Poverty

2. Population growth & urbanization

3. Natural resource degradation

4. Climate change

5. Geopolitics & conflicts

1. Poverty remains an issue

• While some regions of the world have been successful in terms of reducing poverty, gains have not been even.

• Prosperity has spread to the cities much faster than the countryside.

• Vulnerable groups, such as minorities and women, are still more likely to be poor despite reductions in national poverty rates.

• Some areas in otherwise prosperous countries retain stubbornly high levels of poverty.

2. By 2050, 9.8 and urbanized

United Nations, Department of Economic and Social Affairs, Population Division (2017). World Population Prospects: The 2017 Revision, Key Findings and Advance Tables. Working Paper No. ESA/P/WP/248.

Receding Famine

Rural, subsistence, smallholder

farming

Diets high in grains, tubers, low in

animal source foods, seasonal

access to local fruits & vegetables

High labor intensity jobs on farms,

mines

Cook food at home with less fuel

efficiency

High stunting, micronutrient

deficiencies and communicable

diseases, shorter life expectancy

Transitioning Economies

Peri-urban, urban, service-based

economy

More processed & packaged

foods, street food, vegetable oils

and sugar

Increased sedentary-type work,

increase public transport and cars

Eat prepared foods away from

home, cook less

Increased obesity, non-

communicable diseases, longer

life expectancy but more disability

Modern Systems

Mainly urban or connected, small

town living

More dietary diversity and variety,

access to animal source foods,

fruits and vegetables

Greenspace, bike pathways,

purposeful physical activity

Eat away from home, food

deliveries

High obesity and non-

communicable disease burden,

but better health care, thus higher

life expectancy

With urbanization, comes the nutrition transition

Popkin and Drewnowski 1993

Many micro-food environments among nutrition transitions

HLPE 2017 Report Nutrition and Food Systems

3. Depletion of Natural Resources in the Food Supply

Khoury et al 2014 PNAS

Myers et al 2017 Public Health Reviews; Myers et al Lancet 2015

4. Climate Change, Everything Change

Number (in millions) of undernourished children under age 5 years in 2000 and 2050 from extended results of the IMPACT model published in the Global Food Policy Report February 2017

Climate Change, Everything Change

No. of undernourished children under age 5, in millions

2050 Additional no. of children

undernourished because of

climate change 2010-2050

Region 2010, base climate

Without climate

change

With climate

change

Sub-Saharan Africa 40.9 37.0 39.3 2.4

South Asia 77.1 50.4 51.9 1.4

East Asia/Pacific 21.9 7.8 8.2 0.4

Latin America & Caribbean 4.3 1.5 1.8 0.3

Middle East/North Africa 4.0 1.7 1.9 0.2

Europe and FSU 1.8 1.5 1.6 0.1

WORLD 150.0 99.9 104.8 4.8

Climate Change Impacts on Future Food Prices

5. Food Geopolitics: Food Crises & Social Unrest

Andrew Holland Arab Spring and World Food Prices: http://www.americansecurityproject.org/climate-security-report; Hendrix C (2016) When Hunger Strikes: How Food Security Abroad Matters for National Security at Home. The Chicago Council on Global Affairs, Chicago USA.

Conflict, Hunger and Undernutrition

Hendrix C (2016) When Hunger Strikes: How Food Security Abroad Matters for National Security at Home. The Chicago Council on Global Affairs, Chicago USA.

Arid Land Stress and Conflict

Copyright: Brent Stirton

Part 5: Ten Ideas Towards Solutions

Sustainable Diets

Those diets with low environmental impacts which contribute to food and nutrition security and to healthy life for present and future generations. Sustainable diets are protective and respectful of biodiversity and ecosystems, culturally acceptable, accessible, economically fair and affordable; nutritionally adequate, safe and healthy; while optimizing natural and human resources.

Johnston, Fanzo and Cogill 2014 Adv NutFAO 2012. Sustainable Diets and Biodiversity: Directions and Solutions for Policy, Research and Action

1. Global Goal Setting Matters

In 2017, yet again, the world is off course to meet nutrition targets – and, therefore, SDG 2.2

Number of countries categorised by assessment category for global targets on nutrition

No data / insufficient trenddata to make assessment

no progress or worsening / off course

Some progress

On course

4

4

4

4

7

150

146

136

142

163

181

189

189

137

16

16

21

9

49

7

7

24

26

8

20

31

29

18

Diabetes, women

Diabetes, men

Obesity, women

Obesity, men

Anaemia

EBF

Overweight

Wasting

Stunting

Integrate Nutrition into the SDGs

1

2

3

4

5

Makingconnections

Improving nutrition will be a catalyst for

achieving goals throughout the SDGs…

...and tackling

underlying causes of

malnutrition through

the SDGs will help to

end malnutrition.

Global Nutrition Report 2017

SUSTAINABLE FOOD PRODUCTION

1

Agricultural yields will decrease as temperatures rise by more than 3°C.

More carbon dioxide will meanless protein, iron, zinc and other micronutrient content in major crops consumed by much of the world.

More sustainable diets could make a significant difference to climate change, biodiversity and our waters. Food production uses 70% of the world’s freshwater supply, agriculture produces 20% of all greenhouse gas emissions, and livestock uses 70% of agricultural land.

SYSTEMS INFRASTRUCTURE

2

Infrastructure like roads, sanitation and electricity is needed to deliver food, water and energy more equitably. This includes cities: the world’s urban population will reach 66% by 2050, yet deprived areas are underserved, while infrastructure has made it easier to deliver foods that increase the risk of obesity.

Improved nutrition supports ‘grey matter infrastructure’: healthy people with the knowledge, ability and energy to drive economic development and build the future. Good nutrition gives people more labourand mental capacity, offering a $16 return for every $1 invested.

HEALTH SYSTEMS

3

A well-functioning health systemis vital to deliver preventative interventions at scale, to prevent and treat undernutrition, particularly in young children and mothers, and to tackle diet-related NCDs and obesity.

Undernutrition leads to 45%of all under-5 deaths.

Improved nutrition reduces sickness and lowers death rates, and so reduces the burden on health systems.

EQUITY AND INCLUSION

4

Education is associated with improved nutritional outcomes. Mothers who have had quality secondary school education are likely to have significantly better nourished children. Nutrition is linked to GDP growth: a 10% rise in income translates into a 7.4% fall in wasting.

Well-nourished children are 33% more likely to escape poverty, and each added centimetre of adult height correlates to an almost 5% increase in wage rates. Improved nutrition means better outcomes in education, employment and female empowerment, as well as reduced poverty and inequality.

5

The proportion of undernourished people living in countries in conflict and protracted crisisis almost three times higher thanthat in other developing countries.

Malnutrition will not endwithout peace and stability.

Investing in food security and the fair distribution of natural resources is critical for both nutrition resilience and reduced fragility.

PEACE AND STABILITY

2. Align National Dietary and Food PoliciesUS and Swedish food-based dietary recommendations in weight compared with global supply averages for 2009

Wiggins and Keats 2013 ODI Dietary Shifts Report

Shauna M. Downs, Alex Payne, Jessica Fanzo (2017) The development and application of a sustainable diets framework for policy analysis: A case study of

Nepal. Food Policy, Volume 70, 2017, 40–49. http://dx.doi.org/10.1016/j.foodpol.2017.05.005

Case Study: Nepal

MSNP = Multi-Sectoral Nutrition PlanNBSAP = National Biodiversity Strategy and Action PlanADS = Agriculture Development Strategy

3. Take on double or triply duty actions

WHO 2017

4. Improve food systems for better diets and nutrition

5. Maximize Entry Points, Minimize Exit Points for Nutrition

Fanzo, J. C., Downs, S., Marshall, Q. E., de Pee, S., & Bloem, M. W. (2017). Value Chain Focus on Food and Nutrition Security. In Nutrition and Health in a Developing World (pp. 753-770). Springer International Publishing.

Support Small and Medium Holder Farmers

Herrero, M., Thornton, P. K., Power, B., Bogard, J. R., Remans, R., Fritz, S., ... & Watson, R. A. (2017). Farming and the geography of nutrient production for human use: a transdisciplinaryanalysis. The Lancet Planetary Health, 1(1), e33-e42.

Food & Nutrient Loss and Waste, and its ties to safety

6. Consider Climate-Smart, Nutrition-Smart Solutions

Fanzo et al 2017 IFPRI

7. Improve the food environment• Improve the built environment for healthier eating – food

swamps, food deserts

• Incentivize retailers and sellers of food through tax breaks

• Reformulate foods – remove trans fats, reduce sugar and salt

• Phase out advertising and promotion of unhealthy foods to children and adolescents

• Limit the sale and serving of unhealthy foods in schools or near schools

• Promote healthy eating by introducing new foods to young taste buds thru school meals

• Information warning, certifications and safety standards on foods

Eliminate Food Deserts and Swamps

PRODUCTION & VALUE CHAIN CONSUMPTIONFOOD ENVIRONMENT

IMMANA Food Environment Working Group, 2017

Bring food to low-income areas

“Mo Gro” in Native American Neighborhoods of USA Southwest

“Arrabars” in African American Neighborhoods of Baltimore

Milk “Tarakwo Dairies” In urban slums of Kenya

Food/ beverage taxes Nutrient-focused taxes Subsidies

Effect on

consumption

Strongest evidence for SSB taxes –

reduce consumption by same

percentage as tax rate.

Subsidies increase healthy food

intake. Strongest evidence for

fruit and vegetable subsidies.

Reduce consumption of target but may

increase consumption of non-target

nutrients; may apply to core foods; better

if paired with subsidy.

Effects on body

weight/disease

outcomes

Substitution will affect total calorie

intake. Most effective to target

sugar sweetened beverages.

Limited evidence for disease

outcomes.

Disease outcome affected by

substitution – nutrient profile taxes

less likely to have unintended effects

than single nutrient-based taxes.

Subsidies may also increase

total calorie intake and body

weight. Very likely to reduce

dietary NCD risk factors.

May be most effective for low-

income populations; may have

greater effect on those who

consume most.

Mixed socioeconomic status

effects for population subsidies,

may benefit wealthy. Targeted

low-income subsidies effective.

May be more likely to have

regressive effects as more likely to

apply to core foods.

Differential

effects

Taxes and subsidies

Realize that Taxes are not a Panacea but One Tool

Fable et al 2016 AJPH; Stern et al JN 2016; Cochero et al 2017 Health Affairs

Promotion and Sponsorships

Food Advertising is a major problem…

A Solution: Front of the Pack Labels in Chile

• The labels are one part of a three-pronged approach set in motion by a law passed in 2012.

(1) front of the pack black-labeled food

(2) Black-labeled food cannot be advertised to children under 14 or include toys

(3) Black-labeled food cannot be sold in or near schools.

• It is not the government's intention to regulate the content of food, but to "change the environment" by informing consumers of the fat, sodium calories and sugar in foods.

8. Creating Demand for Healthier Foods

• KNOWLEDGE: Provide information, awareness, incentives for consumers to choose healthier choices – labels, dietary guidelines, and nutrition education.

• MASS MEDIA CAMPAIGNS: These can be provocative and influential. Media themselves are also very influential.

• NUDGING: Positive reinforcement and indirect suggestions to encourage better choices.

• CHANGE THE DEMAND!

Arno and Thomas 2016 BMJ

Certifications and safety qualifications

Mass media campaigns

Intakes of fruits increased from 1.5 to 1.7 servings/day and vegetables from 2.6 to 3.1 servings/day

9.3% reduction in using salt at table

1.5 million New Yorkers who saw the ad campaign said they consequently scaled back on soda consumption

Consider Nudges & Choice Architecture

• Nudging includes positive reinforcement and indirect suggestions to encourage better choices.

• Nudging does not include direct instruction, legislation, or enforcement.

• Nudging alters people’s behavior in a predictable way without forbidding any options.

Arno and Thomas 2016 BMJ

SR showing nudge interventions on average cause a 15.3% increase in healthier consumption decisions

9. Consider the Future of Sustainable Alternatives

“Eat Food. Not too much. Mostly Plants.” Michael Pollan

10. Empower Women as the Nutrition Caretakers

IFPRI 2012. Women’s Empowerment in Agriculture Index. International Food Policy Research Institute, Washington DC.

Conclusion

Future Sustainable Diets: I Leave You With 5 Questions

1. Is it even possible to have both human and planetary health and if yes, what are the trade-offs we are willing to live with? And how to we account for and measure those trade-offs?

2. How can create more social equity and justice across the food system and who should be responsible for ensuring that?

3. Who owns the food system and if no one owns it, how do we hold anyone accountable? How do we deal with power dynamics?

4. Where can we better align policies, policy decision making and funding to have double and triple duty effects?

5. How do we model the unknown/less certain drivers/shocks of food system change and their impact on diets?

Do we have the right to eat wrongly?

If we take a social justice approach in that all people share a common humanity and therefore have a right to equitable treatment, support for their human rights, and a fair allocation of community resources….

Don’t we have a social contract to ensure that everyone has a fair share of nutritional benefits from our food system?

Thank you!

Foodandnutritionsecurity.org@jessfanzo