FOOD AND Agriculture Global Practice An Overview of Links Between Obesity and Food Systems Implications for The Food and Agriculture Global Practice Agenda June 2017 FOOD AND AGRICULTURE GLOBAL PRACTICE An overview of links between obesity and food systems implications for the Food and Agriculture Global Practice agenda June 2017 Contents Abbreviations and Acronyms v Acknowledgmentsvii Executive Summary ix Agricultural Production Subsystem x Food Storage, Transport, and Trade Subsystem (postharvest level) xi Food Transformation Subsystem (agroprocessing level)  xii Food Retail and Provisioning Subsystem (retail level)  xii Introduction and Relevance of This Work 1 Objectives 5 Nutrition Transition: The Changing Dimension of the “Malnutrition Challenge” 7 Overweight/Obesity: A Complex Challenge of High Cost to Society 13 Role of Agriculture and the Food System in Promoting Safe, Diversified and Healthy Diets with a Focus on Overweight/Obesity 17 Role of the Agricultural Production Subsystem 19 Role of the Food Storage, Transport, and Trade Subsystem (postharvest level) 24 Role of the Food Transformation Subsystem (agroprocessing level) 25 Role of the Food Retail and Provisioning Subsystem (retail level) 28 Conclusions 33 Entry Points for Possible Action 34 Future Research 40 Annex 1The Full Obesity System Map from the UK Government Foresight Report 41 Annex 2Food Production and Food Consumption Clusters of the Obesity System Map 43 References 45 TABLES Table 1.  Leading Risk Factors for Human-Caused Diseases and Death (measured by reduction in disability adjusted life years) 10 FIGURES Figure 1.  Overall Trend (total population for adults 181): Declining Undernourishment and Exploding Overweight 9 Figure 2.  Overall Trend (children under 5 (U5)): Declining Stunting and Increasing Overweight 9 Figure 3.  Global and Regional Trends of Child Overweight Prevalence, 1990–2013 (children < 5 years) 10 Figure 4. Obesity Rises with Income—with a Few Exceptions 11 An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda iii Figure 5.  Framework to Categorize Obesity Determinants, Moderators and Solutions 15 Figure 6.  Conceptual Framework Showing Link between Diet Quality and the Food System  19 Figure 7. Projections of Fruit and Vegetable Adequacy to 2025 and 2050 20 BOXES Box 1.  What Is a Healthy Diet? 3 Box 2. NOURISHING Framework Policy Actions 18 Box 3.  Top Companies Incorporating Nutrition Considerations in Their Business Models 31 iv Food and Agriculture Global Practice Abbreviations and Acronyms Agriculture GP Food and Agriculture Global Practice IARC International Agency for Research on ASA Advisory Services and Analytics Cancer ASF Animal Source Foods IFC International Finance Corporation ATNI Access to Nutrition Index IFPRI International Food Policy Research BMI Body Mass Index Institute CGIAR Consortium of International Agricultural KP Knowledge Product Research Centers LAC Latin America and the Caribbean EAP East Asia and the Pacific MENA Middle East and North Africa ECA Europe and Central Asia NCDs Noncommunicable Diseases FAO Food and Agriculture Organization (of NGO Nongovernmental Organization the United Nations) OECD Organisation for Economic Co-operation FBGDs Food-Based Dietary Guidelines and Development FDA Food and Drug Administration OFSP Orange Flesh Sweet Potatoes GBD Global Burden of Diseases SAFANSI South Asia Food and Nutrition Security GDP Gross Domestic Product Initiative GNI Gross National Income SAR South Asia GNP Gross National Product SSA Sub-Saharan Africa GAIN Global Alliance for Improved Nutrition SUN Scaling Up Nutrition Glopan Global Panel on Agriculture and Food TTL Task Team Leader Systems for Nutrition UNICEF United Nations Children’s Fund HFCS High Fructose Corn Syrup WBG World Bank Group HNP GP Health, Nutrition, and Population Global WHO World Health Organization Practice WTO World Trade Organization An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda v Acknowledgments This report was written by Aira Htenas (Task Team Leader, TTL) and Yurie Tanimichi- Hoberg with inputs from Lynn Brown. Peer reviewers were: Harold Alderman (International Food Policy Research Institute, IFPRI); Diego Arias Carballo; Maria Eugenia Bonilla-Chacin (Health, Nutrition and Population Global Practice, World Bank Group); Svetlana Edmeades; Bonnie McClaf- ferty (Global Alliance for Improved Nutrition, GAIN); Stephen Mink (Independent Consultant); and Shobha Shetty. This report benefited greatly from consultations with the following World Bank Group colleagues: Steven Jaffee, Robert Townsend, Asa Giertz, Wijnand Van Ijssel, and Emilie Cassou. Ariana Kripalani supported the production of the report; Caitlin Whittemore provided editorial support; Kimberly Parent worked on the layout of the Annexes; and Shunalini Sarkar worked on the front and back covers. Juergen Voegele, Ethel Sennhauser, Preeti Ahuja, and Mary Kathryn Hollifield pro- vided leadership and guidance throughout the development of the report. Unless otherwise specified, all individuals are with the Food and Agriculture Global Practice of the World Bank Group. An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda vii Executive summary Obesity has emerged as a global challenge, affecting developed and developing coun- tries alike. Globally, overweight and obesity cost an estimated US$2 trillion per year, and 68 percent of all deaths are caused by noncommunicable diseases (NCDs), of which three of the four most common are diet related (namely cardiovascular dis- eases, cancers, and diabetes). Moreover, two-thirds of deaths from NCDs take place in developing countries, where also two-thirds of overweight or obese people live, casting obesity no longer as only a developed country challenge. While the World Bank Group (WBG) has embraced the global nutrition challenge since the launch of the Scaling Up Nutrition movement in 2010, the Food and Agri- culture Global Practice’s (Agriculture GP) efforts to date have focused largely on one dimension of the malnutrition spectrum, undernutrition and micronutrient deficien- cies, leaving a role for the GP in addressing the challenges associated with the other dimension of the spectrum, overweight and obesity. This Knowledge Product (KP) is an initial attempt to better understand how agricul- ture and food systems can contribute to and mitigate against the rising incidence of overweight and obesity in WBG client countries, and to do so by presenting evidence- based interventions (policies and actions) in the agriculture and food systems domain. This report is based on literature review, and not primary research. It is intended pri- marily to inform World Bank staff in related operational and analytical work. Obesity is a multi-sectoral and multidisciplinary challenge that requires a collaborative effort; any successful intervention strategy and actions would need to be multifaceted. This report has been undertaken at the request of the World Bank’s Health, Nutrition and Population GP and to complement their ongoing analytical work on preventing and controlling overweight and obesity: approaches and policy options that examines overweight and obesity through the lens of many other sectors, including and beyond agriculture and food systems. As the world faces an evolving malnutrition crisis, with countries moving from the challenges of undernutrition and micronutrient deficiency to a crisis that also includes An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda ix overweight and obesity, one thing remains constant: agri- outcomes documented, are arranged under their respec- culture and the food system have an important role to tive subsystems. play in ensuring access to a high quality diet that includes diversity of foods that are safe, and provides levels of This work emphasizes the overt need for context-specific energy appropriate to age, sex, disease state and physical piloting of suites of interventions, paired with vigor- activity as well as micronutrients (Glopan, 2016). While ous monitoring and assessment, given both the strong there is no available quantification of the share or impor- cultural/behavioral context of the obesity problem and ­ tance of agriculture and the food system within the set of the unknown universality of intervention success within factors that contribute to rising obesity (and that share, the agriculture and food systems domain. This report’s even if quantifiable, would likely differ from country to recommended entry points for action—intended to sup- country), most studies indicate that a comprehensive port- port the goal of improving diet quality with a focus on folio of interventions “targeting a broad set of variables overweight—have been developed, with respect to each and different levels within the obesity system” is necessary subsystem, accordingly. to tackle the crisis. Agricultural Production This report discusses direct and indirect policies, as well as program and project actions affecting diets with a focus Subsystem on overweight and obesity, but not exclusively so. This is a. Role of Agricultural Research—­Agricultural couched upon the realization that many of the suggested research greatly affects relative profitability of dif- actions for reducing overweight and obesity also serve ferent crop choices, farmer decision making, and the purpose of reducing undernutrition and/or micro- consequently affects relative prices of raw material nutrient deficiency. Thus, policies and actions that sup- supply to the food system, which likely influences port the provision of and access to a safe, diversified, and the processed food produced. While over 7,000 healthy diet should be supported continuously across the different crops have been historically harvested entire food system as countries transition from focusing for consumption, today, 50 percent of all plant on undernutrition to overlapping malnutrition problems sourced calories come from just three crops: rice, increasingly including overweight and obesity. While evi- wheat and maize. These three are also amongst dence of impact is still being generated based on expe- the crops that have received the most attention rience within the agriculture and food systems domain, by the agricultural research community, most there is ample evidence of impact for interventions to notably starting with the Green Revolution, and control and prevent obesity in areas outside the domain continuing today under the Consortium of Inter- of this report. national Agricultural Research Centers (CGIAR), and private sector research efforts. Surplus pro- This report uses the Global Panel on Agriculture and duction of staple grains since the 1970s has not Food Systems for Nutrition (Glopan) conceptual frame- been matched by productivity gains in other cere- work that illustrates the link between diet quality and the als, such as pearl millet, as well as in fruits and four subsystems of the food system: agricultural production; vegetables, where a global production deficit food storage, transport and trade; food transformation; and food currently exists. Based on current WHO recom- retail and provisioning. The remainder of this KP is orga- mendations, production of fruits and vegetables is nized based upon Glopan’s conceptual ­ framework—with 22 percent below global population requirements, a slight modification to include the significant impact and 58 percent below consumption needs in low- made by agricultural research on ­ agricultural/food income countries. Based on medium population ­ production—beginning with the ‘farm’ or agricultural forecasts and assuming business as usual, this situ- production subsystem and continuing onto the ‘fork’ or ation will worsen with the supply to needs ratio food retail and provisioning subsystem. All suggested falling to 0.35 in 2025 and 0.33 in 2050. In turn, interventions, most of which have been tested and their without a change in the agricultural research and x Food and Agriculture Global Practice technology domain, by 2050 the production of ENTRY POINTS FOR POSSIBLE ACTION fruits and vegetables will be 67 percent below that Agricultural Research Subsystem required in low-income countries, which will lead 1. Incentivize more public sector research on high to increased prices, and thus compromise access to quality and underserved foods (legumes, fruits, veg- diversified and healthy diets. etables) to increase productivity and shift relative b. Role of Agricultural Production—­ prices. Agricultural production generates the foods and 2. Ensure that cereal research and provision on inputs include a nutrition focus, and not just a yield focus, ingredients that form the basis of the quantity, and that results are communicated to producers. diversity and relative prices of foods available for 3. Encourage private sector advances in research favor- human consumption. Although diet diversity has ing high quality and underserved foods. long been recognized as important for adequate Production Subsystem nutrient intake and human health, the concept 1. Ensure that bio-fortified cereals are the norm, where of nutritional diversity is typically not integrated they are available and agronomically competitive, into planning and assessments of agricultural and rather than the exception. food systems and policies. In fact, in the context of 2. Eliminate subsidies and other production/price sup- global agricultural development, ‘nutrition sensi- port measures for production of unhealthy ingredi- tive agriculture’ has gained traction only recently ents for food processing. as part of a 2010 movement to focus attention on 3. Encourage production (and consumption) of fruits, vegetables, and pulses. a multi-sectoral approach to improving nutrition. Success of agricultural systems, rather than based on the providing of diverse, required nutrients, is reduce the risk of heart disease and stroke, contribute to more often evaluated by metrics of crop yields, prevention of some types of cancer, lower risk of eye and economic output and cost-benefit ratios. And, digestive problems and have a positive effect on blood while agriculture’s contribution to food security sugar that can help keep appetite in check thereby being has traditionally focused on supply issues with, an effective tool in weight control. Therefore, preventing perhaps, its greatest achievement enshrined in the overweight and reducing micronutrient deficiency share Green Revolution—one unintended consequence a common goal of a high quality diet rich in fruits and was a shift in prices of staple grains relative to vegetables. other foods, such as legumes, fruits and vegeta- bles that did not experience such yield increases, resulting in a loss of dietary diversity toward more Food Storage, Transport, cereal-based diets. This consequently led to lower and Trade Subsystem intake of micronutrients (e.g., iron, vitamin A, and zinc) as relative prices of cereals decreased dra- (Postharvest Level) matically and became more accessible to the poor. When food is not consumed by the farmers themselves, The phenomenal success of the Green Revolution immediately after food is harvested it is handled, treated, in the 1960s and 1970s led to an overemphasis on stored, packed, moved, transported and traded. Interven- raising yields of a few select cereals as the central tions adopted in the food storage, transport and trade focus of agriculture in developing countries—a subsystem to improve diet quality are also interventions trend which continues today. that are undertaken for more conventional objectives of raising profitability of the value chain. Actions include Self production and trade are two ways to increase diversity investments to reduce food losses and waste, address food of the food supply. Irrespective of the strategy employed to safety and comply with export requirements. The fact that drive the development of a more diverse food supply, evi- the objectives of improving diet quality and profitability dence clearly shows that a diversified and healthy diet that can be achieved through the same measures is an advan- is rich in fruits and vegetables can lower blood pressure, tageous situation because no new or customized actions An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda xi are needed, unlike in the production subsystem where ultra-processed products is tightly correlated with overall actions aligned to conventional profitability maximizing diet quality. objectives do not necessarily deliver for the objective of improving diet quality. ENTRY POINTS FOR POSSIBLE ACTION Food Transformation Subsystem ENTRY POINTS FOR POSSIBLE ACTION 1. Increase market supply of fortified foods with ade- Food Storage, Transport and Trade Subsystem quate micronutrients. 1. Reduce food loss and waste of underserved nutri- 2. Build more awareness toward unhealthy ingredients tious food groups (especially fruits, vegetables, for food processing, food, and products. pulses, poultry, fish). 3. Incentivize product reformulation to reduce 2. Use trade to improve the quality of the local diet. unhealthy ingredients in the processing stage (sugar/ sweetener, sodium, trans fats, etc.). Food Transformation Food Retail and Subsystem Provisioning Subsystem (AgroProcessing Level) (Retail level) Food processing combines raw food ingredients to pro- Most food is purchased at market-based formal and infor- duce marketable food products that can be easily prepared mal retail outlets such as markets (traditional wet markets and served by the consumer. It ranges from simple forms and modern supermarkets), street vendors or restaurants. of transformation such as slicing, drying, or freezing to Another channel for food provision is the public procure- highly extractive forms where the nutrients of the original ment system where the government purchases food and ingredients are highly depleted through the various pro- provides meals for institutions such as state-run schools, cesses. “Ultra-processed” foods, or products characterized hospitals or prisons. Retailers and governments (in the as “durable, accessible, convenient, attractive, ready-to-eat, or ready- case of public procurement of food) can play a role in to-heat,” are considered to be problematic for public health promoting safe, diversified, and healthy diets by what they in two ways: first, their principal ingredients (oils, solid sell and how they position certain foods. This subsystem is fats, sugars, salt, flours, starches) make them excessive in closer to the actual consumption point, and thus is argu- total fat, saturated or trans fats, sugar and sodium, and ably the most effective in changing the food environment short of micronutrients and other bioactive compounds, and consumption behavior that lead to obesity. and of dietary fiber. Taken together this increases the risk of various serious diseases. Secondly, their high energy density, hyper-palatability, their marketing in large and ENTRY POINTS FOR POSSIBLE ACTION supersizes, and aggressive and sophisticated advertising Food Retail and Provisioning Subsystem all undermine the normal processes of appetite control, 1. Build more awareness toward healthy eating. leading to overconsumption, and therefore obesity, and 2. Disincentivize the consumption of unhealthy foods diseases associated with obesity. through taxes. 3. Regulate or limit access to unhealthy foods. Consumption of ultra-processed foods is increasing globally. Many experts believe that the rapid expan- Some of the interventions listed above can be discussed sion of ultra-processed foods, more so than any other with and undertaken by the ministry of agriculture in cli- subsystem with the agriculture and food system, is the ent countries, while others require multi- and cross-sectoral major factor in the obesity epidemic. Studies that exam- cooperation among ministries and agencies responsible ine the impact of ultra-processed products on obesity for health, gender, trade, transport, and more. The need and chronic noncommunicable diseases show consistent for collaboration across boundaries is further reinforced results. In several countries, the level of consumption of by the impact on overall diet quality, obesity, and chronic xii Food and Agriculture Global Practice noncommunicable diseases of the level of consumption safe, diversified, and healthy diets for all. In contrast to of ultra-processed products. Partnerships with the WBG’s other domains affecting obesity where there is ample evi- International Finance Corporation (IFC), the private sec- dence for interventions that control and prevent obesity, tor, and civil society are just a few that need to be pursued evidence of impact in the agriculture and food systems in order to influence that part of the food system. domain is still being generated. This report and the peer review process have identified possible topics for further In recent years, the Agriculture GP has made concerted examination, such as the changing economic determi- efforts to broaden its focus from ending poverty by deliv- nants of food choices, including agriculture policy and ering primarily on yields, profits, and jobs, toward also food policy biases; the role of food processing industries addressing the nutrition dimensions which underpin (i.e., industries that purchase raw farm commodities); health and human development. The process is not the role of retail structures (e.g., supermarkets etc.); and over. The nutrition-sensitive agriculture agenda needs to identification of locations where households do not have evolve to address overweight and obesity as agriculture access to diverse foods, both in terms of quantity and rela- and food systems can and should play a role in delivering tive prices. An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda xiii INtroduction and relevance of this work In order to permanently end poverty and hunger by 2030, the world needs a food system that can feed every person, every day, everywhere; that can raise real incomes of the poorest people; that can provide safe food and adequate nutrition; and that can better steward the world’s natural resources. In this context, the World Bank Group’s Food and Agriculture Global Practice (Agriculture GP) work is aligned around four strategic pillars: (i) ensuring a more climate-smart agriculture, (ii) improving nutri- tional outcomes, (iii) strengthening value chains and improving market access, and (iv)  promoting rural livelihoods and agriculture employment—as illustrated in the GP’s 2015 Ending Poverty and Hunger by 2030: An Agenda for the Global Food System publica- tion (Townsend, 2015). The GP’s 2016 The Future of Food: Shaping the Global Food System to Deliver Improved Nutrition and Health (World Bank Group, 2016) publication focuses on how food systems can contribute to improved nutrition and health and lays out a spec- trum of food system interventions to address different forms of malnutrition, which include reducing energy deficiency (hunger), reducing micronutrient deficiency (hid- den hunger), reducing excessive net energy intake (overweight/obesity), and improv- ing food safety. The World Bank Group has embraced the nutrition challenge as a multi-sectoral agenda. Since the launch of the Scaling Up Nutrition (SUN) movement at the Bank’s Spring Meetings in 2010, the Bank has worked across internal silos to address nutri- tion, and to set in practice the understanding that addressing underlying causes of malnutrition requires broader, nutrition-sensitive approaches implemented through multiple sectors in addition to health, including agriculture. Efforts in the Agriculture GP have largely focused on undernourishment (hunger) and one dimension of the malnutrition spectrum (undernutrition) and micronutrient defi- ciencies, leaving a role for the GP in addressing the challenges associated with the other dimension of the spectrum, overweight and obesity. Undernutrition and micro- nutrient deficiencies have been at the core of policies and operations because, despite significant progress, 795 million people are still not meeting their minimum dietary An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 1 energy needs, more than 2 billion people are not getting research determines the relative productivity and eco- all the vitamins and minerals necessary for growth and nomic returns of crop choices for farmers, which in turn healthy development, and 165 million children under five partly determines the relative prices of different dietary are stunted. Meanwhile, though, the prevalence of over- elements emanating from the agricultural production sys- weight and obesity is increasing, leading to much higher tems by virtue of the balance of production and availabil- incidence of diet-related noncommunicable diseases ity relative to needs. (NCDs),1 and resulting in the coexistence of different forms of malnutrition as the “new normal” (Global Nutri- Agriculture is part of the food system which refers to the tion Report, 2014). Globally, overweight and obesity cost set of institutions, resources, stakeholders, and behaviors an estimated US$2 trillion per year, and 68 percent of all involved in the production, transformation, delivery, sale, deaths are caused by NCDs, of which three of the four and consumption of food. As a driver of food availabil- most common are diet related (namely, cardiovascular dis- ity, affordability, access, and acceptability, it is responsi- eases, cancers, and diabetes) (McKinsey Global Institute, ble for providing diet options (Global Nutrition Report, 2014; WHO, 2015). Moreover, two-thirds of deaths from 2016). Studies have linked low quality diets (Global Panel, NCDs take place in developing countries, where also two- 2016) or unhealthy diets (The Chicago Council on Global thirds of overweight or obese people live, casting obesity Affairs, 2011) to different malnutrition and health out- no longer as only a developed country challenge (World comes, such as stunting, wasting, overweight and obe- Bank Group, 2016). sity, micronutrient deficiencies, high blood pressure and NCDs. The World Health Organization (WHO) identifies In light of the above, the role of agriculture and food unhealthy diets as one of the behavioral risk factors that systems in nutrition is being re-examined. Good nutri- can cause overweight and obesity, which in turn increases tional outcomes require good consumer and caregiver the risk of NCDs. An increasing amount of research is knowledge, good health, safe water and hygiene practices, focusing on food environment/food system factors such and most importantly a safe, diversified and healthy diet as production, marketing, affordability, and accessibility (Box 1). As such, agriculture has an essential role in nutri- of foods that affect diet choices, to more systematically tion as it directly influences the availability and accessibil- prevent and control diet-related diseases and overweight ity of nutrient rich foods such as fruits, vegetables, pulses, and obesity. dairy and fish. And this is so regardless of the specific nutrition objective: a safe, diversified and healthy diet is a There is a need to revisit an approach to nutrition that is goal across the nutrition challenge spectrum. Agricultural almost exclusively focused on hunger and undernutrition, and embrace a more significant focus on agriculture’s role 1 The four main types of NCDs comprise cardiovascular diseases (like heart in delivering safe, diversified, and healthy diets that not attacks and stroke); cancers; chronic respiratory diseases (such as chronic obstruc- only address undernutrition and micronutrient deficien- tive pulmonary disease and asthma); and diabetes. Source: WHO Fact Sheet cies, but also address the growing challenge of overweight on Noncommunicable Diseases, 2015 (http://www.who.int/mediacentre/ and obesity in our client countries. factsheets/fs355/en/). 2 Food and Agriculture Global Practice Box 1. What is a healthy diet? There is no universal definition of what constitutes a healthy, or high quality diet, as the exact composition of it depends on indi- vidual characteristics and needs (e.g., age, gender, lifestyle, etc.), but also on culture and availability of food. Nevertheless, the World Health Organization (WHO) advises that for adults a healthy diet comprises: »» fruits, vegetables, legumes (e.g,. lentils, beans), nuts and whole grains (e.g., unprocessed maize, millet, oats, wheat, brown rice). »» at least five portions of fruits and vegetables a day (note: potatoes, sweet potatoes, cassava and other starchy roots are not considered fruits or vegetables) to reduce the risk of NCDs and help ensure an adequate daily intake of dietary fiber. »» less than 30 percent of total energy intake from fats helps prevent unhealthy weight gain. Also the risk of developing NCDs is lowered by reducing saturated fats to less than ten percent of total energy intake, and trans fats to less than one percent, and replacing both with unsaturated fats. Unsaturated fats (e.g., fats found in fish, avocados, nuts, and sunflower, canola and olive oils) are preferable to saturated fats (e.g., found in fatty meat, butter, palm and coconut oil, cream, cheese, ghee and lard). Industrial trans fats (found in processed food, fast food, snack food, fried food, frozen pizza, pies, cookies, margarines and spreads) are not part of a healthy diet. »» less than ten percent of total energy intake from free sugars, which is about 12 level teaspoons for a person of healthy body weight consuming around 2,000 calories per day. WHO guidelines suggest ideally less than five percent of total energy intake for additional health benefits. Free sugars are all sugars added to foods or drinks by the manufacturer, cook or consumer, and sugars found naturally present in honey, syrups, fruit juices and fruit juice concentrates. Excess consumption of free sugars contributes to unhealthy weight gain, which can lead to overweight and obesity. »» less than one teaspoon of salt per day, and use iodized salt. The majority of people consume too much sodium through salt, and not enough potassium that can mitigate the negative effects of elevated sodium consumption. This combination contrib- utes to high blood pressure, which in turn increases the risk of heart disease and stroke. In 2015, the International Agency for Research on Cancer (IARC), the cancer agency of the WHO, advised people to moderate consumption of red meat and processed meat to reduce the risk of cancer. Red meat refers to all mammalian muscle meat, includ- ing, beef, veal, pork, lamb, mutton, horse, and goat. Processed meat refers to meat that has been transformed through salting, cur- ing, fermentation, smoking, or other processes to enhance flavor or improve preservation. Most processed meats contain pork or beef, but processed meats may also contain other red meats, poultry, offal, or meat by-products such as blood. The risk of cancer increases with the amount of meat consumed, but the data available for IARC’s evaluation did not allow for a conclusion about whether a safe consumption level exists. Sources: WHO. Healthy Diet. Fact Sheet No. 394. Updated September 2015. http://www.who.int/mediacentre/factsheets/fs394/en/ WHO Statement. Links between processed meat and colorectal cancer. 29 October 2015. http://www.who.int/mediacentre/news/statements/2015/ processed-meat-cancer/en/ International Agency for Research on Cancer (IARC); WHO. IARC Monographs evaluate consumption of red meat and processed meat. Press Release No. 240. 26 October 2015. http://www.iarc.fr/en/media-centre/pr/2015/pdfs/pr240_E.pdf An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 3 Objectives This Knowledge Product (KP) is anchored within the framework outlined in the Agenda for the Global Food System (Townsend, 2015), and the 2016 Future of Food publication (World Bank Group, 2016). Given that energy/food supply and availabil- ity are a recognized contributing factor to overweight and obesity, this report is an initial attempt to better understand how agriculture and food systems can contribute to and mitigate against the rising incidence of overweight and obesity, and to do so by presenting evidence-based interventions (policies and actions) in the agriculture and food systems domain. This work is based on literature review, and not primary research. Obesity is a multi-sectoral and multidisciplinary challenge that requires a collaborative effort; any successful intervention strategy and actions would need to be multifaceted. This report is undertaken at the request of the Health, Nutrition and Population Global Practice (HNP GP) of the World Bank Group and in order to com- plement their currently ongoing Advisory Services and Analytics (ASA) on preventing and controlling overweight and obesity: approaches and policy options that examines overweight and obesity through the lens of many other sectors, including and beyond agriculture and food systems. An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 5 Nutrition transition: the changing dimension of the “malnutrition challenge” According to the WHO, nutrition is defined as the intake of food considered in rela- tion to the body’s dietary needs. Good nutrition—an adequate, well-balanced diet combined with regular physical activity—is a cornerstone of good health. Poor nutri- tion can lead to reduced immune response, increased susceptibility to disease, impaired physical and mental development, and reduced productivity.2 Poor nutrition comes in multiple forms: undernourishment (hunger), undernutrition (poor nutritional status due to nutritional deficiencies), micronutrient deficiencies (when a person does not get enough important vitamins and minerals in their diet), and overweight and obesity (when a person eats too many calories and/or lacks sufficient exercise). Past data have shown that as poverty levels fall, undernutrition and micronutrient defi- ciency rates also fall. That is, as poverty levels fall, less people suffer from widespread and chronic undernutrition or hunger challenges. As incomes rise, people choose to eat better quality staple grains,3 as well as more diversified diets, including more animal source foods (ASF), fruits and vegetables. Studies show that undernutrition (defined as low weight- for-age) declines at about 50 percent of the rate that Gross National Product (GNP) per capita increases. Cross-country results resemble those coming from household surveys of individuals (Alderman, 2012). This is illustrated in the global decline of people suffering from undernourishment and children who are stunted. In 1990 more than a billion peo- ple worldwide suffered from undernourishment, whereas currently the numbers are less than 800 million. In terms of child stunting, 250 million children under the age of five were stunted in 1990 compared to about 156 million in 2015. About 40 percent of them live in South Asia (Aguayo and Menon, 2016), while more than one-third live in Sub- Saharan Africa. Progress on reducing stunting is particularly slow in Sub-Saharan Africa. Both Asia and Latin America and the Caribbean have cut stunting rates by over one-third 2 http://www.who.int/topics/nutrition/en/ 3 Consumers choose more expensive staple grains, e.g., rice with less grit, and the average cost of a calorie increases. An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 7 since 2000 while Sub-Saharan Africa saw a reduction of are overweight (Body Mass Index (BMI) ≥ 25), of which only one-sixth during the same period (UNICEF, 2016). about 641 million are obese (BMI ≥ 30).9 This means that about one-third of the entire global population is obese, Micronutrient deficiency is more difficult to recognize, with and the number of overweight is more than double the the exception of anemia, since laboratory assessments are number of undernourished people globally (Figure 1). expensive and intrusive.4 Thus, large-scale representative The same trend can be observed for data on children data are lacking even though effects on disease incidence, under 5 which shows declining rates of stunting and an cognitive and physical growth are well established. This increase in the prevalence of overweight children (Fig- has led some to label micronutrient deficiency as ‘hidden ure 2). Until very recently no country had reversed the hunger’ as opposed to the more visible form of undernu- increasing trend of overweight, although some high- trition (‘hunger’ ). However, existing data indicates that as income countries such as the United Kingdom (UK), poverty levels fall, micronutrient deficiency rates also fall and Italy have been showing signs of stabilizing (OECD, owing to improved access to diverse diets, adequate mater- 2014). Nauru has achieved a small decline in adult male nal and child care, as well as access to fortified foods.5 In obesity from 39.9 percent in 2010 to 39.7 percent in 2014 fact, out of the three most prevalent micronutrient defi- (Global Nutrition Report, 2015), and in the U.S. the prev- ciencies worldwide (vitamin A, iron, and iodine), only iron alence of obesity increased to 13.9 percent by 2003–2004 deficiency persists in high-income countries. Vitamin  A and then decreased to 9.4 percent in children aged 2 to deficiency, a leading cause of preventable blindness in 5 years by 2013–2014 (Ogden et al., 2016). In both cases, children and which increases the risk of disease and death however, the decline is very slight, and beyond the scope from severe infections, has been almost eliminated glob- of this paper to explain. ally except for in Sub-Saharan Africa and South Asia (Ste- vens et al., 2015). The number of countries where iodine Until quite recently the overweight and obesity epidemic deficiency is a public health problem decreased dramati- was considered a problem for only high-income countries. cally over the past decade leaving only 54 countries con- This is no longer the case as the number of overweight sidered to be iodine deficient by the WHO.6 Even for iron is exploding in developing countries, and this increase is deficiency, which is the most common and widespread affecting all regions. Figure 3 shows that since 1990 child- nutritional disorder in the world affecting over 2 billion hood overweight prevalence has been rising globally, and people, global trends are promising. WHO estimates show most rapidly in Europe and Central Asia (ECA) followed that globally the prevalence of anemia (caused by various by Latin America and the Caribbean (LAC). Prevalence factors of which about half is estimated to be iron defi- rates were high to begin with, and continue to rise in Mid- ciency) fell by 12 percent between 1995 and 2011—from dle East and North Africa (MENA). Growth rates seem to 33 percent to 29 percent in nonpregnant women and from be flat in Sub-Saharan Africa (SSA) and East Asia and the 43 percent to 38 percent in pregnant women.7 Pacific (EAP). Child overweight prevalence remains the lowest in South Asia (SAR) compared to other regions, Overweight, and its extreme form, obesity,8 show the but is rising. It is beyond the scope of this KP to explore opposite trend. Globally, approximately 2 billion people regional differences in overweight prevalence. 4 Anemia is not expensive to monitor and can be done with portable screening overweight; 30 and above is obese. Cutoffs were established by a WHO expert tools (like hemocue). This assessment is however generic and further tests are consultation in 2000 (http://www.who.int/nutrition/publications/obesity/ needed to determine iron deficiency anemia from infections. WHO_TRS_894/en/) to intentionally be linked to the risk of NCDs. BMI of 5 Anemia, defined as hemoglobin levels below 10.9 g/dl, declines at about 25 and above indicates that the risk of NCDs is increased, and the risk increases 25 percent of the rate of income growth (Alderman, 2012). as the BMI gets higher. There is an existing discussion that BMI cutoffs should 6 http://www.who.int/nutrition/topics/idd/en/ be different for people depending on origin or occupation. 7 http://www.who.int/nutrition/topics/globaltargets_anaemia_policybrief 9 The most comprehensive estimate for global overweight showed about 2.1 .pdf ?ua=1 billion people are overweight (Ng et al., 2014). WHO estimates put the global 8 A condition characterized by excess body fat, typically defined for children overweight figure in 2014 as 1.9 billion (WHO Global Health Observatory on the basis of weight-for-height, and for adults by Body Mass Index (BMI). data). The most recent estimate for obesity in 2014 was 641 million (NCD Risk A normal range of BMI is between 18.50 and 24.99. A BMI of 25 or above is Factor Collaboration, 2016). 8 Food and Agriculture Global Practice Figure 1. Overall trend (total population for adults 181): declining undernourishment and exploding overweight 2,000 1,800 1,600 1,400 1,200 1,000 800 600 400 200 0 2011 1990 1991 1992 1993 1995 1996 1997 1998 1999 2000 2001 2002 2003 2005 2006 2007 2008 2009 2010 2012 2013 2015 1994 2004 2014 Undernourishment (million) Overweight (million) Linear (overweight (million)) Source: Undernourishment data—FAOSTAT; Overweight data—Overweight prevalence from WHO Global Health Observatory Data (overweight for adults 18+ (body mass index ≥ 25), age-standardized (%)) and UN World Population Prospects, 2015 Revision (total population for adults 18+). Figure 2. Overall trend (children under 5 (U5)): declining stunting and increasing overweight 300 250 200 150 100 50 0 2011 1990 1991 1992 1993 1995 1996 1997 1998 1999 2000 2001 2002 2003 2005 2006 2007 2008 2009 2010 2012 2013 2015 1994 2004 2014 U5 Stunted U5 Overweight Linear (U5 stunted) Linear (U5 overweight) Source: Joint Malnutrition Estimates (WHO/UNICEF/World Bank), 2016. According to the risk analysis of the Global Burden of (Table 1). High BMI is known to be amongst the causes of Diseases study in 2015, which studied preventable causes other leading risk factors such as high blood pressure and of disease and premature deaths, having a high BMI was diabetes (identified by high fasting plasma glucose levels) found to be the fourth largest risk globally, and it was the that are also leading risk factors in all regions of the world risk factor that increased the most between 1990 and 2015 except for Sub-Saharan Africa. High BMI was the second An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 9 Figure 3. Global and regional trends of child overweight prevalence, 1990–2013 (children < 5 years) 14 SUB-SAHARAN AFRICA 12 SOUTH ASIA Overweight prevalence (%) 10 MIDDLE EAST & 8 NORTH AFRICA LATIN AMERICA & 6 CARIBBEAN 4 EUROPE & CENTRAL ASIA 2 EAST ASIA & 0 PACIFIC 1990 1995 2000 2005 2010 2014 GLOBAL Time Source: UNICEF, WHO, and World Bank, 2014; cross-reference with HNP ASA on global obesity. Table 1. Leading risk factors for human-caused diseases and death (measured by reduction in disability adjusted life years) Leading Three Risk Factors for Human-Caused Diseases and Death Rank of   1 2 3 High BMI Global Blood pressure Smoking Fasting plasma glucose  4 High income Smoking Blood pressure BMI  3 ECA Blood pressure Smoking BMI  3 LAC Fasting plasma glucose Blood pressure BMI  3 EAP Blood pressure Smoking Sodium  5 MENA Blood pressure BMI Fasting plasma glucose  2 SAR Blood pressure Fasting plasma glucose Particulate matter 10 SSA Childhood undernutrition Unsafe sex Unsafe water 10+ Source: GBD Risk factors collaborators, 2016. Note 1: Dark shaded box = high BMI, light shaded boxes = risk factors that are known to be partially caused by high BMI. Note 2: •  Blood pressure = high systolic blood pressure (over 110–115mm Hg) •  High fasting plasma glucose (over 4.8–5.4 mmol/L). A fasting plasma glucose test, or fasting glucose test (FGT), is a blood test used to help diagnose diabetes or prediabetes •  High BMI (over 25 kg/m2) •  Particulate matter = ambient particulate matter pollution (Annual average daily exposure to outdoor air concentrations of PM with an aerodynamic diameter smaller than 2.5 μm, measured in μg/m3 over 2.4–5.9 μg/m3) •  Sodium = diet high in sodium (24-hour urinary sodium over 1–5g per day) •  Unsafe water = unsafe water source measured by the proportion of households with access to different water sources (unimproved, improved except piped, piped water supply) and reported use of household water treatment methods (boiling or filtering; chlorinating or solar filtering; no treatment) •  Smoking measured by the proportion of the population with cumulative exposure to tobacco smoking; proportion of the population who currently smoke •  Childhood undernutrition measured by childhood (under 5) underweight, wasting and stunting •  Unsafe sex measured by the proportion of the population with exposure to sexual encounters that convey the risk of disease 10 Food and Agriculture Global Practice largest risk in the Middle East and North Africa; the third (ii) middle-income countries with similarly high obesity largest risk in high-income countries, Eastern and Cen- prevalence (> 20 percent); and (iii) low-income countries tral Europe, and Latin America and the Caribbean; and with low obesity prevalence rates (< 11 percent). Japan the fifth largest in East Asia and the Pacific. Only in Sub- and South Korea are the only clear outliers with obesity Saharan Africa was high BMI (or high blood pressure or prevalence rates much lower than what would be inferred high fasting plasma glucose) outside of the top 10 risks for according to their income levels (< 6 percent). Another diseases and death. study indicates that the relationship between GDP and mean BMI is positive and linear up to about US$5,000 Initially, the obesity epidemic was considered a problem per capita per year; at greater GDP, the relation between only in the U.S. and in some Western European countries. GDP and BMI is almost flat (Swinburn et al., 2011), Overall obesity prevalence does appear to be correlated indicating almost zero effect of one to the other. In the with a country’s wealth. Figure 4 clearly shows coun- U.S., more than half of adults in some age/gender/race/ tries categorized in three groups: (i) high-income coun- ethnic specific subpopulations were overweight or obese, tries with high obesity prevalence rates (>18 percent); and key factors included worsening diet quality (higher Figure 4. Obesity rises with income—with a few exceptions 40 35 Saudi Arabia USA Egypt 30 Turkey New Zealand Mexico Canada Australia UK South Africa 25 Obesity prevalence (%) Spain Russia France Italy Morocco Brazil Germany 20 Sweden Denmark Netherlands 15 Nigeria 10 Thailand China Kenya 5 S. Korea Ethiopia Japan Vietnam 0 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 Per capita GDP (2014 US$) Source: Original figure with 2008 values found in McKinsey Global Institute (2014). Figure updated for this report by Yurie Tanimichi-Hoberg. Obesity prevalence (BMI > 30): WHO Global Health Observatory, 2014 data, average of male and female prevalence rates. Per capita GDP: World Bank, 2014 current US$. An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 11 consumption of processed foods, eating out especially at namely undernutrition and micronutrient deficiencies. This fast-food restaurants) as well as reduced physical activity. increased burden is often referred to as the ‘double burden of malnutrition’. This double burden of malnutrition can In developing countries, overweight and obesity was ini- exist at the individual level (for example, children who are tially closely associated with high socioeconomic status stunted, by height for age, and are also obese, by weight for in urban areas. As early as 2000, the WHO was already height, at the same time), at the household level (when a indicating that “obesity prevalence is increasing worldwide at an mother may be overweight or anemic and a child or grand- alarming rate in both developed and developing countries. It is still parent is underweight) and at the population level (where relatively uncommon in African and Asian countries, but is more prev- there is a prevalence of both undernutrition and overweight alent in urban than in rural populations. In economically advanced in the same community, nation or region). regions, prevalence rates may be as high as in industrialized coun- tries” (WHO, 2000). However, in the early 2000s evidence Medical evidence also shows complex biological rela- began to emerge showing shifts to low socioeconomic sta- tionships between being overweight and factors that are tus groups and rural areas as a country’s GDP increased. beyond the individual’s control. For example, nutritional In Brazil, one of the few middle-income countries with deficiencies or an excessive rate of weight gain (such as repeated cross-sectional surveys of BMI, this shift was through exposure to interventions to promote compensa- particularly evident for women, with obesity rates increas- tory growth following a period of faltering growth) during ing rapidly in the lowest income groups (Monteiro et al., gestation, as well as not being exposed to breastfeeding 2007). A 2014 study in low- and middle-income countries for an adequate period, contribute to a predisposition to found that the prevalence of overweight is increasing in overweight and an increased risk of noncommunicable nearly all countries, and in about half of all countries diseases later in life (Popkin et al., 2012). This means that (33  percent), overweight in rural areas is increasing at a early stage undernutrition, including in utero, relates to rate greater than that in urban areas (Jaacks et al., 2014).10 increased risk of overweight later in life. This is particu- larly relevant to developing countries undergoing rapid Thus, the reality on the ground in most developing countries social and economic changes where large groups of infants is that they are faced with the costs and challenges stemming and young children are exposed to a mismatched environ- from overweight and obesity while still also managing the ment of nutritional deficiencies very early in life followed residual risks stemming from other forms of malnutrition, by excesses. For example, children’s anthropometric indi- cators may show low weight for age (underweight), but high weight for height, potentially overweight, due to the 10 KP team exchanges with the ASA team have confirmed that obesity rates are not reported by urban/rural status. The Global Burden of Disease (GBD) child being stunted (height for age), which is determined reports overweight (and obesity) prevalence by sex and by age. between conception and two years of age. 12 Food and Agriculture Global Practice Overweight/obesity: a complex challenge of high cost to society Being overweight harms health in many ways. High BMI is a known risk factor for diseases such as diabetes, heart disease, osteoarthritis, and some cancers, to name just a few, and reduces the life span by about three (3) years for overweight people and up to eight (8) years for the obese (Grover et al., 2014). Treating obesity and obesity related conditions costs billions of dollars a year. There is wide variance in estimates of the economic cost of obesity since different studies include different costs. Direct costs typically include all or some of costs related to health service delivery to treat obesity related health problems such as the cost of hospitalization, medical consultations in outpatient clinics and the consumption of medications. Indirect costs typically include all or some of the costs associated with lost productivity when individuals must tem- porarily (absenteeism) or permanently leave work for health reasons (disability or pre- mature mortality). Reduction in the productivity of workers in the workplace whose performance is impaired by their illness is also sometimes included. Some studies also include changes in insurance premiums since employers pay higher life insurance pre- miums and pay out more for workers’ compensation for employees who are obese than for employees who are not. McKinsey Global Institute estimates the global economic impact of obesity as roughly US$2 trillion per year or equivalent to 2.8 percent of global GDP. This includes the cost of lost economic productivity through the loss of productive years, direct costs to health care systems, and the investment required to mitigate the impact of obesity. The McKinsey Global Institute’s estimates put obesity as the third most costly human caused social burden behind only smoking (US$2.1 trillion per year) and ‘armed vio- lence, war and terrorism’ (US$2.1 trillion per year) (McKinsey Global Institute, 2014). In the U.S., the medical care costs to treat obesity were estimated to be US$147 billion dollars in 2008, and the annual nationwide productive costs of obesity related absen- teeism ranged between US$3.38 billion to US$6.38 billion.11 Combined, this roughly equates to about 1 percent of GDP in the U.S. In the U.K., another high-income 11 https://www.cdc.gov/obesity/adult/causes.html An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 13 country with a high prevalence of obesity, the cost to and food market prices in the food production cluster, the economy of overweight and obesity was estimated at and the variety and availability of food in markets, the £15.8 billion per year in 2007, including £4.2 billion in nutritional quality of available food, and the rate of eat- costs to its National Health Service.12 This roughly equates ing (speed at which people take their meals) in the food to 4 percent of GDP in 2007. consumption cluster (Vandenbroeck et al., 2007). Overweight and obesity are complex challenges with Another commonly used framework that categorizes obe- multiple contributing factors. Although immediate causes sity drivers/determinants,15 moderators/modulators and of overweight and obesity are relatively simple, namely solutions is by Swinburn (Figure 5, Swinburn et al., 2011). an imbalance of energy intake and energy expenditure The framework is again complex with different levels of resulting in a positive energy balance, there are many determinants that affect energy (im)balance from sys- other factors that directly or indirectly affect energy bal- temic drivers, such as taxation and regulatory regimes, to ance, and combine to contribute to the causes of obesity. environmental drivers on food and physical activity. The Child undernutrition is a similarly complex issue, which framework recognizes that energy balance is affected by benefited from the development of a conceptual frame- behaviors and environments. Accordingly, food appears work with strong buy-in from a wide range of stakehold- as an environmental driver, specifically as “food supply ers: the UNICEF causes of malnutrition framework that and marketing environments that promote high energy was developed as part of its Nutrition Strategy in 1990. intake,” and as a behavior pattern, namely “high food and Obesity is a newer epidemic compared to child under- energy consumption with associated low physical activity nutrition, and thus, there is not yet a singular conceptual levels.” Moreover, the authors locate “obvious possible framework for global stakeholders to rally around. drivers” of obesity in the food system, and specifically the rise in the supply of cheap, tasty, and energy dense food; A complex system map, the Foresight Obesity System improvement of distribution that renders food conveni- Map (Annex 1), developed by the U.K. Government, is ent and accessible; and food marketing. The additional comprehensive and the most commonly referenced obe- contribution of the framework is the insight it provides to sity framework. It identifies 108 separate factors (varia- possible solutions to obesity. The left-hand side refers to bles) in seven (7) individual and population-level clusters policy and system-wide interventions that hold the great- (physiology, individual activity, physical activity environ- est potential impact and have the widest population reach, ment, food consumption, food production, individual psy- but are also politically the most difficult to implement. chology, and social psychology) that directly and indirectly The right-hand side of the table lists the individual-based affect the core equation of energy balance (energy intake interventions, like drugs and surgery, that are relatively vs. energy expenditure)13 (Butland et al., 2007). Variables easy to implement and come with low or no political cost in each cluster interact with each other, and with variables (but with high medical/health care cost). To add to the in other clusters through a web of causal relationships. complexity of the matter, these medical and individual- There are four key variables affecting the core system based interventions have a stronger evidence base of suc- engine. The “force of dietary habits” is the key variable cess in curbing obesity. They, however, do not represent associated with the food production and consumption a financially viable and sustainable way to treat entire clusters (Annex 2) collectively referred to as the food envi- ronment in the System Map.14 It is affected by sets of vari- ables characterizing the food industry’s business model, 15 According to the framework, a driver/determinant of obesity is an “environ- mental factor that has changed substantially during the past 40 years (coinciding with the upswing of the [global obesity] epidemic), is global in nature (affecting 12 https://www.noo.org.uk/NOO_about_obesity/economics almost all countries with enabling economic conditions), and is rapidly trans- 13 At the core of the Obesity System Map is “energy balance” (energy intake vs. missible (in view of the near simultaneous nature of the epidemic across coun- energy expenditure), also referred to as the engine, or core engine. tries).” Moderators/modulators are defined as “environmental conditions that 14 The other three are: psychological ambivalence (under the psychology clus- operate on a population to accentuate or attenuate the effect that the drivers ter); degree of primary appetite control (physiology cluster), and level of physi- have on the trajectory of changes in obesity prevalence.” These can be cultural cal activity (physical activity cluster). body-size preferences, levels of active or car transport in a country, etc. 14 Food and Agriculture Global Practice Figure 5. Framework to categorize obesity determinants, moderators and solutions Environmentals Behaviours Physiology Environmental moderators Systemic Environmental Behaviour Energy drivers drivers patterns imbalance Policy and economic Food supply and Sociocultural, socioeconomic, High food and energy High total energy systems enable and marketing recreation, and transport consumption with intake pushing promote high growth environments environments which amplify associated low energy imbalance and consumption promote high of attenuate the drivers physical activity levels energy intake Policy Interventions Drugs, surgery Health promotion programmes, social marketing, etc. Population effect and political difficulty Source: Swinburn et al., 2011. populations. Thus, emphasis is placed on the left-hand intervention strategy would need to be multifaceted and side of interventions despite the sparse evidence on how tailored to a heterogeneous population. All these frame- they operate and how successful they are. works show that agriculture and the food system play a key role in such a strategy, especially pertaining to the clusters The complexity of the Obesity System Map and the of food production and consumption, and that changes in Swinburn et al. (2011) framework explain why, at an indi- the way we think and operate are needed. Some of these vidual level, it is so difficult for people to ‘just eat less, and changes are highly synergistic with efforts already under- move more to lose weight’, and why at a population level taken to address the other forms of malnutrition, and they no country has fully succeeded in reversing the obesity all fall under the common goal of promoting safe, diversi- trend. The complexity further illustrates how a successful fied and healthy diets. An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 15 Role of agriculture and the food system in promoting safe, diversified and healthy diets with a focus on overweight/obesity As the world faces an evolving malnutrition crisis, with countries moving from the challenges of undernutrition and micronutrient deficiency to a crisis that encompasses also overweight and obesity, one thing remains constant: agriculture and the food system have an important role to play in ensuring access to a high quality diet that includes a diversity of foods that are safe, and provides levels of energy appropriate to age, sex, disease state and physical activity as well as micronutrients (Glopan, 2016). Obviously, given the complexity of malnutrition as evidenced in the UNICEF frame- work for child malnutrition as well as the UK Foresight Report Obesity System Map and the Swinburn framework of obesity, agriculture and food systems are only part of the solution, since the set of associated factors that cause the problem is far reaching and amounts to a tightly knit obesogenic environment that sustains people to eat more and exercise less. There is no available quantification of the share or importance of agriculture and the food system within the set of factors that contributes to rising obesity, and that share, even if quantifiable would likely differ from country to country. Most studies take the approach that while research generates more evidence, “as many interventions as pos- sible must be delivered to have significant impact” because almost all interventions that are commonly discussed in obesity prevention/mitigation are highly cost effective from a societal viewpoint (McKinsey Global Institute, 2014), and that “a strategy to tackle obesity needs a comprehensive portfolio of interventions targeting a broad set of variables and different levels within the obesity system. Although, alone, each com- ponent part of the strategy may not create significant impact, their complementary and reinforcing action is critical to achieving the significant shift required in popula- tion obesity trends.” (Butland et al., 2007). An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 17 Box 2. NOURISHING framework policy actions Each letter in the word NOURISHING represents one of ten actions that governments can take: N = Nutrition label standards and regulations on the use of claims and implied claims on food O = Offer healthy food and set standards in public institutions and other specific settings U = Use economic tools to address food affordability and purchase incentives R = Restrict food advertising and other forms of commercial promotion I = Improve nutritional quality of the whole food supply S = Set incentives and rules to create a healthy retail and food service environment H = Harness food supply chain and actions across sectors to ensure coherence with health I = Inform people about food and nutrition through public awareness N = Nutrition advice and counseling in health care settings G = Give nutrition education and skills Letters in the word NOURISHING, and associated actions, fall within one of the three domains, as follows: NOURIS actions fall under the domain of the food environment; H represents the food system; and ING falls under behavior change communication. Source: http://www.wcrf.org/int/policy/nourishing-framework/about-nourishing It is possible to identify interventions through both policies support the provision of and access to a safe, diversified and programs/projects in agriculture and the food system and healthy diet should be supported continuously across that can contribute to preventing overweight and obesity. the entire food system as countries transition from focus- There are some policies that affect diets indirectly, such ing on undernutrition to overlapping malnutrition prob- as policies on agricultural development and investments lems increasingly including overweight and obesity. While in infrastructure, and others that have specific dietary evidence of impact is still being generated based on expe- objectives (Keats and Wiggins, 2014). The NOURISH- rience within the agriculture and food systems domain, ING framework (Box 2), developed by the World Can- there is ample evidence of impact for interventions to cer Research Fund International, provides an often cited control and prevent obesity in areas outside this domain. list of the latter type of policy actions that governments can take to promote healthy diets and reduce overweight This report uses the Global Panel on Agriculture and Food and obesity. The framework highlights ten policy actions Systems for Nutrition’s (Glopan) conceptual framework in three domains: food environment, food system and that shows the link between diet quality and the four sub- behavior change communication.16 Actions broadly fall systems of the food system: agricultural production; food under the food system in that they affect both supply and storage, transport and trade; food transformation; and demand of food. food retail and provisioning (Figure 6). The remainder of this document will organize itself using this conceptual This report will discuss direct and indirect policies, as framework, starting with the ‘farm’ or agricultural pro- well as program and project actions affecting diets with duction subsystem and continuing onto the ‘fork’ or food a focus on overweight and obesity, but not exclusively so. retail and provisioning subsystem. The only modification This is couched upon the realization that many of the introduced is the consideration of agricultural research as suggested actions for reducing overweight and obesity an important and separate aspect of the agricultural pro- also serve the purpose of reducing undernutrition and/or duction subsystem given its outsized role in affecting the micronutrient deficiency. Thus, policies and actions that agricultural/food production system. Under each subsystem examples of suggested interven- The framework is accompanied by a regularly updated database listing imple- 16 mented government policy actions accessible here: http://www.wcrf.org/int/ tions are listed. Most of these suggested actions have been policy/nourishing-framework tested and their outcomes documented. However, even 18 Food and Agriculture Global Practice Figure 6. Conceptual framework showing link between diet quality and the food system Drivers of food systems upply system Food s Agricultural Food environment Food storage, production transport and subsystem trade subsystem Consumer Nutrient quality & Diet Food taste of quality labeling available food Purchasing Physical power Food access promotion Food retail Food to food and provisioning transformation subsystem Food price subsystem Source: Glopan (Global Panel on Agriculture and Food Systems for Nutrition), 2016. when an intervention works well in a particular setting, supply to the food system, which likely influences the pro- the universality of its success is unknown. In fact, given cessed food produced. Throughout history, 7,000 crops have the strong cultural and behavioral context of the obesity been used for food, but today just 12 crops and five (5) ani- problem, it is likely that any successful intervention must mal species provide 75 percent of the world’s food. Fifty per- be customized to the local context. Context-specific pilot- cent of plant-sourced calories come from just three crops: ing of suites of interventions, paired with vigorous moni- rice, wheat and maize (Kennedy, 2015). These three are also toring and assessment, would be important to discover amongst the crops that have received the most attention by the best mix of actions and policies to undertake. The the agricultural research community, most notably starting suggested actions in the rest of the report do not include with the Green Revolution, and continuing today under the those that are only available in a high-income context Consortium of International Agricultural Research Cen- or pertain to clusters not associated with food, such as ters (CGIAR), and private sector research efforts. South reducing screen time for children, or offering business tax Asia illustrates the impacts of the Green Revolution. In incentives for establishing exercise and outdoor recrea- 1969–1971, the surplus production of staple grains over tional facilities. consumption requirements was just 10 million metric tons. By 2009–2011 the surplus was more than 60 million metric Role of the Agricultural tons, and more than 89 percent of the staple grain surplus production subsystem was made up of rice, wheat and maize and just 11 percent related to other cereals, reflecting the lower productivity (a) Role of agricultural research gains in other cereals, such as pearl millet (Pingali, 2015). Background: Agricultural research greatly affects relative profitability of different crop choices, farmer decision mak- Global performance in staple grain production has not ing, and consequently affects relative prices of raw material been matched by performance in fruits and vegetables An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 19 Figure 7. Projections of fruit and vegetable adequacy to 2025 and 2050 Projections to 2025 Projections to 2050 1.0 1.0 Supply:Need Ratio Supply:Need Ratio 0.8 0.8 0.6 0.6 0.4 0.4 0.2 0.2 0.0 0.0 All Low Lower Upper High All Low Lower Upper High countries income middle middle income countries income middle middle income income income income income High fertility Medium fertility High fertility Medium fertility Low fertility Current scenario (2009) Low fertility Current scenario (2009) Source: Siegel et al., 2014. where there is a global production deficit. An analysis of bio-fortification, and not just a yield focus; and (3) encour- global data (Figure 7) reveals that, based on current WHO aging private sector advances in research and technology recommendations, global production of fruits and vege- favoring high quality and underserved foods. tables is 22 percent below the global population needs, 1.  Incentivizing more public sector research with a supply to needs ratio of 0.78. The situation for on high quality and underserved foods low-income countries is worse, with a median supply to (legumes, fruits, vegetables) to increase needs ratio of just 0.42, indicating that fruit and vegeta- productivity and shift relative prices: ble production is 58 percent below the consumption needs The Consortium of International Agricultural of people in low-income countries (Siegel et  al., 2014). Research Centers (CGIAR) allocated half of its Inadequate production levels result in higher prices, par- research funding in 2012 to rice and maize. While ticularly given the short shelf life and fragility of these livestock, fish and some pulses received some allo- products in transportation, compromising access by the cation, research for fruits and vegetables (except poor to a healthy diet. Based on medium population fore- for bananas) was minimal (Glopan, 2016). CGIAR casts and assuming business as usual, this situation will is a donor to the World Vegetable Center, that worsen with the supply to needs ratio falling to 0.35 in focuses on vegetable research and development. 17 2025 and 0.33 in 2050. Without a change in the agricul- In 2005, the Center cofounded the Global Horti- tural research and technology domain, by 2050 the pro- cultural Initiative to increase awareness amongst duction of fruits and vegetables will be 67 percent below international policy makers of the value of fruit that required in low-income countries, which will lead to and vegetables in combatting global malnutrition increased prices, and thus compromise access to healthy and poverty. Efforts could be expanded to rein- diets for the poorest. force the Center’s work even further. 2. Ensuring that cereal research and provi- Pathways to influence diet quality (with a focus sion on inputs include a nutrition focus, on overweight): In the agricultural research subsys- and not just a yield focus, and that results tem the three main pathways to improve diet quality are are communicated to producers: Increasing through: (1) incentivizing more public sector research on high quality foods (legumes, fruits, vegetables) to 17 Founded in 1971 as the Asian Vegetable Research and Development Center increase productivity and shift relative prices; (2) ensur- (AVRDC) with a focus on tropical Asia, today the work of the World Vegetable ing that cereal research includes a nutrition focus, such as Center spans the globe. https://avrdc.org/ 20 Food and Agriculture Global Practice supply of cereals is a traditional objective of agri- messages related to undernutrition and micronu- cultural development in most countries, and even trient deficiencies, and often in collaboration with more so in developing countries where food secu- the health community. They have not been used rity and the maintenance of livelihood for the to convey messages related to overweight/obesity, majority of the rural poor is often the primary but presumably they could. objective of the sector. Toward this objective, farm 3. Encouraging private sector advances policies in many developing countries are geared in research favoring high quality and toward improving the productivity of basic cereals underserved foods: Glopan (2016) reports by increasing access to modern inputs such as high that approximately 45 percent of private sector yield seeds, agrochemicals and improved water research investments focus only on maize. Nota- management infrastructure. This type of inter- bly this exceeds the maize seed share (25 percent) vention, while effective in addressing widespread of the seed industry, but it is illustrative of the hunger, has no positive effect on addressing micro- industry’s experience that maize seed production nutrient deficiency or overweight. In fact, a singu- is profitable. Other crops have not received such lar focus on this approach has been shown to be investments. In situations where there is a growing detrimental to it. A parallel action could include private sector capacity for agricultural research, developing new metrics in agriculture that mea- governments can promote research on high qual- sure aspects related to nutrition, such as an alter- ity and underserved foods through the private native to standard yields (nutrient content per unit sector with competitive research grants or other of land or labor), and minimum cost of a quality services. diet.    These research results will need to be dis- (b) Role of agricultural seminated to farmers through channels including production subsystem an effective extension system capable of taking on (farm level) knowledge related to nutrition. Agriculture exten- Background: Agricultural production generates the sion workers have direct and ongoing contact with foods and ingredients that form the basis of the quantity, smallholder farmers, and therefore have a unique diversity and relative prices of foods available for human opportunity to strengthen messages regarding con- consumption. Despite the fact that diet diversity has long sumption of nutritious foods based on WHO rec- been recognized as important for adequate nutrient intake ommendations of what constitutes a healthy diet. and human health, the concept of nutritional diversity is Extension services are delivered by public and pri- typically not integrated into planning and assessments vate entities via extension agents, such as national of agricultural and food systems and policies. Success of ministries of agriculture, and large agribusinesses. agricultural systems is more often evaluated by metrics Farmers, nevertheless, may not receive an exten- of crop yields, economic output and cost-benefit ratios, sion agents’ visit for years due to poor logistics and and does not reflect the diversity of nutrients provided by resource constraints. In order to overcome these the system and required for a healthy diet. In the context limitations, and to also convey messages more of global agricultural development, ‘nutrition-sensitive easily, a variety of channels are increasingly used agriculture’ has gained traction only recently as part of a including radio, print media, and information movement to focus attention on a multi-sectoral approach and communication technology (ICT)-enabled for improving nutrition as espoused by the Scaling Up tools, such as cell phones and videos, the enabling Nutrition movement that began in 2010. role of which is well documented.18 Agriculture extension systems have been used to disseminate Agriculture’s contribution to food security has tradition- ally focused on supply issues with, perhaps, its greatest World Bank. (2017). ICT in Agriculture: Connecting Smallholders to Knowledge, Net- 18 achievement enshrined in the Green Revolution. Thanks works, and Institutions. Updated Edition. Washington, DC: World Bank. largely to the Green Revolution, the developing world An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 21 tripled its production of cereal crops despite a doubling of ways to increase diversity of the food supply. A recent population, with only a 30 percent increase in land area cross-country study19 cited in the Glopan Foresight Report cultivated (Wik et al., 2008). Agricultural output per per- (2016) found that while food imports (and income) are son grew by 61 percent from US$209 per person in 1961 associated with a more diverse food supply in high- and (2004–06 international prices), to US$336 per person in middle-income countries, the diversity of agricultural 2010. Consequently, between 1961 and 2010, real prices goods produced by a country is the stronger predictor of cereals fell by roughly 60 percent (Alston and Pardey, in low-income countries. Regardless of what drives the 2014). This phenomenal feat was accomplished by intensi- development of a more diverse food supply, evidence fying the use of modern inputs—in particular machinery, clearly shows that a diet rich in fruits and vegetables can fertilizers and irrigation, combined with improved genetic lower blood pressure, reduce risk of heart disease and material and methods of production derived from orga- stroke, contribute to prevention of some types of cancer,20 nized scientific research, mainly from CGIAR centers. lower risk of eye and digestive problems, and have a posi- tive effect upon blood sugar that can help keep appetite The Green Revolution focused on basic food staples such in check thereby being an effective tool in weight control. as rice, wheat and maize, because of their importance in Therefore, preventing overweight and reducing micronu- the diets of the poor as primary sources of calories, and trient deficiency share a common goal of a high quality because there was significant research already conducted in diet rich in fruits and vegetables. But while there is con- developed countries for these crops. One unintended con- sensus among the health community regarding the ben- sequence of the Green Revolution was a shift in prices of efits of a diet rich in fruits and vegetables, advice varies on staple grains relative to other foods, such as legumes, fruits the health benefits and risks associated with the consump- and vegetables that did not experience such yield increases, tion of certain meats. resulting in a loss of dietary diversity toward more cereal- based diets. This consequently led to lower intake of micro- Evidence shows that while meat consumption, in general, nutrients as relative prices of cereals decreased dramatically is an important source of protein and some micronutri- and became more accessible to the poor. In some cases, tra- ents like iron and vitamin B12, high intake of red meat ditional crops that were important sources of critical micro- and processed meat is associated with an increased risk nutrients (such as iron, vitamin A, and zinc) were displaced of heart disease, diabetes, and colon cancer, as well as by staples promoted by the Green Revolution. The Green weight gain. Thus, many in the health community advise Revolution was one of, if not the most important advance replacing red and processed meat with nuts, beans, fish, or in modern agriculture, and thus its influence on agriculture poultry to lower the risk of heart disease and diabetes and practitioners and policy makers alike has been profound. to aid in weight control (Bernstein et al., 2010 and Mozaf- The phenomenal success in dramatically raising the yields farian et al., 2011). Therefore, a nuanced message needs of three major crops (rice, wheat and maize) in the 1960s to be developed for the promotion of livestock produc- and early 70s, and the much delayed and less publicized tion (beef and pork) since the recommendation does dif- gradual release of high yield varieties in other crops such as fer by the type of malnutrition challenge being addressed, pulses and root crops till the 1980s, led to an overemphasis unlike with fruits, vegetables, and pulses, where the mes- on raising yields of a few select cereals as the central focus sage remains consistent. In the agricultural production of agriculture in developing countries. This continues today. subsystem at the farm level the three main pathways to The response to the 2007–08 food price crisis was a call to increase production and productivity of staple grains. Simi- 19 Remans, R., Wood, S. A., Saha, N., Anderman, T. L., and Defries, S. A. 2014. larly, the focus of climate smart agriculture has largely been Measuring nutritional diversity of national food supplies. Global Food Security, 3, on staple grains; yet arguably fruits and vegetables are far 174–182, http://dx.doi.org/10.1016/j.gfs.2014.07.001 20 High consumption of non-starchy vegetables—such as lettuce and other leafy more sensitive to temperature changes and water stress. greens, broccoli, bok choy, cabbage, as well as garlic and onions—and fruits “probably” protect against several types of cancers, including those of the Pathways to influence diet quality (with a focus mouth, throat, voice box, esophagus, and stomach; fruit probably also protects on overweight): Self production and trade are two against lung cancer (Wiseman, 2008). 22 Food and Agriculture Global Practice improve diet quality are through: (1) ensuring that bio- a subsidy to encourage consumption of certain foods may fortified cereals are the norm, where they are available be preferred to taxing certain unhealthy foods. and agronomically competitive, rather than the excep- 1.  Ensuring that bio-fortified cereals are tion; (2) eliminating subsidies and other production/price the norm, where they are available and support measures for production of unhealthy ingredients agronomically competitive, rather than for food processing (sugar, corn [where there is estab- the exception: Bio-fortification is a method of lished local capacity to develop high fructose corn syrup breeding crops to increase their nutritional value (HFCS)], palm oil etc.); and (3) encouraging production focusing on making plant foods more nutritious as (and consumption) of fruits, vegetables, and legumes. the plants are growing. Some of the bio-fortified crops use traditional plant breeding techniques One aspect to consider is that because not all of what (non-transgenic), such as the crops being devel- is produced is consumed by humans, it is more efficient oped by HarvestPlus with other CGIAR centers. to subsidize/tax the consumption of underserved nutri- Others use genetic, or transgenic modification tious and less healthy food groups closer to the retail/ techniques such as the Golden Rice being devel- consumption point to alter consumption patterns as oped by the International Rice Research Institute. opposed to the production of these same food groups. Bio-fortified crops have been demonstrated to Similarly, raw food ingredients are only a small part of the improve vitamin  A and iron intakes—­ alleviating full content of a highly processed food that may or may two micronutrient deficiencies that cause a not be healthy. Thus, taxing or subsidizing an ingredient large number of deaths and disabilities. While into processed foods is a highly indirect and inefficient increased production of nutritious foods may way to affect its prices or consumption behavior. Despite have some independent impact on dietary con- the popular belief, for example, that the vast U.S. farm sumption and micronutrient status, the evidence subsidy programs are fueling the U.S. obesity epidemic, a shows that nutrition education around those foods careful analysis does not support this claim. Alston, Sum- strongly enhances the effect. A review of food- ner, and Vosti (2008) assessed the effects of U.S. farm pro- based approaches to reduce iron and vitamin A grams (not just the crop support portion), and found that deficiency found that only those food-based inter- even if the entire farm subsidy were removed in the U.S., ventions with education, social marketing, or mass the effects on commodity production and subsequently media demonstrated an impact on nutritional out- their prices are much smaller than expected from a text- comes (Alderman et al., 2013). book understanding of how subsidies work (reduction of 2. Eliminating subsidies and other 3–12 percent of output level, and reduction of 0–4 per- production/­ price support measures for cent in price for soybean, wheat, maize and rice), because production of unhealthy ingredients for the price depressing effects of the subsidy are contained food processing: These ingredients may include (or even reversed) by other policies, such as set-aside sugar, corn (if there is capacity to process into high requirements, and also because subsidy rates in the U.S. fructose corn syrup (HFCS)), and palm oil. As men- are determined according to past acreage and yield infor- tioned earlier, this pathway will likely not be as effi- mation, and not current levels. Therefore, theoretically, cient in changing consumption patterns as a tax measures under this pathway will not be as cost efficient as near retail/consumption (e.g., taxing sugar sweet- subsidizing/taxing closer to retail/consumption in its final ened beverages or snacks that use these food ingredi- form of consumption. This does not necessarily mean ents). Furthermore, a country may be promoting the that there is no effect on production diversification and production of certain crops, such as maize or palm dietary diversity. But it does point to the need for further oil, as part of its biofuel policy. In such a case, taxa- research. Another aspect to take into account when con- tion near retail/consumption of the processed good sidering taxing or subsidizing foods is the welfare effect would make more sense to curb its consumption. on low-income consumers. Since food comprises a larger 3. Encouraging production (and consump- proportion of expenditure among low-income consumers, tion) of fruits, vegetables, and pulses: An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 23 Interventions in this category are effective in addressing malnutrition across the spectrum Role of the food from undernutrition to overweight/obesity. The storage, transport, Glopan Foresight Report (2016) found that cur- and trade subsystem rent consumption of fruits and vegetables is (postharvest level) below WHO recommended levels in all regions Background: When food is not consumed by the farm- of the world except for East Asia. It is not very ers themselves, immediately after food is harvested it is clear to what extent this trend is due primarily to handled, treated, stored, packed, moved, transported and low production, or low trade, or high prices, but traded. Interventions adopted in this subsystem to improve difficulty in production and distribution due to diet quality are also interventions that are undertaken for their highly perishable nature is the most cited more conventional objectives of raising profitability of reason for low availability. Studies, although the value chain. Actions include investments to reduce with limitations, seem to converge on a call to food losses and waste, address food safety and comply increase availability and affordability of fruits with export requirements. The fact that the objectives of and vegetables (Miller et al. 2016; Siegel et al. improving diet quality and profitability can be achieved 2014; WHO Nutrition Topics,  n.d.). In order through the same measures is an advantageous situation to achieve this, public sector investments in because no new or customized actions are needed, unlike research, technology, extension, and in infra- in the production subsystem where actions aligned to con- structure to produce, store, transport, distribute, ventional profitability maximizing objectives do not nec- as well as trade fruits and vegetables could go essarily deliver for the objective of improving diet quality. a long way (this possibility is examined under other subsystems). For pulses, production at the Pathways to influence diet quality (with a focus global level has sharply increased since 2005, on overweight): As in the previous production sub- and between the 1980s and 2011 there was a system, one key goal is to maintain the supply of under- fourfold increase in the pulses trade. Neverthe- served nutritious foods (fruits, vegetables, pulses, poultry, less, pulse prices continue to be high. A compre- fish) into the market, and also to minimize the supply of hensive 2016 study by the International Food undesirable ingredients for food processing from the mar- Policy Research Institute (IFPRI) concluded that ket (sugar, corn where there is established local capacity to there are “low yields in developing countries develop HFCS, and palm oil, etc.) To maintain the supply since pulses are mainly grown in marginal areas of underserved nutritious food groups, key entry points under low input conditions, small-scale produc- that pertain to the food storage, transport, and trade sub- tion, weak institutional arrangements, and low system are: (1) reducing food loss and waste; and (2) using research priorities and government support trade to improve the quality of the local diet, including compared to cereals.” These challenges need to measures to reduce the imports of ingredients for food be overcome. Examples of actions at the farm processing and unhealthy foods and conversely increase level include: small-scale household produc- the import of underserved nutritious food ingredients. tion models such as kitchen gardens or com- 1.  Reducing food loss and waste: Food loss and munity plots; and bio-fortification (for cassava, waste is particularly important when dealing with beans and orange flesh sweet potatoes (OFSPs)). overweight because food losses in industrialized Nutrition education and behavior change com- countries are as high as in developing countries, munication are needed to increase demand for but in developing countries more than 40 per- diversified and high-quality foods. cent of the food losses occur at postharvest and 24 Food and Agriculture Global Practice processing levels, while in industrialized countries, a high sales tax following its accession to WTO more than 40 percent of the food losses occur in 2012. Fiji still bans the import of fatty mutton at retail and consumer levels. Loss and waste is flaps (Snowdon and Thow, 2013). As of 2013, no especially high, reaching about 50 percent of pro- formal objections to Fiji’s ban had been raised to duced amounts, for fruits and vegetables, many of the WTO (Snowdon and Thow, 2013). As import which are highly perishable and where retailers bans are forbidden by WTO rules, countries are set standards in size and aesthetics in many devel- advised to seek alternative measures.22 oped country markets (FAO, 2011). Additionally,    A different story emerges in the U.S. for sugar, adapting new agricultural technologies (such as a commodity that has been historically kept out aeroponics and hydroponics for vegetable produc- of the domestic market. The historical import tion) in developing countries enables production restriction of sugar in the U.S. has helped maintain in urban centers reducing the need for cold chains higher than global sugar prices, thereby dampen- and transportation, where losses appear. ing its demand. However, this has also aided in the 2. Using trade to improve the quality of the explosion of producing and consuming another local diet: In theory, trade can increase availabil- sweetener, high fructose corn syrup (HFCS), after ity and affordability of healthy food. Nevertheless, it was developed in the 1970s. Despite some initial as mentioned under the role of the agricultural evidence that HFCS led to more weight gain com- production sub-system, a recent cross-country pared to sugar (Bray, Nielsen, and Popkin, 2004), study21 cited in the Glopan Foresight Report more recent studies refute this indicating that there (2016) found that food imports are associated is no additional adversarial effect of consuming with a more diverse food supply only in high- and HFCS on obesity or other diseases beyond the middle-income countries, and not in low-income effects for sugar. Leading major American agen- countries. Moreover, traded foodstuff can be cies23 such as the Mayo Clinic, American Heart used in the food processing industry to produce Association, and the Department of Agriculture’s food of low nutrient quality. In terms of mini- guideline for healthy diets recommend reducing mizing the supply of undesirable ingredients for the consumption of all sugars, including HFCS, food processing and unhealthy foods, the Pacific without singling it out as presenting extra concerns. Island countries, which have one of the world’s highest prevalence of overweight and obesity and Role of the food also rely heavily on food imports, have imposed restrictions and tariffs on processed foods high in transformation fats, sugar and salt. Fiji, a World Trade Organiza- subsystem tion (WTO) member since 1996, began in 2012 (agroprocessing level) to tax ingredients for food processing, such as a Background: Food processing combines raw food ingre- 32 percent import duty on palm oil and mono- dients to produce marketable food products that can be sodium glutamate, as well as to remove existing easily prepared and served by the consumer. It ranges from 5–32 percent import duties on fruits and vegeta- bles. In the past, Samoa banned imports of fatty meats such as turkey tails, which was replaced with 22 Suggestions include to involve health professionals in negotiations of trade agreements (Snowdon and Thow, 2013), and/or seek a collective approach through international institutions/organizations instead of undertaking unilat- Remans, R., Wood, S. A., Saha, N., Anderman, T. L., and Defries, S. A. 2014. 21 eral country actions. Measuring nutritional diversity of national food supplies. Global Food Security, 3, 23 The U.S. is the leading producer of high fructose corn syrup and has the high- 174–182, http://dx.doi.org/10.1016/j.gfs.2014.07.001 est level of per capita consumption at 55 pounds per year. An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 25 simple forms of transformation such as slicing, drying, or fat, saturated or trans fats, sugar and sodium, and short freezing to highly extractive forms where the nutrients of of micronutrients and other bioactive compounds, and the original ingredients are highly depleted through the of dietary fiber. Taken together this increases the risk various processes. Monteiro (2010) categorizes processed of various serious diseases. Secondly, their high energy foods into three groups: (1) Type 1—unprocessed or mini- density, hyper-palatability, their marketing in large and mally processed foods (e.g., dried fruits, frozen meats, supersizes, and aggressive and sophisticated advertising, unsalted nuts), (2) Type 2—processed culinary ingredients all undermine the normal processes of appetite control, (e.g., oils, sugar, flour), and (3) Type 3—ultra-processed cause overconsumption, and therefore obesity, and dis- foods (e.g., white bread, cookies, frozen pizza, hot dogs, eases associated with obesity. canned soup, instant noodles).24 Consumption of ultra-processed foods is increasing glob- The characteristics of the ultra-processed foods accord- ally. According to a study using the nationally representa- ing to Monteiro are “durable, accessible, convenient, attractive, tive National Health and Nutrition Examination Survey ready-to-eat or ready-to-heat products. Such ultra-processed products of 2009–10 of American citizens aged one year old and are formulated to reduce microbial deterioration (‘long shelf life’), to higher, ultra-processed foods comprised 57.9 percent of be transportable for long distances, to be extremely palatable (‘high total energy intake, and almost 90 percent of the average organoleptic quality’) and often to be habit forming. Typically, they U.S. daily intake of added sugars25 (292.2 kcal) came from are designed to be consumed anywhere—in fast-food establishments, ultra-processed foods (Martinez et. al., 2015). In another at home in place of domestically prepared and cooked food, and while study, the share of ultra-processed foods of total energy watching television, at a desk or elsewhere at work, in the street, intake in Canada showed an increase from 24.4 percent and while driving” (Monteiro, 2010). As such, he concludes in 1938 to 54.9 percent in 2001. In Brazil, it rose from that these foods are problematic for the public health in 18.7 percent in 1987 to 26.1 percent in 2003. In the most two ways: first, their principal ingredients (oils, solid fats, recent surveys, the share of ultra-processed products is sugars, salt, flours, starches) make them excessive in total almost twice as high in Canada than in Brazil, but relative growth has been higher in Brazil (2.1 percent per year) than in Canada (1.3 percent per year).  The same study 24 (1) Type 1: Unprocessed or minimally processed foods that do not change the looked at consumption patterns of a smaller subset of nutritional properties of the food. Examples include, fresh, chilled, frozen, vac- uum packed fruits, vegetables, fungi, roots and tubers; cereals (grains) in general; ultra-processed foods (frozen processed foods,26 snacks,27 fresh, frozen and dried beans and other pulses (legumes); dried fruits and 100 and soft drinks28) for 79 middle- and high-income coun- percent unsweetened fruit juices; unsalted nuts and seeds; fresh, dried, chilled, tries (with a minimum 2012 per capita GNI of US$1,036). frozen meats, poultry and fish; fresh and pasteurized milk, fermented milk such The results showed greatest consumption in high-income as plain yogurt; eggs; teas, coffee, herb infusions, tap water, bottled spring water.   (2) Type 2: Processes that extract and ‘purify’ specific substances from unpro- countries, but greater relative and sometimes absolute cessed foods. Examples are vegetable oils, margarine, butter, milk, cream, lard; sugar, sweeteners in general; salt; starches, flours, ‘raw’ pastas and noodles, as well as food industry ingredients usually not sold to consumers as such, includ- 25 Added sugars are defined as “sugars that are added to foods as an ingredient ing high fructose corn syrup, lactose, milk and soy proteins, gums and similar during preparation, processing, or at the table. Added sugars do not include products. Most end products of type 2 food processing are depleted or devoid naturally occurring sugars (e.g., lactose in milk, fructose in fruits). Examples of of nutrients and essentially provide energy. added sugars include brown sugar, cane sugar, confectioners’ sugar, granulated   (3) Type 3: Ultra-processed products that combine Type 2 ingredients (and, sugar, dextrose, white sugar, corn syrup and corn syrup solids, molasses, honey, rarely, traces of Type 1). Examples are white breads, biscuits (cookies), cakes and and all types of syrups such as maple syrup, table syrups, and pancake syrup. pastries; ice cream; jams (preserves); fruits canned in syrup; chocolates, confec- 26 Frozen processed foods: Bakery products; potatoes; desserts; meat, poultry, tionery (candies), cereal bars, breakfast cereals with added sugar; chips (French fish, seafood, meat substitutes, red meat, processed poultry, processed fish/sea fries), crisps (chips), sauces; savory and sweet snack products; cheeses; sugared food, meat substitutes; dishes such as pizza, ready meals, others. fruit and milk drinks and sugared and ‘no-cal’ cola and other soft drinks; frozen 27 Snacks: Sweet and savory snacks (chips/crisps, corn chips, pretzels, sweet pasta and pizza dishes; pre-prepared meat, poultry, fish, vegetable and other snacks, salted nuts), confectionery (chocolates, sweets, gums, pastilles, jellies), ice ‘recipe’ dishes; processed meat including chicken nuggets, hot dogs, sausages, creams (including frozen yogurt). burgers, fish sticks; canned or dehydrated soups, stews and pot noodle; salted, 28 Soft drinks: Carbonated drinks, fruit and vegetable juices (sweetened juices, pickled, smoked or cured meat and fish; vegetables bottled or canned in brine, nectars, fruit drinks, fruit-flavored drinks), ready-to-drink tea or coffee, sports fish canned in oil; infant formulas, follow-on milks, baby food. and energy drinks, Asian specialty drinks. 26 Food and Agriculture Global Practice increases in middle-income countries. The data suggest could be beneficial for other nutrition interven- that in high-income countries intake of ready-to-consume tions, for example for obesity prevention. Food snacks may remain static and that consumption of soft fortification is complementary to bio-fortification. drinks may be past peak levels (Monteiro et al., 2013). Food fortification is less effective at reaching rural populations who may process and consume more Many experts believe that the rapid expansion of ultra- of their own production rather than purchasing processed foods, more so than any other subsystem with from the marketplace, making bio-fortification the agriculture and food system, is the major factor in particularly effective for the rural poor. However, the obesity epidemic. Studies that examine the impact neither food- nor bio-fortification itself has a of ultra-processed products on obesity and chronic non- direct link in addressing overweight. communicable diseases show consistent results. In several 2. Build more awareness toward unhealthy countries, the level of consumption of ultra-processed ingredients for food processing, food, and products is tightly correlated with overall diet quality. Evi- products: In the U.S., only 50 percent of adults dence from the U.S. shows that consumption of various always or most of the time look at nutrition labels. ultra-processed products such as cookies, white bread, For those that rarely or never check the labels, candy and desserts; sugar-sweetened drinks; processed the primary reason is because ‘they do not know meats; and French fries and potato chips is associated with what to look for even if they did look at it’ (Food weight gain in adults (Mozaffarian et al., 2011). Increase and Drug Administration, FDA, 2016). Experts in fast-food sales predicts an increase in body mass in high advise that nutrition labels can be an important income European, North American, and other countries tool in raising awareness among consumers as of the Organisation for Economic Co-operation and long as they are easy to understand. Examples of Development (OECD) (De Vogli et al., 2014). An analysis innovative and user-friendly labelling include the covering 14 countries in Latin America showed a positive, traffic signal labelling system developed by the strong, and significant association between prevalence U.K.  Food Standards Agency. The system uses of adult obesity and higher sales per capita of ultra- green, amber and red signals to show consum- processed products (PAHO, 2015). ers whether a product is high, medium or low in fat, saturated fat, salt, sugar and, ideally, energy Pathways to influence diet quality (with a focus (in calories). In 2016, Chile implemented a new on overweight): There are three main avenues to food labeling law that requires packaged foods to address the adverse health effects prevalent in the food display a black stop sign label with large letters transformation subsystem: (1) increase market supply of warning, such as “High in fats,” when products fortified foods with adequate micronutrients; (2) build exceed the following per 100 grams: 275 calo- more awareness toward unhealthy ingredients for food ries, 400 milligrams of salt, 10 grams of sugar, processing, food, and products; and (3) incentivize prod- or 4 grams of saturated fats. Commercial hooks uct reformulation to reduce unhealthy ingredients in the such as toys, accessories, stickers or similar incen- processing stage. tives are also banned. 1.  Increase market supply of fortified foods    Another important tool that can be improved with adequate micronutrients: Food forti- to increase its efficacy is the national dietary guide- fication such as enriched flours or vegetable oil, lines. Dietary guidelines provide advice on foods, iodized salt, or fortified complementary foods food groups and dietary patterns to provide the for infants is a targeted, convenient, and effec- required nutrients to the general public to promote tive intervention to address micronutrient defi- overall health and prevent chronic diseases. Devel- ciency. A successful food fortification program opment of these guidelines has been expanding to requires cooperation between private companies more than 100 countries although progress is still and public food regulation agencies and ministries lagging in Africa (only five countries have guide- of health. The establishment of such a structure lines: Benin, Namibia, Nigeria, Seychelles, and An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 27 South Africa).29 Although the guidelines reflect taken the next step to establish voluntary sodium locally available and consumed foods, they typi- content targets for foods and meals. Furthermore, cally offer guidance in terms of raw food ingredi- nine countries have mandated maximum sodium ents (food groups such as vegetables, fruits, grains, content limits for products. Whilst these are mostly and protein) and do not provide ample guidance for bread, Argentina, Bulgaria, Greece and South on how to choose among the wide array of pro- Africa have additional limits for other foods (Trieu cessed foods. Guidelines need to reflect the real- et al., 2015). Reducing sugar has seen less progress ity of heightened consumption of ultra-processed given the technical challenges of simply reducing foods. Brazil’s dietary guideline is an anomaly in sugar in processed foods. Sugar plays a wider role that it clearly advises to ‘avoid ultra-processed than just providing the sweet taste; it provides bulk, foods’, and instead advises to ‘make natural or density, and viscosity (thickness) in food products, minimally processed foods the basis of your diet.’ and with a reduced amount of sugar, products (Brazil Ministry of Health, 2014). often lack the taste, mouth feel, bulk, shelf life, 3. Incentivize product reformulation to and other attributes of the original product. Very reduce unhealthy ingredients in the pro- recently Nestlé announced that it has developed a cessing stage: Food processing actions tar- way of restructuring sugar, allowing the company get mainly industrially produced trans fats and to reduce the amount of sugar in its candy prod- sodium. There are two main approaches: legisla- ucts, and that the new sugar could be introduced tive limits (or bans) of these ingredients allowed in in their products starting in 2018.30 food, or voluntary self-regulation. Product refor- mulation is usually led by voluntary self-regulation Role of the food retail by the food industry (typically framed as a socially responsible industry practice) to reformulate and provisioning their products, within a framework established by subsystem (retail Level) national strategies or health guidelines established Background: Most food is purchased at market-based by the government. Often, they are implemented formal and informal retail outlets such as markets (tradi- as a compromise or substitute to outright regula- tional wet markets and modern supermarkets), street ven- tions that the food industry opposes. There are dors or restaurants. Another channel for food provision examples of product reformulation, mainly in is the public procurement system where the government the U.S. and Europe, most commonly to reduce purchases food and provides meals for institutions such as sodium content and trans fats. Less common ini- state-run schools, hospitals or prisons. Retailers and gov- tiatives involve reducing sugar content or reducing ernments (in the case of public procurement of food) can portion size of processed foods. Typically, these play a role in promoting quality diets by what they sell and initiatives are led by private companies within a how they position certain foods. This subsystem is closer framework established by governments. For exam- to the actual consumption point, and thus is arguably the ple, in the case of salt a high majority (81 per- most effective in changing the food environment and con- cent) of national salt reduction strategies include sumption behavior that lead to obesity. industry engagement to reduce the salt content of products. Globally, bread is the most targeted food The three basic thrusts for improving diet quality at the for reformulation followed by foods such as bakery retail level are: (1) build more awareness toward healthy products, processed meats, dairy products, sauces eating in general; (2) disincentivize the consumption and convenience meals. Thirty-six countries have of unhealthy food; and (3) regulate or limit access to 30 https://www.nytimes.com/2016/11/30/business/nestle-reformulates-sugar- 29 http://www.fao.org/nutrition/education/food-dietary-guidelines/en/ so-it-can-use-less.html?_r=0 28 Food and Agriculture Global Practice unhealthy foods through voluntary industry measures or 2012. Despite oppositions by the beverage indus- government regulations. try, it has since spread to many European countries, 1.  Build more awareness toward healthy major cities in the U.S.,31 as well as some middle- eating: Governments should lead efforts to build income countries like Mexico and South Africa and community-wide awareness toward healthy eat- some Pacific Island countries. Numerous studies ing. Developing a standardized nutrition labeling have found that such taxes reduce the consumption system that is easy to understand is one impor- of sugar sweetened beverages.32 Other less com- tant tool (discussed in the previous section on the mon taxes on a broader category of unhealthy food transformation subsystem). WHO (2017) recom- is the example of taxing ‘junk foods’, such as taxing mends implementing mass media campaigns foods that have high levels of fats or added sugar. on healthy diets, including social marketing to In 2011, Denmark instituted the world’s first ‘fat reduce the intake of total fat, saturated fats, sug- tax’ on any food item with more than 2.3 percent ars and salt, and promote the intake of fruits and saturated fat. However, this tax was repealed within vegetables. Documented success tends to be in a year since consumers simply circumvented the those targeted at children whose behaviors can tax by purchasing the products across the border be modified easier than adults (Walls et al., 2011). in Germany and Sweden. Hungary currently has The innovative Brazilian dietary guidelines a tax on packaged foods high in fat, salt or sugar. include a suggestion that people develop culinary Although the effect of a tax depends on its design, skills because not having them causes people to taxing junk food is more difficult than taxing soda rely on super processed foods and increase eat- because not all fats are unhealthy, and taxing foods ing away from home (Brazil Ministry of Health, according to fat content would lead to items such 2014), which has been shown to be positively cor- as nuts incurring very high taxes. Also since manu- related with high caloric intake (Mancino et al., facturers regularly update and modify the produc- 2009). A systematic review of cooking classes on tion processes of certain foods, taxing junk food children’s food related preferences, attitudes, and would create a perpetual situation of governmental behaviors showed significant improvements in at catch-up, reevaluation and alteration of tax rates least one criteria such as willingness to try fruits in an attempt to keep up with production changes and vegetables, and fruit and vegetable consump- (Franck et al., 2013). tion, as reported by their parents (Hersch, 2014).    Some countries are known to have exten- A similar review of cooking classes for adults also sive untargeted food subsidy programs as part showed positive outcomes in terms of improved of their social safety nets. The Middle East and dietary intake in key nutrients and health out- North Africa region has historically maintained comes such as reductions in serum cholesterol such food subsidies where they cost an average of levels (Reicks et al., 2014). 1 percent of GDP. In some countries, like Egypt, 2. Disincentivize the consumption of the cost is even higher at about 2.5 percent of unhealthy foods through taxes: Although their GDP (Sdralevich et al., 2014). The program designing a tax on unhealthy foods is highly com- provides Baladi bread, vegetable oil, and sugar at plicated and could incur unintended consequences, the most common case of disincentivizing the con- 31 In 2009, the Obama Administration explored levying an excise tax on sweet- sumption of unhealthy foods through market mea- ened beverages as part of health care reform efforts, but the proposal was aban- sures is the taxation of sugar sweetened beverages. doned after heavy  lobbying  by the beverage industry (http://articles.latimes This is included as a recommendation in the 2016 .com/2010/feb/07/nation/la-na-soda-tax7-2010feb07 ). 32 In 2016, a study of the Mexico case found that annual sales of sodas in final report of the WHO Commission on Ending Mexico declined 6 percent in 2014 after the introduction of the soda tax and Childhood Obesity (WHO, 2016) and is imple- monthly sales figures for December 2014 were down 12 percent on the previous mented in many countries beginning in France in two years (Colchero et al., 2016) An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 29 subsidized prices to the vast majority of the popu- 3. Regulate or limit access to unhealthy lation. Although this program was never designed foods: Evidence is weak on the efficacy of exist- to improve the nutrition status of its beneficiaries, ing self-regulation in the food industry (sometimes it has actually been found to lead to higher rates under corporate social responsibility), which is of overweight among recipients. Egypt today has mainly targeted at children (Sharma et al., 2010; one of the highest female overweight rates in the Huizinga and Kruse, 2016).33 Many of the exist- world, affecting 85 percent of all (nonpregnant) ing regulations have been criticized as being ever-married women 15–49 years of age, while intentionally vague and permissive, making their almost 40 percent are obese. A 2016 IFPRI study implementation difficult to monitor and lacking in found that the probability of child overweight and credible complaint, adjudication, investigation and the probability of maternal overweight increase sanctions mechanisms, and some caution against with the subsidy levels that the families acquire repeating the disastrous experience of industry self- from the program, and shows clearly that incen- regulation by tobacco companies to prevent smok- tivizing overconsumption of cheap, calorie-rich ing to youths.34 Thus, evidence to date shows that foods and unbalanced diets creates an incentive voluntary measures by the food industry itself is a for excess consumption that leads to overweight highly risky approach and should be accompanied (Ecker et al., 2016). Many attempts have been by other measures including regulatory actions by made to reform the food subsidy programs in the government to enforce certain restrictions. countries mainly with the objective of decreas- ing the government’s fiscal burden, and not for its Given the inherent conflict of interest that resides with negative nutritional effects. Such reform attempts food industry companies regulating themselves, govern- have rarely been successful due to the fact that ments should foster a collaborative working relationship they are part of the social safety net and hugely that includes not only the food industry but also third popular with the public. party civil society groups. A key player would be consumer    In instances where the government provides organizations, which are advocacy groups that seek to pro- food in public institutions, it has more control tect people from corporate abuse such as unsafe products, over nutritional aspects such as content, menu for- predatory lending, and false advertising. They exist in many mulation, pricing, and portion size. For example, countries around the world. Consumers International is an adjusting school meal guidelines to ensure opti- international nongovernmental organization (NGO) that mal nutrition practices are in place is a good entry represents 240 organizations in 120 countries and already point. However, in reality political pressure can be does work in the food arena.35 Other key players include strong to adjust large procurement programs such as national school meals. In the U.S., for example, 33 Examples include the 2006 Alliance for a Healthier Generation by Coca- the Department of Agriculture recently finalized Cola, PepsiCo, and Cadbury Schweppes that adopted School Beverage Guide- comprehensive new school meal guidelines that lines, which  regulates the size and contents of beverages sold at schools; the increased vegetables, fruit, and whole grains and 2007 Children’s Food and Beverage Advertising Initiative by 15 leading food and beverage companies to devote no less than 50 percent of their child- curbed sodium, saturated fat, and trans fat. But due directed advertising to the promotion of “healthier dietary choices and/or to to political pressures, the agency was not able to messages that encourage good nutrition or healthy lifestyles”; the 2009 initiative fully implement the meal guidelines recommended by Disney and Nickelodeon to discontinue the use of their names and licensed by an expert panel at the Institute of Medicine characters on packaging for foods that do not meet their self-defined criteria for healthier food (Sharma et al., 2010). (Lagarde, 2008). Also, even when appropriate 34 Brownell and Warner, 2009 lay out similarities between self-regulatory actions guidelines are in place challenges for implementa- taken by the tobacco industry and those taken by the food industry today. tion still exist such as budgeting for the higher costs 35 Consumers International has a recommendation towards a Global Conven- of purchasing and preparing more healthful foods tion to protect and promote heathy diets. The suggested actions include: estab- lishing and implementing national evidence-based nutrient recommendations and coaxing children to accept the more healthful and food-based dietary guidelines (FBDGs); food and nutrition knowledge and options that they may not be familiar with. skills training in primary and secondary school education programs; clear infor- 30 Food and Agriculture Global Practice Box 3. Top companies incorporating nutrition considerations in their business models The Access to Nutrition Index rates food and beverage manufacturers´ nutrition related policies, practices and disclosures world- wide on a recurring basis, and publishes results every year. The first Global Index was launched in 2013, and the second Global Index in January 2016. The top three companies in the 2016 Index are Unilever, Nestlé and Danone, which also led the Index in 2013. The report states: “Although all companies still have a long way to go, Unilever, Nestlé and Danone have clearly embedded a commitment to addressing global nutrition challenges into their core business models; commitments are translated into practice and reported on publicly. This is commendable. It should be regarded as an example of best practice and as a guide to improvement for other companies. Unilever leads with regards to providing healthier products to consumers worldwide. The company has a strong Nutrient Profiling System (NPS) against which the global product portfolio is checked for levels of key nutrients. Nestlé stands out with a clear corporate nutrition strat- egy that is approved at the highest levels of the company and includes a comprehensive set of objectives that cover the reformulation of products to make them healthier, access to healthy foods and responsible marketing. Danone remains relatively strong in including nutrition in its business strategies as well as its processes. It leads for including affordability considerations in its product Research & Development (R&D) programs, and for stakeholder engagement. However, Danone dropped in the overall rankings mostly because the company’s nutrition targets for the next few years had not yet been published at the time of the research for this report.” Source: https://www.accesstonutrition.org/sites/in16.atnindex.org/files/resources/atni-global-index-2016.pdf health policy organizations such as the Access to Nutrition hydrogen to vegetable oil, which causes the oil to become Index (ATNI) that compiles objective ranking of large food solid at room temperature.37 It is less likely to spoil, so and beverage companies on their policies and practices foods made with it have a longer shelf life. Trans fats are towards nutrition36 (Box 3). This approach also models suc- now virtually banned in several European countries, the cess in other sectors with wider public/private participation U.S. (starting in 2018), and in some middle-income coun- in governance like the Forest Stewardship Council or the tries like Argentina, Brazil, Chile, and South Africa. In Marine Stewardship Council (Sharma et al., 2010). these countries, the bans were typically preceded by an earlier regulation requiring manufacturers to clearly label Governments have traditionally been granted author- the existence of trans fats on their packaging, which helps ity to reduce risks posed by unsafe foods, for example to raise public awareness as well as give manufacturers in connection to foodborne diseases. As the obesity epi- time to adjust their product formulations. Other exam- demic continues, and the cost of obesity prevention and ples include the active role of governments in reducing care rises, more governments are expanding this author- salt intake. An area where government regulation could ity to target foods that are closely linked to obesity and play an important role, yet has not to date, except for the associated diseases. One such example is the restriction new law implemented in Chile from 2016, is on regulating on trans fats, which began in 2003 in Denmark. Trans marketing of unhealthy food to children (advertisements, fats are formed through an industrial process that adds product placements, etc.). mation about the nutritional quality of a food or beverage product at the point of choice; restricting advertising, promotion and sponsorship in order to protect 37 Trans fats are contained in: Baked goods:  Most cakes, cookies, pie crusts children from exposure to the promotion of unhealthy food and beverage prod- and crackers contain shortening, which is usually made from partially hydro- ucts; and removing all artificial trans fats from food and beverage products sold genated vegetable oil. Ready-made frosting is another source of trans fat. within their jurisdiction (Consumers International, 2014). Snacks: Potato, corn and tortilla chips often contain trans fat. And while pop- 36 The ATNI global index was founded by The Global Alliance for Improved corn can be a healthy snack, many types of packaged or microwave popcorn Nutrition in 2009, and subsequently launched as an independent nonprofit use trans fat to help cook or flavor the popcorn. Fried food: Foods that require organization in 2013. It is funded by the Bill & Melinda Gates Foundation, the deep ­frying—french fries, doughnuts and fried chicken—can contain trans fat Wellcome Trust and the Children’s Investment Fund Foundation. The index from the oil used in the cooking process. Refrigerator dough: Products such as ranks the world’s largest 20 food and beverage companies’ nutrition related canned biscuits and cinnamon rolls often contain trans fat, as do frozen pizza policies, procedures and disclosures. https://www.accesstonutrition.org/global- crusts. Creamer and margarine: Nondairy coffee creamer and stick margarines index/homepage-global-index also may contain partially hydrogenated vegetable oils. (Mayo Clinic) An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 31 Conclusions The Agriculture GP has made great strides in internalizing and acting on the nutrition sensitive agriculture agenda designed to address the undernutrition and micronutrient deficiency challenges. Embracing the challenge of overweight and obesity is a natural next step given that the role and responsibility of agriculture and food systems is to deliver safe, diversified, and healthy diets for all. Preventing obesity and improving other forms of malnutrition can best be achieved by one common approach—the promotion of a high quality diversified diet. Actions and policies that support the provision of and access to a safe, diversified and healthy diet should be supported continuously across the entire food system as countries transition from focusing on undernutrition to overlapping malnutrition problems increasingly including overweight and obesity. As demonstrated, actions adopted in the food storage, transport and trade subsystem to improve diet quality are also interventions that are undertaken for more conven- tional objectives of raising profitability of the value chain. In other subsystems new or customized actions are needed, as for instance in the agricultural research and produc- tion subsystem where actions to maximize profitability are not aligned with improving diet quality, and in the food retail and provisioning subsystem, where traditionally the Agriculture GP has been less active. The remainder of this section will list entry points for actions, discuss what is needed to translate them into policy dialogue between the Agriculture GP teams and country clients to enable future action, and list areas for possible future research. Some of the listed interventions can be discussed with and undertaken by the ministry of agriculture in client countries, while others require multi- and cross-sectoral cooperation among ministries and agencies responsible for health, gender, trade, transport, and more. The need for collaboration across boundaries is further reinforced by the impact on overall diet quality, obesity, and chronic noncommunicable diseases of the level of consump- tion of ultra-processed products. Partnerships between the Agriculture GP and the WBG’s International Finance Corporation (IFC), the private sector, and civil society are just a few that need to be pursued in order to influence that part of the food system. An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 33 Entry points for interventions are already being undertaken against under- nutrition and micronutrient deficiencies to illustrate the possible action interventions that generate the greatest joint benefits; and Evidence-based interventions in the different sub-systems they also show what policy action of the NOURISHING examined in this report that support the goal of improv- Framework they correspond to. It is also important to ing diet quality, with a focus on overweight, but not exclu- note that in contrast to experience within the agriculture sively so are presented in the following tables. This choice and food systems domain, where evidence of impact is of presentation is couched upon the realization that many still being generated, there is ample evidence for interven- of the suggested actions for reducing overweight and obe- tions to control and prevent obesity outside this domain sity also serve the purpose of reducing undernutrition that this report is not covering. and/or micronutrient deficiency. The tables indicate what Actions in the production subsystem that support the goal of improving diet quality (with a focus on overweight) Main Examples Nutrition NOURISHING Notes indicate association, if Goal of Actions Challenges Framework any, with overweight/obesity (a) Actions in the agricultural research subsystem that support the goal of improving diet quality Incentivize more Increase targeted public M, O I, H, G Half of CGIAR research funding in public sector research research 2012 was allocated to rice and maize. on high quality and While livestock, fish and some pulses underserved foods received some allocation, research (legumes, fruits, for fruits and vegetables (except for vegetables) to increase bananas) was minimal (Glopan, productivity and shift 2016). Further support work of relative prices World Vegetable Center and Global Horticultural Initiative. Develop new metrics in U, M, O I, H Examples include (1) an alternative to agriculture that measure standard yields (nutrient content per aspects related to unit of land or labor) and (2) minimum nutrition cost of a quality diet. Ensure that cereal U, M S, I, G This type of intervention is effective research and provision in addressing widespread hunger and on inputs includes a micronutrient deficiency. A singular nutrition focus, and focus on yield only can be detrimental as not just a yield focus; it can contribute to overweight. and that results are Disseminate research U, M I, G, H Agriculture extension systems have been communicated to results to farmers used to disseminate messages related producers through agriculture to undernutrition and micronutrient extension workers, deficiencies, and often in collaboration and utilize ICT, where with the health community. They have needed not been used to convey messages related to overweight/obesity. Presumably, that could happen. 34 Food and Agriculture Global Practice Main Examples Nutrition NOURISHING Notes indicate association, if Goal of Actions Challenges Framework any, with overweight/obesity Encourage private Governments can M, O I, S Glopan (2016) reports that sector advances in promote research approximately 45 percent of private research favoring on high quality and sector research investment focuses only high quality and underserved foods on maize, while other crops receive underserved foods. through the private relatively little. sector through competitive research grants or other services (b) Actions in the production subsystem that support the goal of improving diet quality Ensure that bio-fortified Bio-fortification M I This involves breeding micronutrients cereals are the norm, into commonly consumed staples such as where they are available corn, wheat, and rice. Some target crops and agronomically are within the underserved nutritious food competitive, rather groups that affect overweight, like beans, than the exception cassava, OFSP, and pearl millet but most the efforts are for staples. Eliminate subsidies O U, I, S In the U.S., corn is the most heavily and other production/ subsidized crop (US$94 billion over price support measures 2005–14).38 This coupled with high for production of U.S. sugar prices (due to import tariffs unhealthy ingredients and producer support) has boosted for food processing production of HFCS. Encourage production Increase targeted M, O I Given the high heterogeneity of fruits (and consumption) of production subsidy and vegetables, designing a targeted fruits, vegetables and production subsidy could be difficult. pulses However, pulses could be included in commodity crop support programs that exist in many countries.39 Increase public sector M, O I, S (Examined under other subsystems); Self investments in research production and trade are two ways to and technology, and increase diversity of food supply. in infrastructure to produce, store, A recent cross-country study40 cited in the transport, and distribute, Glopan Foresight Report (2016) found as well as trade that while food imports are associated with a more diverse food supply in high- and middle-income countries, the diversity of agricultural goods produced by a country is the stronger variable in low-income countries. 38 39 40 (continued) 38 https://farm.ewg.org/region.php?fips=0000 39 In the U.S., selected pulse crops (dry peas, lentils, and small and large chickpeas) became eligible for some commodity programs under the 2002 Farm Bill, and cover- age for these pulse crops continues under the 2014 Farm Bill through the Agricultural Risk Coverage (ARC) and Price Loss Coverage (PLC) programs as well as through the marketing loan program (https://www.ers.usda.gov/topics/crops/vegetables-pulses/policy/). 40 Remans, R., Wood, S. A., Saha, N., Anderman, T. L., and Defries, S. A. 2014. Measuring nutritional diversity of national food supplies. Global Food Security, 3, 174–182, http://dx.doi.org/10.1016/j.gfs.2014.07.001 An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 35 Main Examples Nutrition NOURISHING Notes indicate association, if Goal of Actions Challenges Framework any, with overweight/obesity Increase demand for M, O I, G A commonly promoted intervention diversified and high- to address undernutrition, and quality foods through micronutrient deficiencies which will nutrition education, also have benefits for overweight. Tends including through to focus on women. agricultural extension, (importance of vitamins and minerals, food preparation, preservation, etc.) Note 1: U = undernutrition, M = micronutrient deficiency, O = overweight/obesity. Note 2: Each letter in the word NOURISHING represents one of ten actions that governments can take: N = Nutrition label standards and regulations on the use of claims and implied claims on food O = Offer healthy food and set standards in public institutions and other specific settings U = Use economic tools to address food affordability and purchase incentives R = Restrict food advertising and other forms of commercial promotion I = Improve nutritional quality of the whole food supply S = Set incentives and rules to create a healthy retail and food service environment H = Harness food supply chain and actions across sectors to ensure coherence with health I = Inform people about food and nutrition through public awareness N = Nutrition advice and counseling in health care settings G = Give nutrition education and skills Actions in the food storage, transport and trade subsystem that support the goal of improving diet quality (with a focus on overweight) Main Examples Nutrition NOURISHING Notes indicate association, if Goal of Actions Challenges Framework any, with overweight/obesity Reduce food loss and Improve rural roads U, M, O Not applicable This is a broad-stroke action that waste of underserved and rural energy will support a wide range of rural nutritious food groups development (grid and development objectives, including, but (especially fruits, off-grid sources) not limited to reducing overweight. vegetables, pulses, Implement logistical M, O Not applicable A commonly promoted intervention poultry, fish) upgrades, including cold to address horticultural development chain infrastructure thereby increasing the supply of fruits (cold storage, and vegetables. refrigerated transport, freezing facilities, etc.), and preservation technology such as drying, packaging, etc. 36 Food and Agriculture Global Practice Main Examples Nutrition NOURISHING Notes indicate association, if Goal of Actions Challenges Framework any, with overweight/obesity Adapt new agricultural M, O Not applicable technologies, such as aeroponics and hydroponics for vegetable production, in developing countries enabling production in urban centers and reducing the need for cold chains and transportation, where losses appear Use trade to improve Raise import duties for O U, S Evidence seems to suggest trade is a the quality of the local ingredients for food strong predictor for diversity of food diet processing supply only in middle- and high-income countries. Remove import duties from ‘underserved As import bans are forbidden by nutritious food groups’ WTO rules, countries are advised to seek alternative measures. Suggestions include involving health professionals in negotiations of trade agreements (Snowdon and Thow, 2013), and/or seeking a collective approach through international institutions/organizations instead of undertaking unilateral country actions. Note 1: U = undernutrition, M = micronutrient deficiency, O = overweight/obesity. Note 2: Each letter in the word NOURISHING represents one of ten actions that governments can take: N = Nutrition label standards and regulations on the use of claims and implied claims on food O = Offer healthy food and set standards in public institutions and other specific settings U = Use economic tools to address food affordability and purchase incentives R = Restrict food advertising and other forms of commercial promotion I = Improve nutritional quality of the whole food supply S = Set incentives and rules to create a healthy retail and food service environment H = Harness food supply chain and actions across sectors to ensure coherence with health I = Inform people about food and nutrition through public awareness N = Nutrition advice and counseling in health care settings G = Give nutrition education and skills An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 37 Actions in the food Transformation subsystem that support the goal of improving diet quality (with a focus on overweight) Main Examples Nutrition NOURISHING Notes indicate association, if Goal of Actions Challenges Framework any, with overweight/obesity Increase market Food fortification M Not applicable Not a direct tool for addressing supply of fortified overweight. foods with adequate micronutrients Build more awareness Clear official nutrition M, O N Nutrition labels must be easy to toward unhealthy labelling that is easy to understand to help consumers choose. ingredients for food understand processing, food, and Dietary guidelines M, O I, G Guidance should not just be in serving products that go beyond raw size of the various food groups. They ingredient food groups should provide sufficient and easy to implement guidance that reflects the reality of high consumption of processed foods. Incentivize product Coordination with the O O, U, S Initiatives are primarily limited to the reformulation to reduce food industry to foster U.S. and Europe. Success has been unhealthy ingredients voluntary product reported in reducing salt and trans in the processing stage reformulation fat in product formulation. Reducing (sugar/sweetener, sugar has been more challenging due to sodium, trans fats, etc.) technical difficulties. Activities to support food O O, U, S, I Successful private sector initiatives rely industry reformulation on a strong and coherent legislative efforts (developing framework. national strategies, public health campaigns to influence consumer demand, data collection, regulatory and legislative actions) Note 1: U = undernutrition, M = micronutrient deficiency, O = overweight/obesity. Note 2: Each letter in the word NOURISHING represents one of ten actions that governments can take: N = Nutrition label standards and regulations on the use of claims and implied claims on food O = Offer healthy food and set standards in public institutions and other specific settings U = Use economic tools to address food affordability and purchase incentives R = Restrict food advertising and other forms of commercial promotion I = Improve nutritional quality of the whole food supply S = Set incentives and rules to create a healthy retail and food service environment H = Harness food supply chain and actions across sectors to ensure coherence with health I = Inform people about food and nutrition through public awareness N = Nutrition advice and counseling in health care settings G = Give nutrition education and skills 38 Food and Agriculture Global Practice Actions in the food retail and provisioning subsystem that support the goal of improving diet quality (with a focus on overweight) Main Examples Nutrition NOURISHING Notes indicate association, if Goal of Actions Challenges Framework any, with overweight/obesity Build more awareness Comprehensive nutrient M, O N See discussion in the food towards healthy eating labelling transformation subsystem. Public health campaigns M, O I Evidence is weak on its efficacy. for healthy eating Culinary education for M, O G There are positive results that show that children and adults participation in cooking classes leads to changes in food consumption behavior (and some health changes). Disincentivize (Market based measure) O U Taxing sugar sweetened beverages is one consumption of Implement tax on of the recommendations by the WHO unhealthy foods unhealthy foods such Commission on Ending Childhood through taxes as sugar-sweetened Obesity (2016). beverages (Market based measure) U, S Food subsidies, where they exist, are part Remove distortive food of a social safety net. Subsidized food subsidy policies items are typically staples or imported food items such as oils and sugar. Nutrition considerations are usually not taken into account. (Public procurement) O O Adjustment should be to increase Adjust school meals content of healthy underserved nutritious food groups while limiting unhealthy goods. Regulate consumption Coordination with O I, S The track record of successful self- or limit access of the food industry as regulation by the food industry is poor. unhealthy foods they develop voluntary measures Foster engagement O S, I Government should foster a with third-party civil collaborative platform that includes organizations to monitor the food industry and third-party private sector activities civil society groups such as consumer protection organizations and food policy research organizations. Regulatory and O S Trans fat bans are spreading globally legislative actions as are salt reduction mandates. Other areas show little progress, such as limits on advertisement of unhealthy foods and beverages toward children in media outlets. Note 1: U = undernutrition, M = micronutrient deficiency, O = overweight/ R = Restrict food advertising and other forms of commercial promotion obesity. I = Improve nutritional quality of the whole food supply Note 2: Each letter in the word NOURISHING represents one of ten actions S = Set incentives and rules to create a healthy retail and food service environment that governments can take: H = Harness food supply chain and actions across sectors to ensure coherence N = Nutrition label standards and regulations on the use of claims and im- with health plied claims on food I = Inform people about food and nutrition through public awareness O = Offer healthy food and set standards in public institutions and other N = Nutrition advice and counseling in health care settings specific settings G = Give nutrition education and skills U = Use economic tools to address food affordability and purchase incentives An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 39 Future research franchising and other means. In middle-income countries the most dynamic, fast growing segment In contrast to other domains affecting obesity where there of the consumer food market has become that for is ample evidence for interventions that control and pre- snacks, beverages and confectionary. vent obesity, evidence of impact in the agriculture and »» Assess role of retail structures (e.g., supermarkets food systems domain is still being generated. This report etc.). The spread of super/hypermarket develop- and the peer review process have identified possible topics ment in the urban areas of developing countries for further examination. These are: has provided an improved vehicle for the mass »» Research the changing economic determinants of distribution of locally produced or imported pro- food choices (increasing price of unhealthy foods cessed foods. There has been a growth in the com- and beverages, decreasing the price of healthy mercialization of work and school canteen food foods) to address high prevalence of obesity in spe- distribution systems which often has not resulted in cific population groups. This may include research improved dietary offerings. The increased connec- into agriculture policy and food policy biases tivity of populations—via cell phones, television, which have contributed to a large growth in avail- radio, etc., has increased the range of means by able low-cost, energy-dense food ingredients. Such which branded foods have been advertised. policy biases as well as other factors (e.g., the state »» Identify where households do not have access of physical infrastructure, strength of logistical ser- to diverse foods, mainly fruits/vegetables, both vices, value addition and profit considerations by in terms of quantity and relative prices. These food companies) have, in many countries, resulted areas are where opportunities may exist for pro- in a pattern of relative consumer food prices which moting food production in order to bring prices tilts purchasing behavior toward high energy foods down, and/or supply markets (jointly with efforts and away from higher nutrient foods. to increase demand). This could be done through »» Assess role of food processing industries (i.e., indus- analysis of relative prices of food products across tries that purchase raw farm commodities). Satu- different countries/regions to see where the imbal- rated high-income country markets, combined with ances are in food availability costs according to a urbanization/income growth/lifestyle changes in balanced diet. low-/middle-income countries have led to a geo- graphic redistribution of food/beverage processing While the contribution of energy/food supply and avail- and processed food distribution activities among ability to overweight and obesity is not disputed, prevent- major international companies. Precisely the same ing overweight and obesity through interventions in the factors, and trade liberalization processes, have agriculture and food systems is a new challenge. Any con- driven a geographical redistribution of fast-food tributions to the evidence base are valuable and will help operations by global/regional players—through to shape our engagement. 40 Food and Agriculture Global Practice Annex 1 The full Obesity System Map from the UK Government Foresight report The Foresight Obesity System Map identifies 108 separate factors (variables) in seven (7) individual and population-level clusters (physiology, individual activity, physical activity environment, food consumption, food production, individual psychology, and social psy- chology) that directly and indirectly affect the core equation of energy balance (energy intake vs. energy expenditure)41 (Butland et al., 2007). Social Psychology Individual Psychology Physical Activity Environment Conscious control of accumulation Food Production Individual Importance of Effort to Physical Activity physical need acquire Tendency to energy preserve Strength of Energy energy lock-in to Balance accumulate Food Consumption energy Level of available energy Physiology 41 At the core of the Obesity System Map is “energy balance” (energy intake vs. energy expenditure), also referred to as the engine, or core engine. An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 41 Annex 2 Food production and food consumption clusters of the Obesity System Map Variables in each cluster interact with each other, and with variables in other clusters through a web of causal relationships referred to as “feedback loops,” and are repre- sented by arrows in the visual below. Source: Full Generic Map (p. 12). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/ 295153/07-1177-obesity-system-atlas.pdf An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda 43 There are four key variables affecting the core system In other words, if the market price of food decreases, this engine, i.e., energy intake vs. energy expenditure. The reinforces the ingrained human mechanism to acquire “force of dietary habits” is the key factor associated with and preserve energy in what the System Map’s authors the food production and consumption clusters collectively describe as a (negative) “lock-in” (Vandenbroeck et al., referred to as the food environment in the System Map.42 2007). Three sets of variables are at play in the food con- The authors identify the “pressure for growth and profit- sumption cluster, at the center of which rests the “force of ability” of the food industry as the contextual anchor for dietary habits” which feeds into the System’s core energy the food production cluster, driving a set of variables that balance. One set relates to the food market, and comprises make up the industry’s business model. Specifically, these the (level of) food abundance in the market, (level of) food aspects are: (level of) effort to increase efficiency of produc- exposure (or pervasiveness of food products), and (level of) tion; desire to minimize cost; desire to maximize volume food variety. These variables are influenced from forces (sold); pressure to improve access to food offerings; pres- at play in the food production cluster. The (level of) fiber sure to cater for acquired tastes; cost of ingredients; (level content of food and drink, nutritional quality of food and of) standardization of food offerings; and desire to differ- drink, palatability of food offerings, energy density of entiate offerings. These aspects affect the “market price food offerings, and portion size constitute the second set of food offerings,” which according to the Obesity System of variables collectively known as “(health) characteristics Map, act as the defining link between the food production of food products.” This set affects the “force of dietary cluster and the System’s core equation of energy balance. habits” and the level of satiety (found in the physiology cluster). A final variable on its own is the rate of eating (speed at which people take their meals) constitutes the 42 The other three are: psychological ambivalence (under the psychology clus- third set, and positively affects the level of satiety (Van- ter); degree of primary appetite control (physiology cluster), and level of physi- denbroeck et al., 2007). cal activity (physical activity cluster). 44 Food and Agriculture Global Practice References Aguayo, V., and Menon, P. (2016). Stop stunting: improving child feeding, women’s nutrition and household sanitation in South Asia. Maternal and Child Nutrition. Vol- ume 12, Issue Supplement S1 May 2016, pp. 3–11. Alderman, H. (2012). The Response of Child Nutrition to Changes in Income: Link- ing Biology with Economics. CESifo Economic Studies. 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