Chapter 2 Diets and human health: an accelerating crisis

Key messages

We are in a deepening global  nutrition crisis. Malnutrition in  all its forms has become one of  the most serious threats to global  health. Today, sub-optimal diets are  estimated to be responsible for 20%  of premature (disease-mediated)  mortality worldwide and 20% of all  disability-adjusted life years (DALYs).

Links between diet and disease  are increasingly understood as a  triple burden of undernutrition,  deficiencies of vitamins and  minerals, and diet-related non-  communicable diseases (NCDs).  This is due in large part to the global  epidemic of overweight and obesity.  All countries face at least one or all  of these problems. Low- and middle-  income countries (LMICs) are

disproportionately affected because  they carry the greatest burden of  undernutrition and micronutrient  deficiencies, while NCDs are growing  fast. LMICs also have the fewest fiscal  and institutional resources to manage  such challenges.

Improved diets would yield  substantial and wide-ranging  benefits which are integral to  universal policy goals. They will  contribute to better health through  improved nutrition; promote healthier  economies that spend less on treating  diseases associated with sub-optimal  diets; and engender better educational  attainment and labour productivity.

Most countries are not on track to meet most of the nutrition targets

set for 2025 by the World Health  Assembly. So much more has to be done, including shifting  dietary patterns globally. In order  to deliver sustainable, healthy  diets for all, food systems must  be fundamentally transformed.  They remain profoundly  dysfunctional. Most countries  are not on track to meet most of the nutrition targets for 2025  by the World Health Assembly.  So much more has to be done,  including shifting dietary patterns  globally. However, achieving rising  incomes in a country will not by itself guarantee better diets – it is more likely to shift the problem  as consumer demand shifts towards  sugars, unhealthy fats, oils, and red meat.

Unhealthy diets and maternal and child malnutrition are among
the current top risk factors for the global burden of disease and account for about one quarter of global deaths.

FAO and WHO (2018) 1
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What we eat impacts our health. The first  Foresight report, published by the Global  Panel in 2016, highlighted the risks  posed to human health by sub-optimal  diets as: “greater than the combined risks of unsafe sex, alcohol, drug and  tobacco use.” 2 But in the past few years,  evidence supporting these insights and  related recommendations has become  stronger and more worrisome – most  notably in terms of how rapidly diets  are shifting in negative ways, and the  growing prevalence of associated health  problems. The case for urgent action is  clear: food systems are failing to deliver  healthy diets for all.

2.1 Diets and human health: an overview

The World Health Organization (WHO) advises that diets should  include a diversity of foods which are safe and provide levels of energy and other nutrients appropriate to each individual  (see Box 1.1 in Chapter 1). In that framing, the characteristics  of an unhealthy diet include eating too few nutrient-rich  foods (including fruits, vegetables, pulses, nuts and seeds, or wholegrains), or too many food products that contain  ingredients known to carry health risks (such as high levels  of sodium, free sugars, and trans-fats 3 ).

Inevitably, achieving food security is one of the most immediate  concerns for the 50 or so low-income countries that face  structural (multi-year) food deficits. 4 Being seriously food  insecure is itself a major health concern for the roughly 690 million people going to bed hungry every day. 5 However,  meeting minimal calorie intake does not alone resolve or prevent  most of the manifestations of malnutrition. Both the quality and  quantity of foods consumed matter.

For policymakers, the message is clear. Sub-optimal diets are  associated with a wide range of serious health risks, and at least  11 million people die every year from specifically diet-related  illnesses. 6 Conversely, diets that are diverse, nutrient-rich and safe  support robust health, including enhanced immune systems  and better intergenerational (pregnancy and birth) outcomes.

The right combination of foods can provide a person’s energy,  protein, and micronutrient requirements. A shortfall in any of these nutrients leads to a range of deficiency syndromes  which are associated with disease states, including child growth  impairment, blindness and high blood pressure. 7 8

The links among diet, nutritional status and disease are  increasingly understood as a ‘triple burden’ threat as described  in Chapter 1. Poor-quality diets are important factors in  undernutrition, but they also contribute to deficiencies of  vitamins and minerals, as well as playing a key role in diet-related  NCDs.  9 10  11 The health risks associated with diet-related NCDs are  now manifest globally. Vitamin and mineral deficiencies are also  a global problem with large numbers of people in middle- and  high-income countries still suffering iron-deficiency anaemia and  deficiencies in B12, folate and vitamin D, in particular. The health  and mortality risks linked to undernutrition are now mainly  found in LMICs, where they continue to represent a significant  brake on development, especially where combined with one or other of the manifestations of malnutrition. For example,  Nigeria, Egypt and Malaysia are dealing simultaneously with  child stunting, maternal anaemia and high rates of adult female overweight. Paraguay and Thailand report co-existing overweight  and anaemia, while India and Niger are experiencing a high  prevalence of both anaemia and stunting.  12

In other words, some nutrition challenges are universal,  some are context-specific, but all countries are experiencing  manifestations of these problems.30

Figure 2.1 shows the considerable burden of malnutrition in  terms of a widely used metric – disability-adjusted life years  (DALYs) lost to ill-health. 13

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Recent Lancet Commission work on  the related global challenges of obesity, undernutrition, and climate change suggests that impacts of sub-optimal diets are  now responsible as well for 20% of all DALYs. 15 Other estimates  suggest that 20% of premature (disease-mediated) mortality  worldwide could be attributable to sub-optimal diets. 16 One  assessment of the drivers of DALY losses in the Economic and  Monetary Community of Central Africa (CEMAC) estimated  that the triple burden of communicable diseases, NCDs and  injuries in 2015 were responsible for lost DALYs with a fiscal  value equivalent to 59% of the region’s total gross domestic  product (GDP). 17

Worse still, poor nutritional status increases the risk of death  from infectious diseases. But there are also non-disease threats to  life related to wasting. A recent modelling exercise of the indirect  effects of impaired access to food coupled with healthcare  disruption caused by the coronavirus pandemic indicated that  these factors could raise the prevalence of child wasting, mainly  in LMICs, which would translate into 18% to 23% additional  preventable child deaths. 18

The links between poor diets and COVID-19 disease  outcomes were widely highlighted during 2020. For example,  the importance of eating a nutrient-rich diet to supporting  improved immune response to disease threats like COVID-19  has been highlighted. 19 The Food and Agriculture Organization  of the United Nations (FAO) made a clear statement that “while no foods or dietary supplements can prevent COVID-19  infection, maintaining a healthy diet is an important part of  supporting a strong immune system”.  20 Conversely, the World  Health Organization’s Regional Director for Africa recently  underscored the concern that already-malnourished individuals  “will find it harder to fight off COVID-19 infection”.  21

While more research is needed to fully elaborate on these  suspected links, the coronavirus pandemic has brought much  greater attention to the known role of diets in health, regardless  of geographic setting. Wherever a person may live, she or he  should be able to eat well. This is not just about supporting  choice (consumer sovereignty), since food systems respond to  a wide range of incentive structures, policy frameworks, legal  regulations, and commercial strategies. Nor is it as simple as  supply responding to, or influencing, demand. Food systems  deliver food items and products to places and at prices that  have been negotiated by many different people and processes.

Transforming food systems to be aligned with health and  sustainability goals will require a focus not on individual foods or  nutrients in isolation, but on how and why foods are chosen and  combined in people’s diets, and how best to offer them to people  in ways which are affordable, nutrient-rich, and sustainable.

The challenge to governments is stark. To improve the health  of all citizens (thereby reducing healthcare costs and increasing  productivity and economic growth), those citizens need to be well-nourished, not simply disease-free. For a population to  be well-nourished, everyone must have access to a high-quality  diet throughout the course of a lifetime, and governments must  support actions in both the public and private sectors which  can effectively manage and prevent the different manifestations  of malnutrition.

2.2 Malnutrition in all its forms

The Sustainable Development Goals (SDGs) were adopted in  2015 as a set of interlocking targets aimed at improving the  development of all nations by 2030. They represent a call for action  through global partnerships. 22 The second of the 17 SDGs includes  a focus on ending hunger, but also on improving nutrition.

Hunger is not the same as malnutrition. Around one in 10  people in the world ‘go to bed hungry’. 23 This represents roughly  690 million people who were estimated to be chronically  undernourished in 2019 (this number is a revision of previous  estimates based on new data on population, food supply and  new household survey data which enabled the revision of the  inequality of food consumption for 13 countries, including  China). 24 After decades of decline, that number has been rising  in recent years due to armed conflict, recurrent natural disasters,  and political instability. The situation is most alarming in sub-  Saharan Africa, where the prevalence rate of undernourishment  has steadily increased in almost all sub-regions of the continent.  Similarly, undernourishment has been rising in parts of South  America, such as Venezuela. Successfully ending hunger, let alone  all forms of malnutrition, by 2030 seems optimistic under such circumstances, but that goal must remain a priority. The full set of  SDGs will not be met without ending hunger and malnutrition. 25  In turn, this cannot be achieved without improved diets being  made available through sustainable food system practices.

SDG2 adopted nutrition targets established by the World Health  Assembly (WHA) in 2012. 26 The WHA targets were agreed by  Member States of the WHO and aim to accelerate progress  globally, not just for a single nutrition outcome, but to “end all forms of malnutrition by 2030”. 27 This meant setting targets  relating to the following six manifestations of malnutrition:  28

Child stunting: Around 144 million children under five years of  age were stunted (too short for their age) in 2019. 29 While there  has been progress in recent years in reducing the global figure  for pre-school children who fail to grow to their expected height  at a given age, the gains have not been universal (around 30  countries bear most of the burden of stunting), nor fast enough  to meet the WHA’s global target of a 40% reduction between  2010 and 2025 (see Figure 2.2).

Child wasting: In 2019 there were roughly 47 million pre-school  children who were wasted (too thin relative to their height). Even moderate wasting raises the risk of disease-mediated  premature mortality for these children; acute wasting increases  that risk significantly (see Figure 2.2). In Asia and Oceania,  wasting currently puts nearly one in 10 children at increased risk  of death. South Asia, led by India, is home to more than half of  all the world’s wasted children (>25 million in 2019). 30

Childhood overweight: Since 1975, obesity has nearly tripled  worldwide and now affects every country in the world. Recent  analysis from six countries in South Asia found that overweight and obesity have been rising in rural as well as urban areas, and  among less-wealthy and less-educated adolescent girls and  women (as well as the wealthier, educated elites). 31 Northern  and Southern Africa are regions already dealing with 11-12% of  preschool children who were overweight in 2019. 32The WHA  target is aimed at preventing a rising caseload by eliminating  further increases in preschool child overweight (see Figure 2.2).

 Anaemia in adult women: A 50% reduction in the prevalence  of anaemia among women of reproductive age (WRA) was set as  the global target for 2025. In 2016, an estimated 38% of all WRA  globally were suffering from anaemia, rising to over 40% among  pregnant women. 33 Asia and Africa have the highest rates of  prevalence. Anaemia is a concern for women’s health, but it also has  impacts on pregnancy outcomes as it is an important risk factor  for haemorrhage, which is the leading cause of maternal deaths. 34  No country is on course to achieve the WHA target by 2025. 35

Low birth weight: Roughly 15% of all live births are below 2.5kg,  which increases the risk of neonatal complications and adds the risk of physical and cognitive impairment in that child’s later  development. 36 While a dozen countries are on track to meet the  WHA target of cutting low birth weight rates by 30% (by 2025),  most are not. The greatest burden of low birth weight falls to  families in central and southern Africa (where one in five births  fall into this category), but some Asian countries such as Nepal,  Bangladesh and The Philippines also post similar statistics.

Eclusive breastfeeding: A high-quality diet starts at birth  in the form of exclusive breastfeeding. A baby born anywhere  in the world requires no other food or liquid than breast milk for the first six months of life, yet only about 40% of infants  globally are given that ideal diet. 37 Most countries in the world  do not collect or report data on exclusive breastfeeding, so it  is unclear how much progress will be made towards the target  of increasing rates up to at least 50%.

2.3 The extra dimension: Diets and NCDs

There is an important additional dimension of the diet-nutrition  relationship which is not fully captured in the six WHA targets – that of the escalating impacts of adolescent and adult obesity  and associated diet-related NCDs on public health and on  national finances (see Box 2.1).

One recent study indicates that  at least 36 risk factors for the world’s disease burden, including  most of those related to sub-optimal diets, will worsen by 2040. 38 They include high blood glucose, high blood pressure, high  cholesterol and high body mass index.

More than a quarter of preventable deaths globally have been attributed to imbalanced diets, mostly from diet-related, chronic diseases that also require costly treatment.

Stanaway et al. (2018) 39

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Box 2.1: Today’s burden of non-communicable diseases (NCDs)

According to the 2018 Global Nutrition Report: “The burden of NCDs is significant: 422 million people have diabetes and 1.1 billion people suffer from high blood pressure. NCDs were responsible for 41 million of the world’s 57 million total deaths

(71%) in 2016, of which diet was one of the four leading risk factors.” 41 Importantly, the diet-related disease burden is highest in low- and middle-income countries (see Figure 2.3), which together account for 85% of all premature deaths from NCDs. 42

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Importantly, although by 2040 sub-Saharan Africa will still have  a large share of years of life lost due to communicable diseases  as well as maternal and young child undernutrition, it will also face rapidly growing healthcare costs associated with diet-related  NCDs such as ischaemic heart disease, strokes, and diabetes.  43

The huge scale of the future health and economic impacts  of poor diets can be illustrated by just one diet-related NCD: diabetes. The number of people affected is projected to rise from  451 million globally in 2017 to 693 million by 2045, increasing  global healthcare expenditure to almost US$1 trillion per year. 44  Estimates of the ‘full economic cost’ of diabetes forecast that the  global economic burden of diabetes will rise from US$1.3 trillion  in 2015 to US$2.5 trillion in 2030, if recent trends continue, with  low- and middle-income countries severely affected. 45 By 2030,

East Asia and the Pacific region are expected to carry the largest  burden of diabetes (with the highest economic impact, reaching  almost US$800 billion annually for that region alone), while in sub-Saharan Africa, the economic impacts of diabetes are  expected to exceed US$52 billion by 2030. 46

But the impact of poor diets goes beyond diabetes, particularly  in LMICs. The 2019 version of the State of Food Insecurity and Nutrition in the World projected that undernutrition will  continue to place a drag on economic growth across South  Asia and sub-Saharan Africa, cutting GDP by up to 11% per  year 47. In other words, although LMICs have yet to feel the full  economic and health system impacts of diet-related diseases,  those impacts are already having effects that compound each  other year-on-year.

If current trends continue, economic losses in low- and middle-income countries from heart disease, cancer, diabetes, and chronic respiratory disease will reach more than US$7 trillion over the period 2011–2025, equivalent to about 4% of these countries’ annual output.

UNICEF (2019) 48

In light of these compounding challenges, it is no surprise that malnutrition in all its forms poses “by far the largest cause of health loss in the world”. 49 There is therefore a growing imperative for LMIC governments to understand how diets and their associated food systems contribute to these health losses, and how improvements in both need to be part of the solution.

2.4 The roles of diets in health

It was recently estimated that more than one quarter (26.4%)  of the world’s entire population does not have regular access  to sufficient nutrient-rich safe foods. 50 Many more do consume  enough calories on a daily basis, but still do not consume  recommended levels of many key nutrients (such as iron or vitamin A) or certain types of foods that are important  contributors to health (such as whole grains, legumes or nuts  and seeds). 51 52

2.4.1 Dietary patterns in LMICs

The poorest households in low- and middle-income countries  allocate roughly two-thirds of their spending on food. 53 It is  arguably the most important fundamental daily need for billions  of people (along with water and shelter). Importantly, even  smallholder farmers are typically net purchasers of food, meaning  that even when they produce commodities, most farmers still  procure food from the market. While the share of spending for food is high in countries across Africa and South Asia, the  absolute amounts are low relative to other parts of the world.


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This means that the bulk of spending on food is used to acquire staples, such as cereals (as grain or flour), or roots and tubers  (like cassava or potatoes).

Figure 2.4 55 shows the global supply picture of foods available  for consumption in terms of calories per person per day (data  from 2011). The largest share comes from grains (rice, wheat  and maize), with smaller shares for dairy and eggs, fruits and  vegetables (listed as ‘produce’), as well as meat and sugar.


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But in LMICs, the need to buy the cheapest source of calories in  the form of staples (home produced and/or purchased) limits  the amount that people can spent on other foods. Figure 2.5  indicates how demand has grown differently in high- and lower-  income countries Of course, diets also differ across geographic regions. Figure 2.6  shows that while the contribution of meat and sugar to diets in  Egypt and Nicaragua is similar, it is quite different in Bangladesh. 58

2.4.2 How diets are changing

The diets of the poor typically have limited differentiation from  one day to the next, lack diversity across types of foods, are  limited in nutrient-rich foods (such as eggs or dairy, fish or meat,  nuts and seeds, or fruits and certain vegetables), and often carry  food safety risks (such as mycotoxins). In general, these diets do not support adequate levels of intake of most important  nutrients for the world’s most nutritionally vulnerable individuals  (children, adolescent girls, and adult women). As such, improving  diets must become a critical policy priority where governments  are concerned about health outcomes, educational attainment,  economic productivity, and societal well-being. Yet, while these areas of policy are all fundamental goals of the SDGs, the  importance of improving diets is not explicitly mentioned in the  SDG framework as a key enabling factor and a necessary target  in its own right.

There are several inherent challenges in bringing about the  dietary shifts needed to achieve the ambitions of the SDGs. The  first is to resolve poverty-related dietary inadequacy. Securing an  adequate supply of staple foods (mainly cereals and tubers), be it  through domestic production and/or imports, remains a priority  for most governments.

This is especially true of low-income food  deficit countries; in 2019, these included Afghanistan, Chad and  Haiti, all of which are struggling to feed themselves. 59 The essential  demand-side equivalence to improving food supply is to reduce  poverty in equitable ways which improve the purchasing power  of the poorest households (see also Chapter 7).

goods

But that leads to a second challenge. As incomes rise,  the world has seen a common pattern emerge in terms  of dietary shifts:

  1. Growth in demand (much more food required in low-  and middle-income countries because it is there where  population growth continues to be greatest, and where  poverty is also declining steadily;
  2. Shifts in demand in favour of sugars, fats, oils, and  substantially more meat; and
  3. Convergence with high-income countries in food system  characteristics such as shopping for fresh foods in  supermarkets rather than wet markets, more food eaten  outside the home (in restaurants as well as fast-food outlets),  and more snacking of highly processed packaged foods and  sugar-sweetened drinks. 60 61

Projections suggest that global demand for food will rise in  the next three or more decades roughly in line with projected  population growth. Recent estimates are for the global  population to reach around 9.5 billion by 2050 and 11 billion  by the end of the century. 62 This would lead to a rise in food  (calorie) demand of between 49% and 56%, depending on assumptions used. 63 64 65 66 At the same time, demand is expected  to grow for animal products (dairy, meat, fish), as well as for  vegetable oils, sugar, ultra-processed foods, and high fat and salty  snacks. 67 These changes are occurring rapidly across the globe.

2.4.3 Poor diets and NCDs

All countries consume too many sugar-sweetened beverages 68 (see Figure 2.7). On average, high-income countries (represented  by dark blue circles) already consume an excess of processed  meats, red meat and salt. Low-income countries, represented by the dark orange circles in the figure, consume lower  levels of processed meats and red meat, but they still exceed recommended intake levels of salt, which contributes to high  levels of elevated blood pressure in many low-income countries.

For fruits, vegetables and wholegrains, all countries irrespective  of wealth fall below the level of intake required for healthy  diets. Recent analytical work by the Global Dietary Database (GDD) underscores the consequences of large gaps between the  availability of nutrient-rich foods (such as fruits and vegetables)  and optimal consumption levels. Low consumption of fruits and vegetables leads to a range of definable disease outcomes  which increase preventable mortality – including over half a  million deaths due to coronary heart disease (CHD), 1.2 million  stroke deaths due to sub-optimal fruit intake (<300g/day), and  over 800,000 CHD deaths due to low vegetable consumption  (<400g/day).60 All countries face these challenges: under current  food consumption patterns, it has been estimated that diet-  related health costs linked to mortality and health effects of  NCDs may exceed US$1.3 trillion per year globally by 2030. 69  The concentration of CHD mortality linked to poor fruit intake  in LMICs underlines the importance of governments in those countries to give priority to appropriate policy actions  (see Figure 2.8).


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Excess consumption of certain food ingredients and products  is known to be deleterious to health, and contributes to disease  and death across the globe. At the global level, between 1990  and 2010, there has been an increase in consumption of both ‘healthy foods’ and those not supporting healthy diets, with the  latter outpacing the former in most regions of the world. 71 While  many processed foods can contribute to diet quality, others high  in unhealthy fats, salt and sugar do not, including packaged,  ultra-processed foods containing high amounts of added sugar,  sugar-sweetened beverages (SSBs), and red processed meats.

High levels of processed meat consumption (mainly red meats)  contributed to half a million CHD deaths globally in 2010, the  highest share of which was found in middle-income countries  such as Costa Rica, Panama, and Colombia. Karageorgou D, Miller V, Cudhea F, Zhang J, Shi P, Onopa J, et al. Estimated Global, Regional, and National Cardiometabolic Disease Burdens Related to Red and Processed Meat Consumption: An Analysis from the Global Dietary Database (P10-073-19). Curr Dev Nutr. 2019.3(Supplement_1). Copyright granted September 2020. Processed meats  are also implicated in the rise of diabetes, including almost  100,000 deaths among diabetics globally (see Figure 2.9).

One recent study on the link between diet and diabetes  reported that “the quality of evidence was high for the  association for increased incidence of type 2 diabetes with higher  intake of red meat” as well as for processed meats and sugar-  sweetened beverages. 72

Another in 2019 reported a “significant  inverse association” between plant-based dietary patterns and  the risk of diabetes. 73 In other words, too much of certain clearly  defined high-risk foods and too little of well-known beneficial  nutrient-rich plant-based foods is strongly linked to the risk of  this specific NCD.

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2.4.4 Poor-quality diets and vulnerable populations

An important caveat to all the trends laid out previously is the  continuing nutritional vulnerability of low-income families across  LMICs, and to some extent also in high-income countries (HICs).  There are many high-income families in LMICs, so national  averages mask considerable variability in income distribution  (discussed further in Chapter 7) and hence in diet sufficiency and quality (lacking diverse, safe, nutrient-rich foods). Some  demographic groups are physiologically more vulnerable to  nutritional inadequacies and deficiencies, including pregnant and  lactating women, infants and young children, and adolescent girls.

For example, poor maternal health and nutrition leads to  poor birth outcomes, such as babies born underweight or too  small for their gestational age at term, which is associated with  new-born and infant mortality and accounts for a substantial proportion of stunting among surviving children. 75 The particular  needs of all nutritionally vulnerable people must be understood  and prioritised in attempts to enhance the quality and quantity  of diets globally, particularly in the context of policy agendas  developed in response to the WHA targets and SDGs. However,  as noted earlier, these targets do not include healthy diets either  as a means of attaining health or environmental goals.

At the same time, millions of people live in extremely fragile  situations caused by conflicts, disasters, physical displacement,  political discrimination and more. 76 According to the  Organization for Economic Cooperation and Development  (OECD), by 2030, the number of people living in fragile settings  is projected to reach 2.3 billion, which includes 80% of the global  poor. That represents another 500 million people over today’s  total. 77 It is crucial that governments and the food-industry do  not ignore the dietary and healthcare needs of people living in refugee camps, remote rural areas poorly connected to  markets and services, or in failed states. While these situations  pose added challenges to effective policy and programming investments, allowing them to remain marginalised also allows  economic and nutritional inequities to persist.

2.5 Summary

Changing patterns of consumption are driving trends in diet-  related mortality around the world. It is therefore important  for policymakers to consider global trends and the patterns  that develop across and within countries (for example rural  versus urban, and income status).

Policymakers can draw two important points from such data.  First, as shown in the first Foresight report, achieving rising  incomes in a country will not by itself guarantee better diets.  And second, better diets are needed for everyone everywhere,  regardless of cultural or religious patterns, or income at either  national or household levels. Improved diets will contribute to  better health, specifically through improved nutrition, but also  healthier economies spend less on treating diseases associated  with sub-optimal diets, and secure the benefits of better  educational attainment and labour productivity.

The role of diets in the future well-being of almost 10 billion  people can no longer be ignored. The need for improved  diets provides a key rationale for growing calls to change the  world’s food systems. But there is a second important reason  for supporting a transition process. The food choices (which  underpin dietary patterns) and the ways in which foods are  produced, together represent major drivers of the unfolding  climate crisis and related environmental degradation. And in turn, the deepening climate and natural resource concerns  are increasingly challenging the resilience of food systems, and  threatening their ability to deliver the foods needed for healthy  diets sustainably. Chapter 3 explores this vicious circle and the  way it operates on a planetary scale.

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