Chapter 7 Encouraging demand: making sustainable, healthy diets desirable

Key messages

Each of the actions proposed in this  report will have limited effect if people  choose diets that do not promote  health and/or cannot be pursued  sustainably. A range of actions is  needed to encourage individuals to  make more informed choices without  being prescriptive or impinging on  consumer aspirations. These changes,  working through consumers’ collective  purchasing power and influences on food industry priorities, open up  potential for market growth which  supports healthy affordable diets for  all, rather than one in which demand  is frequently influenced in favour of  cheap and convenient products with  lower nutritional value.

Specific actions include:

  • Implement policy-based  behavioural nudges via carefully  designed consumer-focused taxes  and subsidies. These offer the  potential to influence behaviour  substantially at relatively low cost.

    Some governments are already  implementing a range of product-  focused taxes or subsidies in high-  income countries (HICs), although  further research is needed for the  context of low- and middle-income  countries (LMICs).

  • Better regulate advertising and marketing, particularly to children. Both strongly influence dietary aspirations and food choices.  Policymakers should focus on  regulations to restrict companies  from encouraging people to make  dietary choices which do not  support sustainable, healthy diets,  especially inappropriate marketing  of ultra-processed foods to children,  and breast milk substitutes to adult women of reproductive age.  Voluntary regulation has not proved  successful in many cases.
  • Upgrade food based dietary guidance and promote enhanced knowledge about implications of dietary choices. Governments  must do much more to empower  individuals to make more informed  dietary choices. Food Based Dietary  Guidelines (FBDGs) can generate  substantial benefits, but they are  still underused, in part because they  are not designed to be user-friendly,  they rarely account for issues of  sustainability, and many do not reflect the best available science and  evidence. Also, FBDGs should be  used to inform government policies.  Additional forms of guidance and  messaging to enhance people’s

understanding of the human and  planetary implications of food  choices must be explored.

  • Define principles of engagement between public and private sectors, and clearly articulate  responsibilities in moving  towards common goals. The food  industry should not be demonised  or ignored; at the same time, nor  should it be allowed free rein to pursue narrow profit motives  where these are antagonistic to  wider societal goals. Companies  need to accept greater responsibility  for their part in driving the global  trend of fast-rising consumption of ultra-processed food, and the  damage to health it causes. It is  therefore important to a incentivise  actions which support government  policy agendas on public health  and environmental sustainability. A comprehensive framework  for engagement is needed. In particular, food business  enterprises of all kinds should be  required to abide by national and  international standards, but for  this to be effective, there must  be appropriate, funded systems  in place to track, monitor, and  hold actors accountable.
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People may decide not to adopt  sustainable, healthy diets even when  they are accessible and affordable. This  is because many other factors influence  consumer demand beyond price,  including advertising, taste, convenience,  nutritional information, and social and cultural norms. A range of evidence-based  actions is needed to encourage individuals  to make more informed choices without  being prescriptive or impinging on  consumer aspirations. While little  evidence is available on the effectiveness  of policy actions in this domain in LMICs,  there are several approaches which are worth pursuing. In other cases,it will be important for policymakers  to trial different approaches, and  carefully monitor their effectiveness,  to inform whether they should be  rolled out further. Enabling citizens to  make better dietary choices will have  major benefits. It will support the  health of consumers themselves and, by  promoting consumption of foods which  are sustainably produced, it will benefit  environmental systems. More generally, it will help to drive the transition towards  transformed food systems.

To support a market for diverse and nutritious food, consumer demand and preferences need to be aligned with a healthy diet. In order to stimulate this demand and shift food preferences, the food system and food environment must be supportive and healthy.

FAO (2018) 1

This chapter discusses how to enable people to make informed  dietary choices in line with health and sustainability goals.
It explores some of the most important influencers of choice  beyond price, and how various actions by the public and private  sectors could do more to achieve positive outcomes. While the  major determinants of demand are well known, evidence of  effective approaches to promoting healthy dietary choices from  LMICs remains limited. 2
There are many studies on willingness- to-pay for different food attributes or price points, assessments  of the effects of advertising, analyses of product placement in supermarkets, and analyses of people’s understanding of the content of labels.

But most of these have been undertaken in high-  income countries, heavily driven by concerns about rising obesity  and non-communicable diseases (NCDs). Also, these studies often  fail to include effective policy guidance or recommendations. 3 4 5

Although much more needs to be known about how dietary  choices are made in LMICs beyond the issue of affordability,  governments need to act today by identifying the best policy  options available to achieve better health and sustainability  outcomes for their populations. The following sections review  the current evidence.

7.1 Advertising and other marketing practices

Dietary aspirations and food choices are strongly influenced  by advertising and marketing. Policymakers should focus on  regulations to restrict how companies encourage potential  consumers to choose foods which are not conducive to  sustainable, healthy diets. This is especially important for  inappropriate marketing of ultra-processed foods to children  and breast milk substitutes to adult women of reproductive age.

Evidence suggests that self‐regulation in the form of voluntary  guidelines has been largely ineffective in reducing the number of food advertisements promoting ultra-processed foods, snacks  and toy-branded fast foods aimed at children. This can in part be  ascribed to companies seeking to be profitable in a competitive  commercial space where one firm does not want to take risks if  others do not. A study in Brazil, for instance, showed that during  432 hours of free-to-air TV broadcasting on three channels, 80% of 1,610 food and beverage advertisements did not meet  Pan-American Health Organization or WHO standards and were  considered eligible for marketing restrictions. 6

Over 90% of the  advertisements that failed to meet nutrition standards were from  just 10 trans-national and domestic local food and beverage  companies, two international fast food chains, and two of Brazil’s  largest supermarket retailers.

Nevertheless, government action can influence behaviour.  For example, legislation in South Korea has led to a decline  in exposure of children to food-related marketing. 7 Indeed, a recent review of 79 countries that have implemented policies  to restrict the marketing of ‘junk food’ found a drop in sales per  capita after implementation, compared to countries without  such policies, which saw an increase in sales. 8

This approach has been relatively effective in large part because of the ‘level  playing field’ effect in which food companies are willing to take  collective action where the individual risk of loss of market share  is taken out of the equation.

By contrast, an assessment of self-regulation of the food and  beverage industry’s application of ‘nutrition criteria’ in Canada  concluded that the nutrition and ‘health value’ of most products  advertised to children on television (on 27 channels between  2013 and 2016) remained poor, and that “mandatory regulations  are needed”. 9

Reduced advertising to children (via television), and more  active marketing of ‘healthy diets’ as an aspirational norm  should be a priority for all nations. 10 However, it will be  important for policymakers to carefully assess context when  deciding on mandatory and/or voluntary regulations and  guidelines. For example, with food placement in supermarkets,  it is important to understand the complex relationships which can exist between food producers and retailers. Supermarkets in  some countries require payments to position a food producer’s  high-profit products favourably (e.g. in terms of shelf height,  position in aisles, proximity to checkouts, position relative to the  supermarket’s low-cost own brand, etc.). Therefore, it is unlikely  to be straightforward to persuade a supermarket to remove  ultra-processed and other snack foods from children’s height  and away from check-out stations (see Box 7.1).

7.2 Taste, convenience, and perceptions of food product traits

Consumers are, of course, not only swayed by lower prices or marketing. There are serious constraints to choices in most  food environments around the world: for example, competing  demands associated with paid work, commuting, and childcare  affect the frequency of shopping outings (and hence continued  access to fresh produce). They can also affect the time for cooking and eating meals. Some people also have limited storage  and refrigeration capacity to keep foods in good condition and  reduce food waste.

These factors show that ‘choice’ is influenced by a number  of drivers and that the outcome may not be the individual’s preference, but rather one that ‘works’.

For example, one study  explored the issue of ‘value conflicts’ among mothers in the  Netherlands when purchasing snacks for their young children. 11  The mothers reported feeling conflicted when they provided  snacks perceived as ‘unhealthy’, but their choice was based on convenience. They were also conflicted when giving snacks  between meals to keep a child from crying, or because other  mothers were using one product over another.

Importantly, this is not simply a ‘rich country’ quandary. There is  ample evidence in LMICs that mothers engaged in agriculture have  significant time constraints for childcare, including the time that  can be spent on nutrient-rich meal preparation for appropriate  infant and young child feeding. 12 One study in India concluded  that the persistence of undernutrition among children is “tied  closely to the high workload and consequent time constraint of mothers who are increasingly pursuing income-generating  activities”. 13 Similarly, in rural Guatemala non-farm employment  raised incomes, but also involved a decrease in the amount of  time spent by mothers on buying food from the market, meal  preparation and overseeing their children’s meals. 14 The same can  be true in cities. In an urban setting in Brazil, for example, recent  research showed that income and time constraints competed with  mothers’ understanding of healthy diets, leading to patterns of food  choice that increasingly included ultra-processed food products. 15

There is also growing evidence that citizens in resource-poor  settings choose certain packaged products and more modern  retail outlets because of assumptions about higher standards  of food quality and safety. Perceived food safety represents an important, relatively new dimension of the overall food security  policy agenda of many lower-income governments and their  development partners. 16 Recent work has shown that poor  families living in informal settlements in Kenya and Uganda are  willing to pay a higher price for food products that they can  trust to be nutrient-rich and safe. 17 Since there are hundreds of millions of households at the base of the income pyramid  globally who allocate between 50% and 75% of total spending  on food, these people represent a vast market. Their willingness  to pay for nutrient-rich, safe foods offers potential for market  growth which supports healthy affordable diets for all, rather than one in which demand is influenced towards cheap and  convenient products with lower nutritional value.

Box 7.1: In-store marketing practices for adults and children

UNICEF’s Regional Office for Latin America and the  Caribbean has showed that “in-store marketing practices  such as product placement and pricing do sway customers’  purchases, across different countries, retail outlets and  socio-economic groups”. 18 Adults revealed that pricing  was the main factor that caught their attention and helped

them make their decision to buy. But for children, the  decisive factor affecting desirability was the packaging.  The common techniques designed to attract children  include eye-level placement of products in retail settings,  encouragement to purchase linked to potential prizes, and the widespread use of licensed film and cartoon characters.


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However, consumer demand is not static. Individual foods or  ingredients can become widely popular and either enter the  mainstream of diets (for example quinoa, kale, and gluten-  free products) or disappear. It remains a substantial challenge  for governments to encourage and incentivise private food  companies to play a significant role in influencing choices  that support healthy and sustainable diets.

7.3 The special case of ultra-processed foods

There is growing concern about the increasing uptake of ultra-  processed foods in diets. For many people, ultra-processed  products, snacks, and drinks are tasty, attractively packaged,  require no preparation, are relatively cheap and widely accessible.  They are also heavily promoted via advertising, free gifts for  children, and forward placement in supermarkets. Many urban  food environments in which large numbers of people make food  purchases rely heavily on ultra-processed foods of all kinds to  attract customers and profits. But since they have a long shelf-life  and are relatively cheap, they are increasingly eaten by infants and  children even in remote rural areas of LMICs such as Cambodia,  Senegal and Nepal. 20 The retail value of ultra-processed food  continues to grow in LMICs (see Figure 7.1). For example, from  2013-2018 the retail value of ultra-processed foods grew by 87%  in Syria, 80% in Bangladesh and 74% in Laos. 21

Ultra-processed foods are manufactured products that are  typically energy-dense and nutrient-poor, and offer large  amounts of energy, fat, sugar, or sodium. The term ‘ultra-  processed’ and its definition are still widely debated. This issue deserves greater policy attention since the consumption of such  products has been identified as a risk factor for obesity and  NCDs.

As defined by the NOVA classification, ultra-processed  food formulations typically have five or more ingredients which  may include added sugars, oils, fats, salt, antioxidants, stabilisers,  and preservatives, as well as other substances not commonly  used in culinary preparations, although more consensus is  needed around definitional parameters. 22 These foods include  snack products such as chips or crisps, some ready-to-eat cereals,  sugary drinks, and some forms of confectionery.  23 They belong  to a ‘class’ of products that dominate the discussion of what is  apparently desirable (for a variety of reasons) to many people,  but deemed to be undesirable by many in the public health and  nutrition communities around the world. 24 25 26
How red meat  alternatives, which have grown in popularity recently because of their perceived health and environmental benefits, fit into  such a classification remains to be determined.

These ultra-processed products have been created to be tasty,  cheap and ubiquitous, and therefore attractive and accessible. 27 Properties that may promote overconsumption of such products  include their “hyper-palatability and quasi-addictiveness for  susceptible individuals”. 28 They are now widely found in even the most remote, rural markets of Africa and Asia. For example,  recent data from 11,537 children aged six months to five years of age in Burkina Faso, Cote d’Ivoire, Mali, and Niger showed that  between 26% (Niger) and 45% (Cote d’Ivoire) had consumed at least one commercial snack food or beverage in the prior 24-hour period. 30 Those from higher-income households were  obtaining almost 50% of total energy intake from such foods.

Many food businesses also favour ultra-processed packaged  foods since they have a longer shelf life than fresh foods, are easily  transported, and can be produced at low cost on an industrial scale.

These features lead to larger profit margins and long-chain  distribution networks, and to more aggressive marketing than for  perishable foods. As UNICEF points out, ultra-processed foods are skilfully marketed, widely available and affordable to many, while  nutrient-rich foods are often more expensive and out of reach. 31  In many settings, the food environment does not lend itself to  supporting nutrient-rich diets, nor is it incentivised to do so.

Efforts to shift demand away from ultra-processed foods  are made more difficult by attitudes to fresh foods in some  emerging economies. For example, in Brazil, fewer than 10%  of consumers in a 2018 survey said they like to eat “healthy,  fresh, nourishing foods” (see Figure 7.2). 32 This preference  supports the commercial impetus to:

  1. deliver ultra-processed products rather than nutrient-rich  fresh foods at prices that make them more attractive and
  2. to resist voluntary product reformulation.

A similar trend is being observed in low-income countries. A recent survey of households in urban Zambia found that  two-thirds use modern and traditional retailers simultaneously, but wealthier households are more likely to rely on supermarkets  for their food purchases. The use of modern retailers is strongly  linked to higher consumption of ultra-processed foods (even  after controlling for income and education). 33 The same trend is increasingly true for rural markets in LMICs. For example, a  study in 2014 of the adequacy and appropriateness of diets of  young children in the Banke district of Nepal (a remote rural  area located in far Western Nepal) found that two-thirds had been fed ultra-processed foods, such as biscuits or dried noodles,  during the previous day. 34

 


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As a result, sales of ultra-processed  foods and beverages per capita across South and South-East Asia are expected to have almost doubled by 2024 compared to 2012  (from 18kg to 33kg, respectively); similarly, Africa is projected to  see per capita sales of ultra-processed products rise from 33kg in 2012 to 46kg by 2024. 36 In both regions, the bulk of increased  sales of beverages is in the form of carbonated soft drinks.

Reversing these trends is possible, as seen in the declining levels  of consumption of ultra-processed food in North America and  Western Europe between 2002 to 2016 (see Figure 7.3). However,  policymakers should remain vigilant: significant damage may  have already been done in those two regions, while the rest of  the world continues to follow in the same direction. 37
Shifting  consumer demand away from ultra-processed foods towards  nutrient-rich fresh foods in LMICs therefore requires a major  strategic shift by governments who need to show robust leadership in pursuing what are major public health goals,  currently neglected for a variety of reasons (see Box 7.2).


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Box 7.2: Consumer sovereignty

It has long been known that “public policies have  been strongly influenced by private interests of large corporations”427, particularly in relation to policies that may  raise prices, limit advertising, or regulate products that are  otherwise commercially profitable. Many factors impede  effective national governance in this space, including lack  of institutional (policy analytical) capacity, party political ideology, the sway of economic arguments around notional  job losses in the wake of policy change, and contested  science on health or societal outcomes. There are few  examples of companies selling profitable products that are thought to be associated with human harm (such as  tobacco-related products, certain chemical agricultural  inputs, etc.) voluntarily removing such products from the  market. Legislation and/or legal actions have been required.  Since commercial companies need to generate profit and  seek to protect market share, governments must incentivise

changes to business models that support national public  health goals.

However, there is also the concept of consumer sovereignty  to consider. Citizens have the right to choose the type and  quality of foods they would like to purchase. While some  people make choices which contribute to a sustainable,  healthy diet or one that is healthy, many do not. Consumer  sovereignty recognises the right of individuals to make their own autonomous choices, even if those choices may  ultimately do them harm, as for example in the case of a  diet biased towards the consumption of high levels of ultra-  processed foods. When food industry players do voluntarily  remove or reformulate harmful products currently on the  market, it is usually because they recognise the interest in  certain features and decide to incorporate this into their marketing strategy.

Improving the capacity of individuals or groups to act independently and make free choices about what they eat and how their food is produced is critical for addressing key challenges which are affecting the ability
to meet the SDGs.

High Level Panel of Experts on Food Security and Nutrition (2020) 39

Overall, governments can attempt to redirect consumer  demand from ultra-processed foods through a range of policy instruments, including information dissemination and behavioural  nudges, improved and refocused dietary guidance (having  relevance across all parts of government policy), and enhancing  the food environment so that the choice of sustainable, healthy  diets is made easier for individuals. But alternatives need to be  made available which offer similar convenience, taste and trust  while being both nutrient dense and sustainably produced. And,  crucially, people have to want to purchase those healthier items.

7.4 The role of governments in shaping dietary demand

Most governments continue to shy away from adopting an active  role in the dynamic space where most people obtain their food;  namely, food environments. One recent study of the political  feasibility of food policy interventions argued that success depends  heavily on citizens’ perceptions of costs and benefits, and that  while individuals may misperceive the real costs or benefits of  various policy actions, it is perceptions that determine public  support. Consequently, government-led interventions can flounder  in the absence of public acceptance. 40 Governments are certainly willing to regulate food safety, because of public health and trade  concerns, but active engagement in markets and with consumers  to improve the sustainability and quality of diets remains minimal.

Discussions in LMICs in preparation for this report confirmed  that some governments are less active and less impactful than  they would like to be. Those governments that do act have used  diverse approaches. Some set restrictions on food ingredients  such as trans-fats, define marketing limits (such as bans on  inappropriate marketing of breast milk substitutes), or establish  economic incentives and disincentives (including taxes and  subsidies on defined foods or container sizes).

Others provide  information (via public campaigns) or mandate the nature of food procurement and provision, including many forms  of institutional meal provision. 41

However, these efforts are too frequently constrained by a lack  of human, institutional and investment capacity 42 to meet three  key requirements:

  1. Funding for relevant interventions;
  2. Uncontested political space for manoeuvre;
  3. An ability to monitor changes.

For example, the capacity to enforce food safety restrictions is  limited in countries such as Nepal which has only 40 certified  food inspectors for the entire country. 43 Similarly, funding for  rigorous scrutiny of alternative sets of cost-effective policy  actions typically gets little or no support.

Governments need to do much more to enable people to make  more informed dietary choices. The starting point should be to agree on that goal across relevant parts of government, and  to establish a common policy agenda. In so doing, it will be  important to articulate the critical role of poor diets in driving  the escalating costs of healthcare and environmental impacts on  entire food systems on which all countries depend. Overall, the  aim should be a better understanding at policy level and among  citizens of the true cost of food choices for people’s health and  for planetary systems.

It is also imperative that governments establish productive  working relationships with the food industry. Those national  strategies that do exist and which are aimed at influencing  consumer choice seldom include a clear articulation of the  roles and responsibilities of the public sector relative to  businesses. Diverse commercial actors (e.g. smallholder  farmers, agribusinesses, food and beverage manufacturers,  food retailers, food service providers and industry and trade  associations) have a substantial role to play in achieving the goal of making healthy and sustainable diets universally  desirable, as well as affordable. 44 The challenge for policymakers  is to realise that potential.

7.5 Using policy-based behavioural nudges to influence dietary choices

The behavioural economics literature has shown that consumers  have many competing preferences, and that even nutrition‐  conscious individuals balance perceived trade-offs between  long‐term health benefits and immediate gratification of tastier  but less nutrient-rich food products. 45

While most actions to ‘nudge’ dietary choices have so far been  pursued in middle- and high-income settings, governments in  resource-poor countries facing multiple burdens of malnutrition  are increasingly considering the potential of similar policy  instruments. 46 However, while this area of intervention remains promising, there is still almost no empirical evidence of  successful interventions in LMIC settings. 47 This is an important  information gap concerning consumer behaviour which must  be urgently filled. 48

There are examples where governments have already explored  actions that may tip the balance in favour of healthier outcomes  by influencing the food environment and hence individual  consumer choices. These have included public advertisement  campaigns which put obesity on a par with cancer (United  Kingdom), encouraging less food waste and greater fruit and  vegetable consumption by offering imperfect, perishable foods in supermarkets (France, Canada), and food package  labelling initiatives (Chile). Other behavioural nudges include:  the provision of healthy meals in public sector institutional  canteens in schools, the military, hospitals and prisons; improved  nutritional labelling of products; highlighting differences in portion sizes; requiring full-service restaurants to include nutrient  facts on menus; and using regulations to ensure nutrition claims

on food packaging are accurate as health claims. 49 However,  the extent to which behavioural nudges would affect home  consumption patterns in LMICs requires further study. This is a top priority for governments seeking to find locally  appropriate, cost-effective solutions to diet-related diseases  in their countries.

7.6 Nutrition knowledge: the unfulfilled potential of food- based dietary guidelines (FBDGs)

Knowledge of nutrition and healthy dietary choices can  contribute greatly to improved nutrition outcomes, and  could do much more to bring food systems in alignment  with sustainability and climate change goals. 50 51 But citizens  need authoritative, trustworthy advice that cuts through the  erroneous, conflicting and changing advice that is sometime  prevalent in the media and on the internet. There is a role for governments to develop and make much more effective use of  FBDGs. The aim of these is to encourage better-informed choices  and hence healthier, and more sustainable, dietary patterns. 52

New analysis commissioned by the Global Panel has considered  the health and environmental implications of existing national  FBDGs. 53 54  55 This analysis has highlighted fundamental issues which need to be addressed. Many countries still  lack formal FBDGs: of the 85 countries identified as having guidelines, only 21 were LMICs. Also, many existing FBDGs lack  understandable and actionable advice. They are rarely used to  inform government policies and there are wide gaps between  national guidance and conformity with WHO recommendations  for intake of recommended foods (e.g. fruits and vegetables), or for limited intake of discouraged foods (e.g. sugar, salt).  Over 80% of the 85 countries met only one or none of these  recommendations; just five countries met three.

A further deficiency is that the majority of FBDGs fail to  incorporate proper consideration of the environmental  implications of dietary choices. 56  57
If they were to do so, the  real ‘cost’ of food production in relation to environmental  parameters would become more apparent, and FBDGs would  have a more explicit and defined role in influencing the design  and goals of government policy as well as understanding of the  implications of food choices.

Few FBDGs take account of global environmental targets relating  to dietary choices: just three FBDGs (Guatemala, Kenya, Sierra  Leone) are in line with the Paris Agreement emissions target for limiting the global temperature increase to two degrees  Celsius; three (Cambodia, Kenya, and Sierra Leone) are aligned  with global land-use targets; and six are aligned with fresh water  targets (Slovakia, Guatemala, Paraguay, Kenya, Namibia, and  Nigeria). Just one (Nigeria) aligns with targets for nitrogen. As a  result, two-thirds of the national FBDGs included in the analysis  were shown to be incompatible with either the Paris Agreement  on climate change or goals aimed at the prevention of NCDs. 58

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Most national dietary guidelines are not ambitious enough to bring food systems within planetary boundaries.

EAT (2020) 60

A final concern is the extent to which people adhere to the  advice embodied in FBDGs. Analysis of the overall degree  of conformity of diets with national FBDGs when averaged  across the relevant country is shown in Figure 7.4. Overall, most countries have very low compliance with national FBDGs,  with most countries meeting less than three recommendations.  Asia and the Pacific have a relatively high attainment of  recommendations relating to fish (40% of countries), but less so for red meat (33%) and sugar (27%). Europe fares relatively  well for fish, fruits, and vegetables, while North America does not  meet any of its own national guidelines. Five countries do meet three of their own recommendations: Spain (fruits and vegetables,  nuts & seeds, sugar), Malta (fruits and vegetables, nuts and seeds,  fish), Bangladesh (fish, sugar, red meat), Benin (nuts and seeds,  sugar, red meat), and Sierra Leone (fish, sugar, red meat).

These examples show that FBDGs are addressing a real need  to change dietary choices, but also that they need to be much more effective (see Box 7.3). They should be redesigned to guide  the intent and design of policies on sustainable, healthy diets,  rather than just informing consumers, where they have little  impact. Most FBDGs are disconnected from the policy actions  that drive food systems and are therefore divorced from the  reality of what people can eat and why. 61

A new generation of FBDGs informed by the evidence of policy impacts on consumer demand, patterns of intake

of various foods and nutrients, and the relative health benefits  of different food choices offer policymakers a valuable tool. Redesigned, they have the potential to be part of a broader  strategy to strengthen the whole domestic food system, and not only the health of individuals.

7.6.1 Potential benefits to be gained from  next-generation FBDGs

The commissioned modelling for the Global Panel shows  the considerable benefits that could accrue if FBDGs were redesigned to focus on national policy directions. If fully adopted  in the 85 countries with FBDGs, premature mortality could be  reduced by 12%. Over half (55%) of this reduction would be due  to improved weight – including a 17% reduction in the global  prevalence of adults being underweight (low BMI), and a very  substantial (almost 25%) drop in obesity. Dietary changes were  responsible for the remaining reduction in mortality, mainly  through higher intake of vegetables (19%), fruits (11%), nuts and seeds (5%), pulses (4%), and fish (4%), as well as a reduced  intake of red meat (3%). (See Box 7.4 for a discussion of the  shifts in consumption of unprocessed red meat in the United  States and elsewhere.) By geography, the predicted reductions in mortality ranged from 7% in Africa, where much of the health  burden is still associated with communicable diseases, to 18% in North America, where high prevalence of obesity is a major  health issue.

Box 7.3: FBDGs – the next generation

National food-based dietary guidelines (FBDGs) need to satisfy the following:

  1. To be based on the best available science, while taking  account of local circumstances.
  2. Not to be static. Policymakers should expect them to  change as science and local conditions change. In China,  the government has progressively adapted its guidance in  the light of prevailing conditions and new health-related  evidence (see Figure 7.5).
  3. To take account of the environmental implications of the recommended diets, as well as health.
  4. To influence directly the goals and instruments of national policies and investments. For example,  what is currently produced and made available in  countries which have FBDGs is, in most cases, very  distant from what is recommended in those FBDGs. That mismatch is a valuable signpost of where policy makers

 

need to focus in order to transform food systems.

  1. To be feasible for citizens to act on, thus going beyond  giving aspirational advice.
  2. To help shape the incentives/disincentives of the economic environment in which commercial entities play a leading role.
  3. To be effectively communicated to citizens, to businesses  involved in the food system, and to relevant policymakers

Finally, FBDGs also need to be integrated into national  food system action plans which should be formulated by  governments and engage all stakeholders in their design  and implementation.

Funding to local authorities should  be earmarked for tailoring of local action plans, effective  implementation, and the transparent collection of data on impacts and costs. Plans will necessarily define which bodies  have a role in achieving specific targets by when.


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The economic value of the reductions in mortality are  estimated at US$7.2 trillion to US$8.9 trillion – equivalent to between 10% and 15% of global GDP. If a less conservative  approach were to be taken (including child undernutrition  and sickness rather than mortality alone), the impacts would  be greater still.

These totals do not take account of the environmental costs  averted by adoption of the same FBDGs. It was found that full  adoption of national FBDGs in the 85 countries considered  would reduce food-related GHG emissions by 11%. 63 Most of  that improvement would be driven by reductions in ruminant

meat consumption. To achieve this, cropland demand would  increase by around 8%, driven by increased acreage to expand  the output of milk, legume crops (including soybeans, green  beans, and peanuts), and fruits and vegetables. This would be  partially offset by a reduction in land area currently dedicated to  production of food for beef cattle and other ruminant livestock  aimed at meat consumption. Overall, demand for fresh water  would be reduced by 4% under this scenario of full adoption of national FBDGs, despite increased demand for fruits and  vegetables, pulses, and milk. The reason for this is less demand  for (and hence production of) sugar, staples, cereals and tubers,  and various animal-source foods.


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7.7 Social and cultural norms – the places where people eat is changing

Culture has a major role in influencing people’s beliefs on  what constitutes a healthy diet. Importantly, cultural norms  and patterns of food choice across all segments of society are  changing. This is partly manifest in where people shop (with global shifts from open wet markets to supermarkets), and what  they buy (an increasing share of food purchases comprising ultra-  processed, packaged foods and sugar-sweetened beverages).
However, there are also significant shifts in where people eat.

In many countries the norm of family meals in the home  is shifting in favour of street foods and eating at fast and full-service restaurants. Diverse factors are driving this trend:  they include relative prices, taste, peer pressure, convenience, and the opportunity cost of time.

Today, more people eat away from home than at any time since  humans were hunter-gatherers. For example, in South Korea,  families already allocate about 48% of their total food spending  to meals outside the home. 65 Figure 7.6 shows the substantial  increases in per capita expenditure on food consumed away  from home in four Latin American countries. 66 Increases in  Brazil, Chile and Colombia are particularly large. These graphs  illustrate how the world’s population is cooking less, and eating  out more due to lifestyle changes and aspirations.

Eating away from home, or having meals prepared by a food  service and delivered to the home, matters to diet quality. Some  restaurants and fast food outlets do not support healthy diets. One  study of eating habits in the United States found that less than 0.1%  of the meals sold in full-service

restaurants were of high quality  (based on the American Heart Association’s diet quality score), and that around 50% of meals sold were of ‘poor’ or ‘intermediate’  quality. 67 Another study found that the share of adults buying fast food for children has been growing (see Figure 7.7)

However fast-food restaurants are not automatically worse  in terms of diet quality compared to full-service restaurants.  Some are already seeking to offer ‘healthy choice’ alternatives  to meat-based processed food. Furthermore, a study of the caloric content of full-service meals conducted in 111 randomly  selected restaurants serving popular cuisines in Brazil, China,  Finland, Ghana, and India found that they contained 33% more  dietary energy (calories) on average than fast-food meals. 68
For example, restaurant meals in Ghana and India were shown  to contain average levels of calories as high as those in the US.  In other words, while fast-food outlets and packaged snacks  have long been of concern to the public health community, the high energy content of restaurant meals must also be considered  as a contributor to the obesity epidemic. 69

7.8 Businesses must contribute to making sustainable, healthy diets desirable

The WHO acknowledges that:

The environments in which people develop their dietary behaviour and make their food choices are a significant influence on what they purchase and, in turn, what they eat.

WHO (2015)370


70

Box 7.4: The dietary shift from meat to plant-based foods

A fall in unprocessed red meat consumption is already  occurring in the US, where growing awareness of health and  environmental consequences has led to reduced demand.  This has been the case particularly among higher income,  more educated consumers who have either shifted to other  meats (poultry and fish) or to meat alternatives.

The food industry has responded to the growing demand  for meat alternatives with large research and development  (R&D) investments and the recent roll-out of multiple,  carefully branded products at competitive prices. While  some meat-alternative products could be classified as highly  if not ultra-processed, this recent development shows that

a combination of altered behaviour and change in retail  priorities can support population-wide shifts that could be  beneficial to health and, indirectly, if coupled with reduced  red meat production, also beneficial in terms of climate and  environmental resources.

There has been an expansion of business lobby groups  promoting plant-based foods 71 and many restaurants in  the US are already offering plant-based meat alternatives on  the menu. However, these trends are not yet apparent in  countries such as Brazil where meat and dairy products, but  also oils and fats, represent the largest net revenue streams  within the food sector (see Figure 7.8).


72

Nevertheless, as in the past with policy initiatives aimed at  curbing tobacco use, requiring seat belts, and restricting the  marketing of breast milk substitutes, new proposals often meet  with significant opposition from key stakeholders. 73

The major class of stakeholder that could oppose change in this case comprises food industry companies; that is, the diverse  commercial interests, local and global in size and reach, that  play the lead role across the food system, from where food is produced to where it is obtained. It is widely argued that  policymakers are constrained by industry lobbying activities and/or promote the position that dietary practices are based  on ‘individual choice’, and therefore that only neoliberal market  and governance models are appropriate for tackling dietary concerns. 74

Changing this will require:

  1. Scientific evidence of cost-effective policy actions that  can indeed shift dietary choices towards more sustainable,  healthy outcomes. These might include price levers via  taxes (for example on certain ultra-processed foods) and  price subsidies (on nutrient-rich foods), alongside better  enforcement of regulations. This points to a need for improved mechanisms to independently and rigorously  assess evidence and knowledge gaps, facilitate common  understanding of the policy implications of key findings, and  generate consensus around key actions and targets. In effect, this means providing similar functions to that provided by the  IPCC, but concerning food systems and nutrition.
  1. Conscious moves to incentivise commercial interests  (large and small, local, and transnational) to act in support  of the public good.
  2. Establishing novel business models for the 21st century  that use incentives as well as regulations to encourage a shift  in business perspectives from a narrow short-term profit  focus towards longer-term community, society and planetary  goals framed by human and environmental health.

In other words, the food industry should not be demonised or  ignored; but nor should it be allowed free rein to pursue narrow  profit motives where these are antagonistic to wider societal goals.  It is therefore important to acknowledge, and build on, the many  positive aspects of commercial activity in the food system and  incentivise actions which support government policy agendas on public health and environmental sustainability (see Box 7.5).

7.8.1 Entry points for engagement

Public sector organisations and civil society organisations (CSOs)  can only achieve their goals to influence diets by engagement  with businesses

involved in all aspects of food environments that  influence dietary choice: i.e. food products and their packaging  and marketing, food services, food outlets and the relative  pricing of foods.

For example, UNICEF identifies five ‘key entry points’ for public  policy engagement with businesses to improve diets. 75 These  require understanding how businesses work (and why) and  how their roles offer huge potential to any public sector agenda. They are:

  1. Business as a provider of essential services supporting  nutrition, e.g. industry support for salt iodisation, mandatory  micronutrient fortification of flour, etc.
  2. Business as a job creator across the food system, as the locus for  employee programmes supporting healthy diets, procurement  supporting demand for local food production, etc.
  3. Business as a community stakeholder through investments at  local level in food product manufacturing, creating demandfor local food products, and supporting local food marketing  and supply chains.

Box 7.5: Incentives for food companies to change behaviour

Food companies are a primary driver of how food systems  operate, heavily influencing what foods are available. While  the nature of these food companies varies (see the Access  to Nutrition Initiative (ATNI) 2018 Global Report 76 and  various ATNI country reports), they all respond to the same  six incentives.

  1. Demand. This is the ultimate driver of change, which is why companies spend so much money on advertising.  Advertising needs to be better regulated, but public  sector behaviour change campaigns also need to be  more compelling and have more effective messaging.
  2. Investor behaviour. There is a growing trend towards  investors – large and small – becoming more motivated by  corporate performance featuring social impact indicators.  Initiatives such as the Responsible Business Pledge being  developed by the World Business Council for Sustainable  Development, Food Industry Asia, International Food and  Beverage Alliance, Consumer Good Forum and the SUN  Business Network for the Nutrition for Growth Summit  can help guide investment towards companies that are  doing more to promote the health of people and planet.
  3. Government policy. Companies are reluctant to be  first movers towards improved social outcomes if itcompromises commercial returns. Governments can play  a role in shifting entire sectors within a nation through  taxes and measures to reduce risks for companies.
  1. Civil society accountability mechanisms. There is a  plethora of accountability mechanisms which have been  generated by civil society organisations (CSOs). 77 Too many  may have a negative effect on corporate accountability  with the costs of engaging becoming too high for  companies. But with the right level of focus, credibility,  and engagement these mechanisms can induce behaviour  change. ATNI is a good example of what can be achieved.
  2. Employees. Younger employees are more motivated  to work with companies that have credible social goals. A recent study shows that employees will take lower  salaries and be more productive in companies with such  a purpose. 78
  3. Champions within the company. Companies have  diverse workforces. Even in the companies that are the  worst performers, when it comes to social and economic  goals there will be individuals who are motivated to  change the status quo in terms of diet quality and  environmental sustainability. Their contribution to  promoting corporate responsibility should be recognised  and valued within companies.

Companies of all sizes must be persuaded to play a leading role  in the transition. The public sector, including governments,  together with civil society organisations must develop these  incentives to help deliver corporate behaviour change across  the board. 79


80

  1. Business as a leading investor in technology R&D and  innovation, strengthening supply chains to support year-  round access to nutrient-rich foods, making improvements  in shelf-life, processing technology, packaging, storage,  increasing productivity and reducing food loss and waste.
  2. Business as an influencer of environmental and resource uses,  championing recycling, optimisation of national resource  inputs to food industry operations, etc. 81

This set of entry points allows some governments to  acknowledge the contributions made by a multitude of  business entities in the food system, but also to better identify  leverage points where economic or other incentives may help  amplify positive effects (i.e. on job creation, scale of coverage of micronutrient fortification laws, commercial R&D supporting  public priorities, etc.), or alternatively where taxes or regulations  are needed to restrict harmful practices. It has recently been  estimated that LMIC businesses “collectively lose between  US$130 billion and US$850 billion a year through malnutrition-  related productivity reductions”. In other words, the nature of public sector interaction with the food industry is critical to determining the characteristics of the food environment,  but industry collaboration with governments is in its own  interest because of the losses borne by industry players due  to the impaired nutrition and health of their workforce. 82

7.8.2 A framework for engagement: commitments,  principles, and accountability

Food-related corporations of all sizes, processing industries,  retailers and food service outlets should all be engaged as  part of a strategy by national and local governments to agree  concrete measurable commitments for which each food  industry stakeholder would be held accountable (see Figure  7.9). 83 Governments must also be held to account for their  actions in holding businesses accountable.

It will be important to establish measurable context-specific  principles of engagement to which all stakeholders can adhere  as a foundation for strategic engagement. The top priorities in this domain include:

  1. Agreement among key stakeholders on a high-level set of  principles for public private engagement around food systems  and nutrition. These must define rights and responsibilities,  accountability frameworks, approaches to target-setting, etc. They must also acknowledge that the public sector has  secondary interests to be taken into account, such as future  electability, donor-driven research agendas, and engagement  with the priorities of non-governmental organisations, as well  as with lobby groups focused on the agriculture and trade  sectors, and pharmaceuticals.
  1. Agreement on ways to operationalise guidelines which  already exist, including the WHO Codex Alimentarius on  Nutrition and Labelling, Voluntary Guidelines on the Right to Food, Principles for Responsible Investments in Agriculture  and Food Systems, and the UN Global Compact’s Guiding  Principles for Business and Human Rights.
  2. Agreement around a Compact on responsible investment  in food systems, as well as the application of best practices  in manufacturing, marketing and distribution of all foods and food products, with sustainable, healthy diets established  as a common goal.

One important opportunity for progress on this front is offered  by the upcoming Nutrition for Growth (N4G) Summit in Tokyo,  planned for 2021. Plans are underway to launch a Responsible  Business Pledge for Better Nutrition at N4G. As a framework for business sector commitments, this pledge will be open for  signature by any company or business organisation with an  impact on diet quality and nutrition. Industry stakeholders that  sign the pledge will commit to making nutrition a long-term,  board-level priority. That will involve putting in place corporate  strategies to help achieve SDGs 2 and 3, while establishing  measures to ensure that investments in nutrition take into  account broader food system concerns, including accessibility, affordability, and environmental stewardship of resources  relating to food production. Companies must also undertake to report regularly on progress through the N4G Accountability  Framework.

Given the need for clearer accountability frameworks for  commercial activity, the N4G business pledge is one step in  the right direction, but much more is needed. There is a role for philanthropic and consumer-focused watchdog organisations  to ensure monitoring and evaluation of marketing practices by  all participating (signed up) and non-participating businesses. This is especially important where governments remain reluctant  to monitor, let alone regulate, food industry marketing and retail activities. There is also a need to disaggregate ‘the private  sector’ so that component parts can be better legislated for and  tracked in terms of compliance. For example, in the domain of  food and beverage marketing alone, there are many approaches,  modalities and targets pursued across businesses of different  kinds. These go far beyond conventional television, radio and  poster messaging and therefore require interaction with a much  broader set of stakeholders, and attention to a much wider range  of potentially positive or harmful activities.

In other words, food business enterprises of all kinds should be  required to abide by national and international standards, but  for this to be effective, there must be appropriate systems in place and funded to track, monitor, and hold actors accountable.  Indeed, food industry players must demonstrably meet national  regulations to ensure food is safe and of adequate quality and satisfies appropriate ethical considerations (see Box 7.6).  Coordination of regional and local actors is critical and should be led by public authorities.

Box 7.6: Ethical considerations

While food companies already play a central role in influencing the desirability and choice of individual foods, some analysts see aspects of the food industry’s influence as unethical. It has been argued that “it is naive to ignore the reality of the global political economy, whereby some businesses actively work against population health by  virtue of their products or when it threatens their political and economic interests”. 84 For example, only two in five infants under six months of age are exclusively breastfed, as recommended, and the promotion of breast milk substitutes in low-income settings is widespread. Sales of milk-based formula foods grew by 41% globally between 2008 and 2013. 85 Even if children are old enough to eat family foods, roughly 44% of children aged six to 23 months globally are not fed fruits or vegetables and only 20% of those children in poor rural households are fed a recommended diverse diet. 86 87

This reality must be acknowledged, and governments must overcome their apparent reluctance to tackle such negative outcomes while also seeking out positive roles for business partners. It has been argued that “commercial food systems rely heavily on high volume sales of foods high in unhealthy ingredients to generate profits and value for shareholders”. 88This reliance will not change without strong actions at the policy level to incentivise alternative goals and agendas, and effectively regulate commercial activities that lead to significant externalities borne by society as a whole, including healthcare costs deriving from diet-related diseases, ecological degradation, the impacts of climate change, etc. Many policymakers are understandably cautious about transformative actions in the food industry because they are concerned about economic growth, employment, tax revenues, and the potential for significant political repercussions.

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