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- 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.

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.
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.
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:
- deliver ultra-processed products rather than nutrient-rich fresh foods at prices that make them more attractive and
- 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
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).
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.
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:
- Funding for relevant interventions;
- Uncontested political space for manoeuvre;
- 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
Most national dietary guidelines are not ambitious enough to bring food systems within planetary boundaries.
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:
- To be based on the best available science, while taking account of local circumstances.
- 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).
- To take account of the environmental implications of the recommended diets, as well as health.
- 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.
- To be feasible for citizens to act on, thus going beyond giving aspirational advice.
- To help shape the incentives/disincentives of the economic environment in which commercial entities play a leading role.
- 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.
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.
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.
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).
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:
- 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.
- Conscious moves to incentivise commercial interests (large and small, local, and transnational) to act in support of the public good.
- 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:
- Business as a provider of essential services supporting nutrition, e.g. industry support for salt iodisation, mandatory micronutrient fortification of flour, etc.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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
- 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
- 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.
- 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:
- 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.
- 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.
- 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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