Hple 83 109
Hple 83 109
Hple 83 109
AND NUTRITION
There has been growing recognition that nutrition and food systems need to be better considered in
different sectoral policies and programmes in order to address the multiple burdens of malnutrition
(Jones and Ejeta, 2016). This chapter focuses not only on nutrition-specific39 policies and
programmes (Bhutta et al., 2013), but also aims to cover nutrition-sensitive40 interventions that
integrate nutrition concerns into a wider perspective and tackle broader dimensions of food systems
(Ruel et al., 2013; Pinstrup-Andersen, 2013).
There are many ways of acquiring evidence – from randomized control trials, to experiential evidence
and traditional knowledge. While better practices to improve diets and nutritional status are emerging
and continue to be collected, there is no single solution to address the multiple burdens of
malnutrition: interventions and actions need to be adapted to the local context, and monitored for
benefits and potential harm, as well as unexpected consequences.
Although many current policies and programmes might have unfavourable or net zero effects on
nutrition and diets, this chapter focuses on successful examples to illustrate possible pathways and
positive directions towards more sustainable food systems that enhance diets and nutrition. It
provides an overview of some of the most promising areas where governments and other food system
actors can intervene at different scales, across sectors, and across the different elements of food
systems (food supply chains, food environments and consumer behaviour) with the view to improve
diets and nutrition outcomes.
39
Nutrition-specific interventions are interventions with the primary objective of addressing nutrition and that target the
immediate causes of undernutrition such as targeted supplementary feeding, vitamin A supplementation for children
of 6 to 59 months of age or iron and folic acid supplementation for pregnant women.
40
Nutrition-sensitive interventions are those in which the primary objective is not nutrition, but that have the potential to
improve the food and nutrition security of beneficiaries through agriculture and food security, healthcare, education,
water and sanitation, etc.
83
cash crops, and use the income they generate to purchase more nutritious foods (Fanzo, 2017). The
appropriate answer heavily depends on the specific context and on individual choices.
Several studies have attempted to better understand the linkages between smallholder farmer
production and dietary diversity in traditional food systems. Evidence gathered to date does not
indicate conclusive links, but both on-farm production and the diversity of that production as well as
access to markets matter for the diets of smallholder farmer families. Studies in Ethiopia, India,
Indonesia, Kenya and Malawi demonstrate the importance of both homestead production and its
diversity, and market transactions (Headey et al., 2012; Sibhatu et al., 2015; Carletto et al., 2015;
Koppmair et al., 2016; Jones, 2017).
Solutions to increase diversity include home gardens and other homestead food production models
(Olney et al., 2015), intercropping and mixed landscapes (Kerr et al., 2007), irrigation (Burney et al.,
2010), aquaculture (Murshed-E-Jahan et al., 2011), and animal production systems including poultry,
goats and cattle (Carletto et al., 2015).
Home gardens are important sources of foods in many countries, including in the Russian Federation,
where the dacha or private garden plot in which Russians grow their own fruits and vegetables is of
critical importance. In the Moscow region, there are over one million dachas and some date back to
the Soviet-era land distribution programmes that made it possible for Russians to survive post-war
food insecurity/shortages (Burggraf et al., 2015). Forest landscapes and other bio-diverse landscapes
as well as integrated crop–livestock farming systems can foster dietary diversity (Cuc, 2015; Remans
et al., 2014; HLPE, 2016, 2017). In a semi-arid area of Central Tanzania, an interdisciplinary and
multi-sectoral team is working with local communities to enhance traditional integrated livestock–crop
systems of nutrient-rich vegetables and small grains and the keeping of indigenous chickens raised
under extensive production systems. Over a two-year period with poor wet season rains, significant
reductions in stunting were noted among children under 24 months of age coming from households
owning chickens when compared with those from households without chickens (Alders et al., 2015;
De Bruyn et al., 2016).
Studies also indicate that animals and fish are critically important for livelihoods, as well as for diets
and nutrition (HLPE, 2016). For example, in Zambia, livestock ownership is associated with improved
dietary diversity both through direct consumption of ASF and through income generated by selling
these. Children living in livestock-owning households are often less likely to be stunted, regardless of
household poverty levels (Carletto et al., 2015). Further results indicate that expanded livestock
ownership can improve livelihoods (Banerjee et al., 2015) and can shift the entire local food economy
in that it influences food consumption by households that lack farm animals (Jodlowski et al., 2016). A
project in Ecuador that provided one egg per day to children aged six to nine months found significant
reductions in stunting, indicating that early introduction of eggs can improve growth in young children
(Iannotti et al., 2017).
In Thailand and the Lao People’s Democratic Republic, crickets were previously harvested from the
wild, leading to a variable supply of this nutritious food and raising food safety issues. Recently,
several small- and medium-scale enterprises have developed methods of farming crickets to stabilize
and increase cricket production and provide additional income for farmers (Durst and Hanboonsong,
2015).
Bio-fortification is an important way of breeding more micronutrients into specific crops (e.g. orange
fleshed sweet potato in Uganda and Mozambique, rice bio-fortified with zinc in Bangladesh and India,
maize bio-fortified with pro vitamin A in Nigeria and Zambia) to deliver specific micronutrients to
people at risk of micronutrient deficiency particularly in Asia and sub-Saharan Africa (Tomlins et
al., 2007).
84
Safeguard Globally Important Agriculture Heritage Systems (GIAHS) in traditional and mixed
food systems
GIAHS consist of important, ongoing agricultural practices and knowledge systems, and sustain high
levels of biodiversity that contribute to FSN in the long term. Diversified agricultural systems are
estimated to have yields between 20 and 60 percent higher than monocultures (Koohafkan and Altieri,
2010). Swiderska et al. (2011) found that traditional varieties grown by indigenous farmers in Bolivia
(Plurinational State of), China and Kenya had higher yields and provided farmers with larger incomes.
The traditional crop varieties themselves are also often better suited to harsh landscapes and
climates, and GIAHS often minimize water use, improve soil and protect other natural resources,
making GIAHS especially important in the face of climate change. They also support traditional
cultures and rural livelihoods (Koohafkan and Altieri, 2010). The Chinese traditional rice–fish
integrated farming system is described in Box 14.
Provide incentives to protect wild foods, local agrobiodiversity in traditional food systems
As stated earlier, studies have shed light on the positive associations between farm diversity and
dietary diversity (Jones et al., 2014; Remans et al., 2011; Figueroa et al., 2009; Masset et al., 2012;
Jaenicke and Virchow, 2013). Traditional food systems are often supported by indigenous knowledge
systems. They rely on local and indigenous, sometimes underutilized, agrobiodiversity,41 often
complemented by the sustainable use of wild resources from forests and aquatic ecosystems (HLPE,
2014b, 2017). Agrobiodiversity is expected to influence dietary diversity in traditional food systems by
giving people access to a wider variety of foods. However, that assumption does not always hold true.
A study in rural areas of the Democratic Republic of the Congo showed that many of the households
did not utilize the huge diversity of wild edible plants with interesting nutritional characteristics
(e.g.,Gnetum africanum and Treculia Africana) freely available in the forest, the fallow lands or around
the homesteads (Termote et al., 2012). Similar results were found in Southern Benin (Boedecker et
al., 2014) and in Kenya, where in areas with higher agrobiodiverse landscapes, this diversity did not
translate into differences in diet diversity for mothers, caregivers or children (Mituki et al., 2017).
Among the most frequently cited reasons for the decline in use of indigenous food species are:
declining availability of wild foods and forest foods due to overharvesting and land clearing for
agriculture; difficulties in regaining or securing access to land and land tenure; local populations’
perceptions about wild foods as being “food for the poor”; loss of traditional knowledge; high work
load to collect, process and prepare traditional foods; and weak integration in market economies and
globalization (FAO, 2009; Bharucha and Pretty, 2010).
41
Agricultural biodiversity is a broad term that includes all components of biological diversity of relevance to food and
agriculture, and all components of biological diversity that constitute the agricultural ecosystems, also named agro-
ecosystems: the variety and variability of animals, plants and micro-organisms, at the genetic, species and
ecosystem levels, which are necessary to sustain key functions of the agro-ecosystem, its structure and processes
(Convention on Biological Diversity; see https://www.cbd.int/agro/whatis.shtml)
85
In this context, two areas of innovation should be considered to help preserve and improve
agrobiodiversity for diets in these systems: first, by combining nutritional traits with environmental
traits, such as tolerance to drought and salinity, as well as seasonal availability, farmers can begin to
see multiple benefits of their conservation and use (Fanzo et al., 2016); second, improvements in
dietary diversity and quality will only be possible if agrobiodiversity is given attention by agricultural
extension services (Mituki et al., 2017).
Improve the links of local farms to school meals
Several countries have implemented farm-to-school programmes to improve the provisioning of
nutritious foods in schools while simultaneously improving linkages between farmers and schools and
creating a guaranteed market for local farmers. Although the findings related to the impact of farm-to-
school programmes are preliminary, they indicate some potential trends in behaviour changes that
could lead to healthier diets for children at the same time as providing more diversified income
streams for local producers (Joshi et al., 2008). In 2003, home-grown school feeding was included as
a key intervention for improving food security in Africa’s Comprehensive Africa Agriculture
Development Programme (ACAADP).42 As of 2014, 47 out of 54 African countries had implemented
school feeding programmes, 20 or more of which included home-grown school feeding (Fernandes et
al., 2016). Box 15 provides an overview of farm-to-school programmes in the Caribbean.
A systematic review concluded that garden-based nutrition intervention programmes (i.e. programmes
that include the opportunity for youth to plant, harvest and prepare a vast array of vegetables and
some fruits through a hands-on-experience that may influence intake of those foods) in certain states
of the United States of America (Idaho, California, South Carolina, Kansas, Oklahoma, Minnesota and
Texas) promote increased fruit and vegetable intake among youth and increased willingness to try
fruits and vegetables among younger children (Robinson-O’Brien et al., 2009).
42
http://www.un.org/en/africa/osaa/peace/caadp.shtml
86
In different cities, policies and programmes support (through provision of land, inputs or training) the
development of urban gardens that enable people to produce and consume healthy food, especially
vegetables. These gardens are especially important in food deserts where access to vegetables is
limited. In Rosario, Argentina, 22 hectares of land were turned into gardens and 400 people were
trained in gardening in 2013. In Quito, Ecuador, 2 700 gardens were created on 2 924 hectares of
land and 19 200 people were trained between 2002 and 2015. In Cape Town, South Africa, 50 to 60
gardens are supported with technical and business training every year (IPES-Food, 2017).
Further investments in research and data collection are needed to better understand the current and
potential contribution of urban agriculture to FSN (Orsini et al., 2013) and to break current constraints
to urban agriculture development, including insecure land tenure, polluted land and water, limited
access to resources and support services and lack of recognition by city authorities (Zezza and
Tasciotti, 2010).
Improve women producers’ livelihoods
Policy interventions designed to empower women working in the agriculture sector and improve
nutritional status need to be based on understanding which specific domains of women’s
empowerment matter for outcomes in a specific context (Malapit and Quisumbing, 2015). Although
the collection of gender-disaggregated data could be more systematic, and despite regional
variations, the available data (see for instance FAO, 2011b, 2014) suggest that women tend to play a
lower role in commercial agriculture and in the formal forest sector, and that they are often more
involved in informal activities in food production or food collection for subsistence use. Verhart et al.
(2012) argue that these subsistence activities are often seen as an extension of their domestic
responsibilities and that, in this context, women can lose the control over a production when it
becomes a commercial or cash production.
Leadership in the community and control of biophysical resources related to production are the most
promising areas for policy intervention to empower women and improve household food security in
Bangladesh (Sraboni et al., 2014). In Gambia, women control rice cultivation but when several new
projects to increase rice production were implemented, they targeted men and thus were
unsuccessful (Dey, 1981). These programmes should also be monitored, as it is possible that more
paid work might mean women substitute convenience foods for cooking meals, particularly as these
are becoming more widely available. This may explain why the relationship between women’s
empowerment and nutritional improvements is neither simple nor linear (van den Bold et al., 2013;
Bhagowalia et al., 2012b; Malapit and Quisumbing, 2015; Sraboni et al., 2014). Access to time-saving
assets in technology and capital can also reduce women’s work and time burdens in agriculture
(Komatsu et al., 2015).
Increasing women’s land ownership has mixed effects. In Nepal, women who own land are more likely
to have increased decision-making power and their children are less likely to be underweight
(Allendorf, 2007). However, in Uganda, a study found that women’s land ownership was not
associated with decreased stunting in their children while women’s education was (Wamani et al.,
2004). Further efforts are needed to better understand the role women play in food and other
agricultural production along with the access they have to resources and the recognition of their
double burden of paid and unpaid work in order to design effective interventions for improving
nutrition.
Redirect agricultural research and development for diets
Investing in agricultural R&D may help governments to identify potential policies and programmes that
could be scaled up to improve production practices (Perez and Rosegrant, 2015) and the way food
moves through the supply chain, subsequently leading to improvements in diets. For example,
investment in R&D in the United States of America was shown to be a major driver of productivity
gains for staple crops (Fuglie and Heisey, 2007). If the implications of these increases in staple crops
productivity may have had the unintended consequence of making highly-processed nutrient-poor
foods cheaper, similar investments in R&D for nutrient-rich crops such as fruits and vegetables, ASF
and neglected underutilized species could lead to improvements in productivity, which has the
potential to lead to improvements in access to better nutrition. Box 16 shows the importance of R&D
in highlighting neglected, underutilized species as part of the local diet in the Federated States of
Micronesia.
87
Box 16 Let’s Go Local: promoting nutritious biodiversity in the Federated States of
Micronesia
In the past few decades, the Federated States of Micronesia (FSM) witnessed significant shifts away
from their traditional diets to an increasing dependence on imported, unhealthy foods. Nutritious local
species and varieties of roots and tubers, fruits and vegetables had been replaced by highly-processed
cereal products and fatty meat off-cuts – a diet high in sugar, salt and saturated fats. Obesity and
diabetes as well as vitamin A deficiency diseases (VAD) were public health concerns in FSM.
To address these health and food system problems, efforts were made from 1998 onwards to identify
local plant foods, such as Karat banana, an orange-fleshed banana from Pohnpei (in FSM) very rich in
beta-carotene, and other yellow-fleshed bananas, that could alleviate the nutrition problems, and
especially VAD. Most of this work was led by the Island Food Community of Pohnpei (IFCP), a national
non-governmental organization working to promote the production, consumption and marketing of local
nutritious plant diversity through its “Let’s Go Local” national campaign.
A large-scale interagency, ethnographic, participatory and community-based approach was undertaken
to promote local biodiversity. Two slogans were all-important: the first, “Go Yellow”, focused on the
yellow-fleshed varieties, including Karat, and the second, “Let’s Go Local”, was broader, promoting
production and consumption of all local food. Many methods were used to mobilize agricultural
biodiversity including: workshops; container garden demonstration plots; school visits; planting material
distribution; planting, cooking and weight loss competitions; posters; youth clubs; breastfeeding clubs;
billboards; mass media (newspaper, radio, television, video); leaflets, newsletters and booklets; songs;
recipes; national postal stamps of Karat, other yellow-fleshed bananas and other foods; postcards,
telephone cards, t-shirts, pens and pencils; gene bank; and charcoal ovens.
There is substantial evidence of the intervention’s impact. Karat and many of the yellow-fleshed
varieties of bananas were not sold at local markets prior to the discovery in 1998 of their rich nutrient
content. Since 1999, Karat and other bananas are being sold and are available in all the local food
markets and other food marts that also carry imported food.
This successful community-based approach has been developed into a set of guidelines that others
can use to ensure that local biodiversity is mainstreamed in order to promote better nutritional
outcomes.
Sources: Engelberger (2011); Engelberger and Johnson (2013).
43
Reliable irrigation is key to improve livelihood resilience of many smallholders around the world. But bad irrigation
practices can also have adverse impacts on farmers and local communities, particularly for smallholder farmers and
indigenous peoples, through, for instance, soil salinization or overexploitation of water resources (HLPE, 2015).
88
preserving perishable foods, increasing shelf life and improving food safety (FAO, 2015b). Some
cities, such as Hong Kong and San Francisco, implement policies to reduce FLW and address the
problem of food filling up landfills, creating GHG emissions and contaminating water (IPES-Food,
2017).
In traditional and mixed food systems, policies should focus on the development of adequate
storage and transport infrastructure, including cold chains, which refers to an uninterrupted series of
activities that maintain a given temperature range from the production point to the consumer (HLPE,
2014a). Cold chains are primarily used for perishable foods such as vegetables, fruits and ASF
including meats, fish, dairy and eggs, which have high nutritional content. Studies in India, Ethiopia
and Zambia found that refrigerated transport of fruits and vegetables as well as milk are key to
reducing spoilage, increasing food safety, improving dietary diversity and creating viable export
markets for producers (Maheshwar and Chanakwa, 2006; Wiersinga et al., 2008; Hawkes and Ruel,
2011; Swanson, 2009).
In modern food systems, some improved technologies for storage and distribution are in
development. While some of these are being piloted only in HICs because of their costs, such costs
will probably come down in the future, allowing a wider use of those technologies for FLW reduction.
An example is satellite technologies, including GPS, which “enables shippers and carriers to monitor
quality, reduce risk (and costs) of liability claims and shorten cargo delivery time. Profitability in
perishable product trade will likely increase further as technologies continue to adapt” (Coyle et
al., 2001).
Preserve food safety during storage and distribution in traditional and mixed food systems
Mycotoxins (including aflatoxin) can contaminate agricultural products, both in the field and during
storage. Emerging research has demonstrated the utility of utilizing biological control strategies to
prevent the pre-harvest aflatoxin contamination of crops (Milićević et al., 2010) such as technologies
that use the ability of native atoxigenic strains of the aflatoxin fungus that compete with the toxic
strains. Box 17 provides an example of improved storage techniques to reduce aflatoxin in Guinea.
89
Develop and promote policies, practices and technologies that protect or add nutritional value
along food chains
Policies and programmes can be put in place to preserve or add micronutrients into foods during
processing (i.e. fortification) or to remove less healthy ingredients (e.g. product reformulation to
reduce sodium and trans fats). Examples of processing include milling, dehulling, germinating and
fermenting to remove anti-nutrients such as phytates, polyphenols and trypsin inhibitors that impact
the absorption of key nutrients (De Pee and Bloem, 2009). More evidence and more solutions related
to primary processing are needed (Hotz and Gibson, 2007; FAO, 2015c). The impacts of processing
technologies on nutrient content and bio-availability (such as germination, malting and parboiling) still
need to be better understood and accounted for by all actors.
Processing and packaging methods such as canning, freezing and Tetra Pak technology can extend
shelf life and ensure that perishable foods can reach those vulnerable groups who cannot access or
afford fresh products.
Facilitate, as appropriate, the use of food fortification in traditional and mixed food systems
As shown in Chapter 2, food fortification can improve micronutrient intakes and, in some cases, health
outcomes (Das et al., 2013) because it “has the dual advantage of being able to deliver nutrients to
large segments of the population without requiring radical changes in food consumption patterns”
(WHO, 2015e).
For example, salt iodization programmes have reduced the risk of goitre, cretinism, low cognitive
function and iodine deficiency in countries worldwide (WHO, 2014b). An innovative partnership in
Ethiopia on salt iodization is shown in Box 18. Iron fortification has been very successful in improving
haemoglobin and iron status of women and children (Das et al., 2013; Gera et al., 2012) through a
variety of fortified foods including rice in the Philippines, soy sauce in China (Chen et al., 2005), fish
sauce in Viet Nam (Thuy et al., 2003) and cornflour in Venezuela (Bolivarian Republic of) (Mannar
and Gallego, 2002). Fish powder is promoted in Cambodia in an effort to improve nutrient intakes
during the first 1 000 days of a child’s life (Bogard et al., 2015).
90
Regulate food processing in mixed and modern food systems
In some countries, food processing policies and programmes have targeted trans fats and sodium to
reduce the burden of NCDs (WHO/WEF, 2011).
Partially hydrogenated oils (PHOs) are the main dietary source of trans fats. They entered the food
supply in the early 1900s and quickly became a key ingredient in processed foods given their low cost
and long shelf life. Denmark was the first country to ban industrially produced trans fats in 2003,
paving the way for other countries, states and cities to implement similar policies. The ban in Denmark
virtually eliminated trans fats from the food supply. In the United States of America, a more local
approach to trans fat bans has been adopted. New York City was the first city in the United States of
America to ban trans fats in restaurants and fast-food outlets, which led other jurisdictions to adopt
similar policy measures, reducing the quantity of trans fats in the food supply. More recently, the Food
and Drug Administration (FDA) of the United States of America proposed to remove the “generally
recognized as safe” (GRAS) status from PHOs in that country, which would essentially act as a
countrywide trans fat ban.
Mandatory labelling of trans fats has been another approach to reducing trans fat availability in the
food supply. Canada and the United States of America were the first countries to adopt trans fat
labelling, which led the food industry to reformulate many of their products leading to significant
reductions in trans fats in the food supply (Mozaffarian et al., 2010; Ratnayake et al., 2009), which
coincided with reductions in trans fat levels in blood serum (United States of America) and breast milk
(Canada) (Ratnayake et al., 2014; Downs et al., 2013).
Prepared and processed foods can contain high amounts of “hidden” salt given that consumers are
not aware of and may be desensitized to those amounts (He et al., 2012). Setting recommended or
mandatory targets or standards for salt levels in different categories of foods might be one of the most
effective ways to reduce this “hidden” salt consumption. As of 2015, 75 countries had developed
national salt reduction policies (Trieu et al., 2015). There is some evidence to indicate that sodium
consumption has declined due to improvements in knowledge, attitudes and behaviour in some
countries; however, more rigorous evaluations of salt reduction programmes are needed (Trieu et al.,
2015).
In the United Kingdom, a salt reduction programme was established in 2003 and continued until 2010,
consisting of three key elements: (i) setting targets and working with industry to reformulate foods to
reduce salt levels; (ii) encouraging the use of improved nutrition labelling to make it easier for
consumers to make healthier choices; and (iii) undertaking campaigns and working with non-
governmental organizations (NGOs) to raise consumer awareness about salt consumption.
Throughout the seven years of the salt reduction programme, there were substantial reductions in the
salt content of foods (up to 70 percent) as well as a 15 percent reduction in sodium levels in humans,
as measured through 24-hour urinary sodium excretion (He et al., 2014; Wyness et al., 2012).
91
smallholders to markets. These include making the product demand more consistent and reliable,
increasing smallholder access to market price information as well as taking actions to stabilize these
prices, increasing smallholder participation in decision-making and supporting smallholder
organizations, and improving processing and storage as well as roads (CFS, 2016).
Encourage supermarkets to procure “healthier” foods in mixed and modern food systems
The “supermarket revolution” in developing countries is impacting dietary patterns and nutritional
outcomes. Policies and programmes should be developed to encourage supermarkets to supply more
nutritious food items such as fresh fruits and vegetables at affordable prices, and to procure local
products, particularly from or smallholders, as has been done in China. In this country, several policy
changes increased the number of supermarkets, such as liberalization of retail and government
investment in supermarket chains. In Shanghai, the top three chains are managed by the municipal
government and are provided with easy access to capital. A government programme, nonggaichao,
explicitly converted wetmarkets to supermarkets through an auction system from 2003 to 2007 in
several large cities throughout the country. Supermarkets have then aimed to increase sales of fresh
products by optimizing procurement to reduce prices to be more competitive with wetmarkets
(Reardon and Gulati, 2008; Hu et al., 2004).
In South Africa, private health insurance company partnerships with supermarkets led to
improvements in nutritious food purchases and lower consumption of foods high in salt and/or sugar,
fried foods, processed meats and fast food (Sturm et al., 2013; An et al., 2013). In East Africa, African
leafy vegetables (such as kale, nightshades, cowpea greens and pumpkin greens) have become a
niche crop, and women farmers are supplying them to larger supermarket chains (Cernansky, 2015).
Nutritious crops such as quinoa, millet and teff, meanwhile, are progressively becoming more
common in Western supermarkets, with potential benefits for smallholder farmers (Bellmare et al.,
2016). The dynamics of the supermarket could change rapidly over the next decade with online
shopping. Some of the downsides of these changes and technologies are that they could reduce
employment opportunities, discourage cooking, increase the consumption of packaged foods that are
not necessarily healthy, and generate more waste.
Support farmer connectivity through information technology
Linked to markets, information technology has played an increasingly important role in today’s
business activities associated with delivering nutritious foods to markets, which has led to the
emergence of e-commerce. In developing countries, business-to-consumer (B2C) e-commerce is
rapidly expanding, particularly in Asia and Africa. China has already emerged as the largest global
market for B2C e-commerce (UNCTAD, 2015). The development of e-commerce has been affecting
the food system, and the relationship has changed across the actors in the food supply chain.
Agricultural firms have been changing the way they think about their business structure and functions
by adopting e-commerce practices (Manouselis et al., 2009). The development of e-commerce
provides new opportunities for farmers, including smallholders, to develop their own businesses and
implement their innovative ideas. They could also be involved in the food supply chain and build
closer market linkages with customers who are demanding certain types of foods through e-
commerce platforms. Due to the existence of several barriers to further development, governments
need to take actions to establish a good e-commerce environment for related actors, including making
national strategies for medium- or long-term development, building legal and regulatory frameworks
for trust transactions between traders, improving awareness and knowledge related to e-commerce
among different actors and providing ICT infrastructure.
92
and orphan crops. Greater understanding of the nutritional and toxicological properties of
underutilized species is needed (Bharucha and Pretty, 2010), and there is a need for whole value
chain research to promote the production, marketing and consumption of orphan crops (Gómez et al.,
2013). Last, in all food systems, many small- and medium-sized enterprises (SMEs) provide a critical
link between smallholder producers, markets and consumers in both rural and urban areas. However,
SMEs still face many challenges that limit their contribution to FSN, including a limited access to
technologies, credit and infrastructure, limited capacities to influence and implement standards, as
well as a lack of knowledge of the determinants of consumer behaviour.
Figure 14 Exit and entry points along the nutrition value chain
Improved and
traditional varieties, School feeding
bio-fortification Aflatoxin control, programs, voucher
strategies refrigeration schemes, targeting
of vulnerable groups
93
5.2 Priorities for action in food environments
Healthy food environments facilitate healthier food choices. Although there has been substantial
research describing food environments in HICs, less attention has been given to LMICs.
Nevertheless, policies and programmes aimed at improving the quality of the food environment have
been implemented worldwide, some of which are described in the section below.
44
See: https://www.nycedc.com/program/food-retail-expansion-support-health-fresh
45
See: http://www1.nyc.gov/assets/doh/downloads/pdf/cdp/healthy-bodegas-rpt2010.pdf
94
Encourage healthier diets through public procurement of foods
The provision of food in schools, hospitals, workplaces and government buildings has the potential to
improve diets and to influence production, including through sourcing food from local producers, e.g.
in Brazil (Hawkes et al. 2016). In Japan, the “Table for Two” programme tackles obesity and
malnutrition at the same time by "transferring" excess energy to those who need it. This is achieved
by partnering with corporations to provide healthy, lean meals in cafeterias, restaurants, vending
machines and now food trucks at an extra USD 0.25 or 20 yen, which is donated to local
organizations in Africa that provide meals to children (Table for Two, 2017).
School meals provide the opportunity to ensure that children in school get at least one healthy meal
per day. They also provide opportunities for supporting local farmers. Home-grown school feeding
programmes exist throughout sub-Saharan Africa. In the case of the Ghana School Feeding
Programme, the creation of local markets also increased food security as measured by household
food access and months of the year with food security for people living around the schools (Sumberg
and Sabates-Wheeler, 2011). A randomized trial in Burkina Faso compared school lunches to take
home rations for girls enrolled in school and found that both attendance and mathematics scores
improved but also that the take home rations improved sibling nutritional status (Kazianga et al.,
2009). A study in the United States of America found that school meals can have positive impacts on
the dietary quality of those children who are nutritionally disadvantaged more so than on those
children who are less in need (Smith, 2017).
Box 20 The use of trade-related policy to reduce fatty meat availability in Samoa and Fiji
Trade-related policy has been used as a tool to try to address the “dumping” of fatty meats in the
Pacific Island countries of Fiji and Samoa. In Fiji, the sale of mutton flaps was banned in February
2000. In August 2007, the Government of Samoa banned turkey tail imports given concerns related to
their high fat content (32 percent). Both these policies led to a sharp decline in the availability of these
fatty meats.
In Fiji, prior to the ban, 221 tonnes of mutton flaps were exported from New Zealand and by 2001 no
flaps were exported from New Zealand. Then, imports increased again to reach around 115 tonnes in
2005, likely because the ban focused on sales rather than imports. Thus mutton flaps could still be
imported for processing if not for direct sale.
In Samoa, turkey tail imports ceased after the ban. A survey conducted by the Samoan Nutrition Centre
found that just under half of respondents shifted consumption from turkey tails to other cheap meats
including sausage or mutton; however, approximately a quarter reported eating lower-fat meat or
seafood, and a few respondents reported eating less meat overall due to the ban. Nevertheless, as part
of Samoa’s accession to the World Trade Organization in 2011, the ban on turkey tails was removed,
given that it was considered a barrier to trade. It has now been replaced by a 300 percent import duty.
Sources: Thow et al. (2010b, 2014a).
95
Box 21 Taxation of sugar-sweetened beverages and non-essential energy-dense foods
in Mexico
In January 2014, an excise duty of one peso (i.e. around 10 percent) per litre was applied to sugar-
sweetened beverages (SSBs) and an ad valorem excise duty of 8 percent was applied to non-essential
energy-dense foods.
A recent survey carried out on consumer purchases from January 2012 to December 2014 was used to
examine purchases of over 6 000 households. The volume of food purchases that was taxed and
untaxed in these households was examined from January 2012 to 2014, controlling for household
characteristics and contextual factors.
In December 2014, purchases of taxed SSBs had declined by 12 percent, and by 17 percent among
lower socio-economic households, compared with pre-tax trends. Moreover, purchases of untaxed
beverages were 4 percent higher than the counterfactual, mainly attributed to increased bottled water
purchases.
A similar pattern was found for non-essential energy-dense foods, where there was a 5.1 percent
reduction in purchases beyond what would have been expected based on pre-tax trends. There were
no corresponding changes in purchases of untaxed foods. Among low socio-economic households,
there was a 10.2 percent reduction in the purchases of taxed foods compared with what would have
been expected – high socio-economic households did not change their purchasing habits.
Sources: Batis et al. (2016); Colchero et al. (2016).
There are also several studies with mixed results related to the Public Distribution System (PDS) in
India. One study found that access to subsidized grain through the PDS has had a positive impact on
calorie consumption as well as on selected nutrients (Parappurathu et al., 2015). On the other hand,
Kaushal and Muchomba (2015) found that, while the increase in income resulting from the subsidy led
to a reduction in the consumption of coarse grains and increased expenditure on non-food items, it
had no effect on nutrition in poor households.
One argument against food taxes is their potential regressivity: they impose a larger burden on the
poor than on the rich. Thow et al. (2010a) found that combining food subsidies with taxes could help
alleviate this potential regressivity and enable consumers to switch to more healthy products without
incurring additional costs. The review indicates that food subsidies and taxes can influence
consumption in HICs and that imposing substantial taxes on fattening foods may improve health
outcomes such as overweight, obesity and chronic diseases. Further research is needed on
consumer responses to food taxes in developing countries (Thow et al., 2010a). A summary of the
evidence on taxes and subsidies is presented in Table 5.
96
Promote healthier diets through price promotions in mixed and modern food systems
Price promotions are an effective tool to encourage consumers to purchase nutritious and healthier
foods. Price decreases have been associated with increased purchases of some nutrient-dense foods
(Chandon and Wansink, 2012).
Understand the effect of remittances on nutrition status in traditional food systems
Remittances can increase access to (purchased) food and may have a consumption smoothing effect,
reducing households’ vulnerability and leading to improved food security and reductions in
underweight. However, remittances appear to have little effect on markers of chronic
undernourishment. Evidence also indicates that the extra income from remittances may compound
trends towards purchasing less healthy foods that are associated with the nutrition transition. There is
an urgent need for further research on the effect of remittances on nutrition and diets, with remittance
income forecast to rise rapidly into the future due to globalization and migration (Thow et al., 2016).
Programmes to ensure that those households receiving remittances move beyond just meeting
energy sufficiency needs to improve their dietary quality could create nutritional benefits (Thow et al.,
2016).
97
The obesity crisis cannot be solved without dramatic changes to the obesogenic marketing
environment that surrounds children (Harris et al., 2009). Public officials have a responsibility to
intervene through policies such as banning the promotion of unhealthy food advertisements or other
methods targeted at children, subsidizing healthier alternatives and restricting or banning certain
ingredients (Harris and Graff, 2015). Governments also are justified in intervening in schools to
promote healthier approaches to eating and physical activity. With regard to advertising junk food to
children, various types of legislation should be considered by states to put strict measures in place to
protect children and assist parents in promoting healthy eating at the household level. Education of
parents and childcare providers on good childhood feeding practices can also impact food-purchasing
behaviour.
Increase transparency of information on labels
Nutrition labelling has been commonplace in many countries for several decades. It aims to provide
consumers with information about the nutrient content of a given food. The Codex Alimentarius
Commission, established by FAO and WHO has developed standards for nutrition guidelines on food
products (FAO, 2012b). Although many countries have adopted back-of-the-pack (BOP) and front-of-
the pack (FOP) information on energy and specific nutrients since the development of the CODEX
guidelines, there is limited evidence to indicate that these labels have influenced consumer
comprehension and food-purchasing decisions (Mandle et al., 2015; UNICEF, 2016d).
Mandle et al. (2015) noted that labelling research and reviews focus mainly on Western countries with
limited peer-reviewed analysis on labelling in countries in the global South calling for more research
evidence in these regions. In Latin America, despite the prevalence of FOP labelling components,
there is a lack of studies evaluating impact or effect on diets and nutrition in the region (UNICEF,
2016d).
These labels require some degree of nutritional literacy, and are difficult to interpret for many people.
For this reason, there have been recent moves to adopt easy-to-interpret labels (e.g. traffic light, star
ratings, etc.) on FOP or on store shelves. It is thought that labels of this type are easier for consumers
to interpret and may help them make better food choices. However, the evidence related to
purchasing behaviour and intake associated with labels is both limited and mixed (Hersey et al.,
2013). Studies indicate that consumers can more easily interpret and select healthier products with
nutrient-specific FOP nutrition labels that incorporate text and symbolic colour to indicate nutrient
levels rather than nutrient-specific labels that only emphasize numeric information, such as guideline
daily amounts expressed as percentages and/or grams. Summary systems may influence consumers
to purchase healthier products (Hersey et al., 2013).
FOP labels can provide an incentive to industry to reformulate their products. There is preliminary
evidence to indicate that Ecuador’s front-of-pack traffic light labels have led to product reformulation
by large and medium food industries with over 20 percent of them reporting a reformulation of at least
one product that contains the red traffic light for sugar, fat or salt (ANDES, 2016). France, in its law of
modernization of the health system (Law n°2016-41, article 14-II), plans to establish a voluntary
graphic nutritional label in order to illustrate the mandatory nutritional information required by the
European regulations and to facilitate consumer choices (WHO, 2017c). An innovative front of the
pack labelling system has also been implemented in Chile as shown in Box 22.
98
Box 22 Regulation of marketing, labelling and the school environment in Chile: a
comprehensive policy to tackle obesity and improve the food system
By 2014, Chile had the second highest obesity prevalence in Latin America, after Mexico. Approximately
two-thirds of Chilean adults were overweight, and 27.8 percent were obese (PAHO, 2016a). Such figures
have been fuelled by the increasing consumption of highly-processed products in the country: sales had
grown from 125.5 kg/capita/year in 2000 to 200.6 kg/capita/year in 2013, ranking Chile as the country with
the second highest per capita sales of highly-processed products in Latin America (PAHO, 2015).
The Chilean Government led a thorough process of debate and investigations in the country that resulted
in the publication of Law 20.606 in 2012 (Chile, 2012), which stipulates that food and drink products shall
be labelled with front-of-pack nutritional warnings if high in energy, fats, sugars and/or salt. These front-of-
pack labels46 came into effect in June 2016. They consist of a black stop sign for items with high
quantities of energy, saturated fat, sugar and sodium.
This law has contributed to build a healthier food system by:
warning citizens about products that should not be the basis of people’s diet (application of
abovementioned front-of-pack warning system);
restricting the demand for such products (ban on the advertising of such products to children);
and
protecting the school food environment (prohibition on the sale, provision, promotion or
marketing of such products in schools).
The regulation restricts advertising of products that require a stop sign to children under the age of 14. If
foods have the black stop sign, they are also not allowed to be advertised on TV or distributed in schools.
This takes labelling one step further in that it promotes programmatic action.
Since the law’s introduction, 93 percent of the population of the Metropolitan region of Santiago de Chile
recognizes the front-of-pack nutritional warnings, and 92 percent has declared that the warnings have
been influencing their purchasing decisions, of which 68 percent indicate that when deciding between
products, they choose those with fewer or no warnings (Valdebenito et al., 2017).
46
See: http://web.minsal.cl/wp-content/uploads/2015/08/decreto_etiquetado_alimentos_2015.pdf
47
Processed foods containing ingredients that aid specific bodily functions in addition to being nutritious.
99
increase traceability and accountability and improve food safety. Zoonotic diseases, such as avian flu,
Ebola and Zika, can also be transmitted into the food supply and need to be combated by
governments through improved surveillance mechanisms (Ordaz-Németh et al., 2017; Barr and
Wong, 2016; Plourde and Bloch, 2016).
There is a need for education, training on, and monitoring of the prevention of food-borne illnesses
among all food supply chain actors and the public. There is also a need for strengthened institutions
and policies through an integrated effort piloted by public authorities, not just individual investments.
For example, to improve cold chain transport, public investment must also include stabilization of the
energy supply, capacity building and control. The HLPE report on FLW further articulates this
approach with Tunisia as a case study (HLPE, 2014a).
Traceability (i.e. the ability to trace and follow food, feed or food-producing animals or ingredients,
through all stages of production and distribution) helps provide safer foods and better connect
producers to consumers. The direct benefits of traceability are supply chain optimization, product
safety and market advantages (Regattieri et al., 2007). Consumers can track the full path of food from
the origin to the table, know the quality of the food and buy safer food to meet their needs.
Improve food quality across all food systems
There may be voluntary guidelines or policy options for improving the quality and composition of foods
in the food environment, e.g. the nutrient profile proposed by the Pan American Health Organization
(PAHO, 2016b). Food and beverage industries are working on reformulations, for example, in
reducing sugar and sugar replacements. In Singapore, the Healthy Hawkers Programme led to an
increase in the availability and affordability of healthier oils for use by street vendors after the Health
Promotion Board worked with oil manufacturers to produce a blended oil with 25 percent less
saturated fat than the one typically used by vendors (palm oil). To bring down the cost of the blended
oil, the Health Promotion Board worked with manufacturers to share logistic services, including
storage and delivery resources, which led to the oil being comparable in price to palm oil and, thus, a
realistic and feasible alternative (Hawkes et al., 2013).
100
Table 6 Summary of key points for intervening in different food systems to improve food environments
101
5.3 Priorities for orienting consumer behaviour towards healthier
diets
Consumers can shape the food supply through their behaviour and demand for specific foods.
Demand-side interventions focus on awareness, behavioural change, willingness to pay, knowledge
transfer and empowerment to increase demand for nutritious foods and thereby improve dietary
patterns. Governments and NGOs can influence consumers’ perceptions of the nutrition value (as
well as aspects of sustainability, heritage and culture, etc.) of foods by implementing regulation, mass
media campaigns, adopting nutrition guidelines and nutrition education (Wilkins, 2005). This section
reviews some of the channels through which consumer behaviour can be oriented towards healthier
diets.
102
multiple interventions to influence demand and stimulate behaviour change (Box 23). An Alive and
Thrive study in Viet Nam (Nguyen et al., 2016) found that a combined exposure to mass media and
interpersonal counselling together resulted in the highest prevalence of exclusive breastfeeding at
31.8 percent, higher than groups that received only either interpersonal counselling (26.1 percent) or
mass media (3.9 percent).
Alive and Thrive has also been involved in similar media campaigns in Bangladesh aimed at reaching
mothers, fathers and key community opinion leaders (Sanghvi et al., 2016). It should be noted that
with Alive and Thrive, in both Bangladesh and Viet Nam, two groups were compared: an intensive
(intensified interpersonal counselling plus mass media plus community mobilization) versus a non-
intensive (standard nutrition counselling plus less intensive mass media and community mobilization).
There was no statistically significant impact of the intensive Alive and Thrive interventions on child
linear growth. Instead, both intensive and non-intensive groups in each country showed rapid and
statistically significant reductions in stunting. The research found that other socio-economic
characteristics made the largest impact on linear growth such as maternal education, socio-economic
status, hygiene and food security (Nguyen et al., 2017). More research is needed on other factors
such as maternal age and nutrition, birth spaces and women’s empowerment and autonomy to make
decisions as key determinants.
48
The Martha Organization was founded in Finland in 1899 to promote well-being and quality of life in the home. It
focuses on: food and nutrition; home gardening and environmental protection; household economics and consumer
issues. https://www.martat.fi/in-english/
103
Kenya and Ethiopia, in order to increase adherence to calcium and iron-folic acid supplementation
among pregnant women, a local support system was developed using an "adherence partner" (i.e.
someone helping the pregnant woman to adhere to the regular supplement regimen at home). (Martin
et al., 2016). In Haiti, “positive deviants” or caregivers in the community that had well-nourished
children despite limited household economic resources, were paired with mothers with poorly-
nourished children, and served as a liaison between the nutrition clinic and community (Bolles et al.,
2002).
Two systematic reviews showed that multi-component behaviour-changing interventions that
incorporate diet, physical activity and behaviour change may be beneficial in achieving small, short-
term reductions in BMI in children aged six to eleven years (Mead et al., 2017) but less so in
overweight and obese adolescents (Al-Khudairy et al., 2017) largely because the quality of evidence
was very low, limiting confidence with inconsistent study results.
To enhance the positive effects of SBCC, more precision is needed in identifying effective delivery
mechanisms that are context-specific, along with agreed-upon strategies for communicating key
messages.
Develop food-based dietary guidelines (FBDGs) for healthy and sustainable diets
Eighty-three countries worldwide have developed FBDGs that can be used by health and nutrition
professionals to provide dietary advice, adapted to local cultures and contexts. These guidelines can
also inform food provisioning. For instance, in the United States of America, national guidelines form
the basis of Federal food and nutrition assistance programmes such as school meals programmes. In
fiscal year 2012, more than 31.6 million children each day received their lunch through the National
School Lunch Program (USDA, 2013). In Brazil, in 2014, 42.2 million students received daily meals
planned according to the national dietary guidelines and prepared with products provided mainly by
small farms.49
Ensure that social protection programmes lead to improved nutritional outcomes
Governments and NGOs can influence consumer perceptions of the nutritional value of foods by
providing social protection programmes that adopt nutrition guidelines, and by introducing nutrition
education (Wilkins, 2005). Social protection programmes such as cash transfers and school feeding
programmes can substantially contribute to the realization of the right to adequate food when
implemented from a rights-based approach (Sepúlveda Carmona et al., 2012), including respecting
the principle of equality and non-discrimination, transparency, participation and accountability.
Cash transfers (CTs) have been effective in terms of improving nutrition outcomes (Rasella et al.,
2013; Lagarde et al., 2007; Bastagli et al., 2016). Many studies examining the impact of CTs on diet
and nutrition outcomes have found improvements in dietary diversity, while a smaller number have
shown improvements in anthropometric indicators (Bastagli et al., 2016). However, given the shifts in
the burden of disease from undernutrition to overweight and obesity, CT programmes will need to be
continuously monitored to ensure that there are no unintended consequences regarding excessive
weight gain.
Conditional cash transfer (CCT) programmes are also important, and Mexico’s Oportunidades
Program, which combined stipends conditional on ensuring school attendance and seeking
preventative medical care, was associated with a lower prevalence of stunting, lower BMI for age
percentile and a lower prevalence of overweight. Although there were significant improvements in
children, there were unintended consequences among adults – a doubling of cash transfers was also
associated with an increased BMI, higher diastolic blood pressure and higher prevalence of
overweight and obesity in participants (Fernald et al., 2008a, 2008b).
49
For more details on Brazilian national school meals programmes, see:
http://www.fnde.gov.br/programas/alimentacao-escolar
104
marketing activities as well as by product branding (Boyland and Halford, 2013). Food preferences
are associated with dietary intakes (Drewnowski and Hann, 1999): consumers are more likely to
consume the foods they consider more acceptable.
The private sector has a strong role to play in increasing the acceptability of foods by producing
packaged foods that are nutritious, and can make it more convenient for people to cook and eat
healthy meals. For example, some companies sell bagged, cut up or shredded vegetables that can
easily be added to salads or cooked: bagged salad mixes and cut up fruit such as apple slices and
berries. Frozen vegetables and fruits are also a way for people to have more convenient healthy
options that are less perishable but require cold storage.
Currently, large amounts of produce are wasted simply because they do not meet an aesthetic
standard that retailers require. While this is a more significant problem in HICs, it also occurs in
LMICs. These “ugly” fruits and vegetables are safe and, in some cases, may even be more nutritious
than their more “attractive” counterparts. Large retailers have started selling more ugly produce –
including Intermarché in France, for example, which introduced the practice in 2014. The produce did
not sell well at first, but sales improved after the retailer launched an advertising campaign (Cliff,
2014). In France, mass media campaigns are used to fight food waste by providing imperfect fruits
and vegetables at a discount (Di Muro et al., 2016).
50
For instance, the Maasai bolster their nutrition by directly consuming or adding to their mainly animal-sourced diet
certain herbs with medicinal properties. Their indigenous knowledge system includes optimal ways and times for
them to prepare and consume these herbs (FAO, 2009).
105
families (Lautenschlager and Smith, 2007; Hartmann et al., 2013; Yuasa et al., 2008; Gillman et al.,
2000). Women can play a critical role as decision-makers in improving the nutritional outcomes of
their families due to their social role in childcare and household food preparation in many societies.
They can serve as the nutrition champions of households.
106
Figure 15 Improved food systems for better diets and nutrition
107
5.4 Investment and intervention priorities across food system types
Each food system type faces its own challenges and limitations, but all of them have the potential to
open specific pathways towards sustainability and to deliver healthier diets that enhance FSN in their
local contexts, and/or for all, now and in the future. “Modern” food systems are not the end goal for
every food system. Traditional food systems, and their associated knowledge systems, are valuable
by themselves and can be a source of inspiration for policy-makers. Figure 16 summarizes where
investments and interventions could be prioritized across the three food system types identified in
Chapter 1.
Availability and
Availability and Retail and Retail and
physical access
physical access markets markets
(proximity)
(proximity)
Promotion,
advertising and Storage and
information distribution
Modern
food systems
Economic
access Processing
(affordability) and packaging
Notes: The right side of the wheel (blue) illustrates the elements of the food supply chain while the left side of the
wheel (green) the elements of the food environment as described in Chapter 1.
(1) Darker slices indicate elements of the food supply or environment that need significant investment and
interventions to improve or change.
(2) Shaded slices indicate elements of the food supply or environment that need some investment to
improve or change but not critical.
(3) Slices left white indicate elements of the food supply or environment which are important investments
but if choices need to be made, they are less of a priority.
108
5.4.1 Traditional food systems
In traditional food systems, policies should focus on availability, and on physical and economic
accessibility of high-quality (i.e. containing essential nutrients) diets. On the production side, this might
involve strategies that increase the resilience of farmers, especially smallholder farmers who are often
net food-buyers, to external shocks, whether natural or human-induced. This might include, for
example, strengthening rights to land and other productive resources, improving access to services
and resources such as credit, technology, inputs, markets and extension (HLPE, 2013, 2016).
Investments in infrastructure and storage facilities that allow for easier transport and safe storage of
food commodities, and integration of technologies such as food fortification and food processing, can
alleviate the burden that consumers experience in trying to meet their dietary needs.
On the consumption side, though nutrition and health education is essential, it is not sufficient:
policies should also focus on affordability of those foods that constitute a healthy diet. Because poor
households often spend a large portion of their household budget on food, stabilizing food prices and
providing social protection programmes for vulnerable groups (particularly in the light of climate
change and increasingly irregular weather patterns) is essential for FSN (HLPE, 2011a, 2012b).
5.5 Conclusion
There are many places to intervene within food systems – across food supply chains, within food
environments and by influencing consumer behaviour. There is no one-size-fits-all approach, and
solutions must be adapted to the different food systems described in Chapter 1 and to each local
context. While we need more research across both programmes and policies to address the multiple
burdens of malnutrition, evidence is emerging on where to act to shift food supply chains and food
environments towards those that facilitate healthier food choices. There is also a need for better
understanding of the exogenous drivers that influence not only how food systems operate but also
who controls them, and how much power consumers have in making decisions within food
environments, bearing in mind that some of the world’s poorest and most marginalized groups have
effectively very little choice regarding what foods they purchase and consume. The final chapter will
discuss how we turn this evidence into action.
109