Towards an understanding of the differences between healthy diets and unhealthy diets
To understand how existing food and agricultural policy support is affecting diets, it is first necessary to understand the differences between what is meant by healthy diets and unhealthy diets. The 2020 edition of this report looked closely at what constitutes a healthy diet through its examination of the evolving view of diet in the food security and nutrition debate, which is summarized in this section.
The exact make-up of a healthy diet varies depending on individual characteristics, cultural context, local availability of food, climatic and ecological conditions, dietary customs and preferences. The basic principles of what constitutes a healthy diet, however, are common across context and are clearly agreed upon and outlined (Box 10). One key element of diet quality is dietary diversity, or the variety of foods from different food groups that make up the diet. Eating a larger variety of foods across food groups is associated with decreased risk of insufficient intake of several micronutrients and related deficiencies.30 Consuming a healthy diet throughout the life-course helps to prevent against all forms of malnutrition, favours child growth and development, and protects against diet-related NCDs such as diabetes, heart disease, stroke and cancer.30 Prevention of all forms of malnutrition is linked with adult productivity and is vital, therefore, for the development of nations.82
BOX 10Description of nutritious foods and healthy diets
In this report, nutritious foods are referred to as safe foods that contribute essential nutrients such as vitamins and minerals (micronutrients), fibre and other components to healthy diets that are beneficial for growth, and health and development, guarding against malnutrition. In nutritious foods, the presence of nutrients of public health concern including saturated fats, free sugars, and salt/sodium is minimized, industrially produced transfats are eliminated, and salt is iodized.83
GUIDING PRINCIPLES OF HEALTHY DIETS:3,84
- start early in life with early initiation of breastfeeding, exclusive breastfeeding until six months of age, and continued breastfeeding until two years of age and beyond combined with appropriate complementary feeding;
- are based on a great variety of unprocessed or minimally processed foods, balanced across food groups, while restricting highly processed food and drink products;*
- include wholegrains, legumes, nuts and an abundance and variety of fruits and vegetables;**
- can include moderate amounts of eggs, dairy, poultry and fish, and small amounts of red meat;
- include safe and clean drinking water as the fluid of choice;
- are adequate (i.e. reaching but not exceeding needs) in energy and nutrients for growth and development and meet the needs for an active and healthy life across the life cycle;
- are consistent with WHO guidelines to reduce the risk of diet-related NCDs and ensure health and well-being for the general population; and
- contain minimal levels or none, if possible, of pathogens, toxins and other agents that can cause food-borne disease.
According to WHO, healthy diets include less than 30 percent of total energy intake from fats, with a shift in fat consumption away from saturated fats to unsaturated fats and the elimination of industrial transfats; less than 10 percent of total energy intake from free sugars (preferably less than 5 percent); consumption of at least 400 g of fruits and vegetables per day; and not more than 5 g per day of salt (to be iodized).30
- * Food processing can be beneficial for the promotion of high-quality diets; it can make food more available as well as safer. However, highly processed foods can contain very high densities of salt, free sugars and saturated or transfats, and these products, when consumed in high amounts, can undermine diet quality. Free sugars are all sugars added to foods or drinks by the manufacturer, cook or consumer, as well as sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates30 ** Potatoes, sweet potatoes, cassava, and other starchy roots are not classified as fruits or vegetables.
Unhealthy diets – those that do not meet the basic principles outlined in Box 10 – tend to be low in a variety of essential nutrients and often high in fat (especially trans or saturated fats), sugars and/or salt. Consumption of unhealthy diets may be due to constrained access to a variety of nutritious foods due to economic or other factors, and/or to knowledge, preferences, motivations, traditions and similar factors. Progressing from unhealthy to healthy diets, therefore, requires concerted and simultaneous efforts to address supply and access considerations, enabling healthy food environments as well as the promotion of healthy diets through education, behaviour change and enabling healthy food environments.
Food and agricultural policies that affect the availability and affordability of healthy diets
Food and agricultural policies affect agrifood systems (Figure 1) through various and complex pathways, including through their effects on production, trade, relative food prices, variety of foods, producer’s incomes, and consumption decisions, among others. Hence, any support to food and agriculture through these policies can potentially trigger shifts in the availability of different foods and in the affordability of healthy diets, which in turn can affect dietary patterns.3,15
The empirical literature reveals that policy support to food and agricultural production, e.g. in the form of fiscal subsidies or border and market measures to protect producers from price volatility or competition, may bring positive effects on beneficiary producers, such as on their incomes.85 These policies, however, may have negative implications on the ability of consumers, in particular the poor, to access healthy diets and dietary diversity, since they affect the relative prices of different foods. For example, increasing price incentives to farmers, as measured by the NRP, is associated with a higher cost of a healthy diet (Box 11).
BOX 11Higher support to producers through price incentives correlates with a higher cost of a healthy diet
Trade and market policies, measured by NRP, that raise the price of a commodity relative to the international one, are associated with a higher cost of a healthy diet for consumers.* This is shown by the positive and significant correlation coefficient (30 percent) between the NRP and the cost of a healthy diet (Table A, column 1).** When the NRP is calculated by different food groups that contribute to a healthy diet, higher rates of protection (or price incentives) to producers of fruits and vegetables and staple foods (mainly cereals) are associated with a higher cost for these specific items for consumers and with a higher cost for a healthy diet as a whole (Table A, columns 3-4).***
TABLE A PAIRWISE CORRELATIONS BETWEEN NRP AND THE COST OF A HEALTHY DIET
Although the NRP indicator captures a variety of policies, results in Table A suggest that a specific group of policies designed to protect domestic producers may ultimately translate into a higher cost of foods for consumers at the marketplace. As an example, while policies like import tariffs protect producer prices from international competition, they might penalize consumers who pay higher prices to acquire the tariff-protected foods and put them at risk of not affording a healthy diet. If higher protection goes to producers of the most expensive components of a healthy diet, namely fruits and vegetables and protein-rich foods that account for 46 and 35 percent of the cost, respectively, consumers may decide to switch consumption to relatively cheaper food groups.
Government support to general services that include R&D of new technologies, infrastructure and institutional reforms, could lower the cost and improve the affordability of foods.66,86 For example, investments in improved infrastructures to decrease transport costs may help lower food prices and diet costs more effectively than trade restrictions.ii Furthermore, investing more in the general services while also reorienting agricultural subsidies could benefit producers and increase the affordability of a healthy diet for consumers (see Section 4.1).
- * See Box 7 in Section 3.1 for a description of the NRP and Section 2.3 for a description of a healthy diet cost. ** Correlation analysis is run on a sample of 44 countries with information available for both NRP and the cost indicator during 2016–2018. The European Union is treated as one single country observation. Overall, 37 HICs are captured in the analysis. *** To identify a common metric between food groups of NRP and of a healthy diet, fruits and vegetables are grouped together, and protein-rich foods include dairy and meat/eggs as well as pulses such as beans and peas.
Repurposing food and agricultural policy support across the food supply chain, if carefully designed and targeted to achieve better nutrition outcomes (see Figure 1), has the potential to help reduce the cost and increase the access of foods that form a healthy diet, hence, contributing to improving their relative affordability and availability. This entails increasing incentives (and decreasing disincentives) for the production and consumption of diverse, nutritious and safe foods through environmentally sustainable practices at all stages of the food supply chain (Figure 1).87 This also implies taking due consideration of all stakeholders, including women and youth, as they often find themselves in a disadvantaged position compared to their adult male counterparts when it comes to the access to, and use of, food and agricultural resources and markets. For example, access to subsidies, inputs, storage facilities, technology, extension services, all would improve the efficiency of women and youth’s activities, food safety and the reduction of post-harvest losses.88 It is also important to keep in mind that inclusive and healthy environmental systems are needed to ensure the sustained and long-term supply of sufficient nutritious food,15 thus contributing to address the trends of and prevent all forms of malnutrition (see Chapter 2), and support all other efforts to ensure food security and good nutrition for all.
Before examining potential policy paths for repurposing food and agricultural policy support, the next sections briefly discuss the nexus between food and agricultural policy support (Figure 17) and the availability and affordability of healthy diets. For the purpose of clarity, the discussion hereafter follows the categorization of policies presented in Section 3.1.
Trade and market interventions: border measures
Trade can improve the availability and affordability of different foods, thereby broadening consumer choices and supporting more diversified diets, including the access to fresh foods.89 For example, countries like Denmark, the Maldives and Mauritania imported more than three-quarters of the quantity of fruits and vegetables available for domestic consumption in 2019.90 At the same time, food trade is often also associated with increased availability of highly processed, energy-dense foods that are high in fats, sugars and/or salt.89 Similarly, while trade can help with climate adaptation by stabilizing markets and reallocating food from surplus to deficit regions,91 production for exports can generate negative environmental externalities, such as unsustainable freshwater withdrawals, pollution, biodiversity loss, deforestation and GHG emissions (including from shipment of food). Trade policies in food and agriculture should therefore tackle the trade-offs between economic, environmental and social objectives and strengthen the resilience of the global agrifood system to shocks.
Border measures, as defined in Section 3.1, affect the availability and relative prices of food and can therefore impact consumer choices, dietary patterns and diet-related health outcomes. Import tariffs are the most commonly used border measure, often employed to shield domestic producers from competition, with tariffs typically varying for different products and across countries (Box 12).
BOX 12 Tariffs on highly processed foods, sugar and confectionery and fruits and vegetables*
Effectively applied tariffs on imported foods vary considerably by country income level and food group, such as highly processed foods, sugar and confectionary, fruits and vegetables or food and beverages overall (Table A).**
Table A Average applied tariffs on different food groups (import value weighted, percent), by country income group
Import tariffs on foods are generally higher in LICs. This raises consumer prices for imported and import-competing foods and may disproportionally affect poor households that spend a larger share of their incomes on food.92 Conversely, HICs, on average, charge lower tariffs on imported foods.***
With respect to import tariffs on foods with different nutritional value, the data show that both highly processed foods and sugar and confectionery generally attract higher tariffs than food and beverages overall, in all but the HICs. For example, LMICs levy an average tariff of 14.7 percent on imported highly processed foods, compared to 8.5 percent on food and beverages as an aggregate benchmark. Crucially, in all countries but those in the high-income bracket, fruits and vegetables are also charged high import tariffs, with LICs on average collecting close to 19 percent duty on imported foods in this group.
These findings are important because tariff changes can shape the domestic availability and consumption of foods with different nutritional value. For example, evidence from Fiji suggests that reductions of high tariffs levied on fruits and vegetables led to higher imports of this food group and increased domestic availability of these products.93 As for foods of high energy density and minimal nutritional value, several studies document that tariff reductions for such foods are associated with an increase in their supply as well as consumption and health-related indicators such as prevalence of obesity. These findings hold for countries at different development stages.94,95,96,97 However, domestic taxes instead of tariffs would be preferable to curb consumption of such foods since they discourage their aggregate consumption regardless of origin and have been found effective in improving diets (see Section 4.2).89,98
Lastly, it is important to note that taxes and tariffs affect overall food consumption and raising them could undermine sufficient intake of food in some contexts if not accompanied by other measures that support access to nutritious food. For example, higher differences in tariffs on highly processed foods versus minimally processed and unprocessed foods in sub-Saharan Africa have been found to be associated with lower levels of obesity but also with a higher prevalence of underweight.97 This suggests that an integrated approach, using multiple policy instruments – such as using revenue from taxes on highly processed foods for well-targeted programmes to reduce undernutrition – may be needed, along with research to identify food groups that can be taxed to combat obesity without detrimental effects on undernutrition.
- * Results obtained from analysing import tariffs cannot be compared directly to results obtained from the analysis of the aggregate NRP indicator in Section 3.1, due to the range of policy instruments considered in the computation of the NRP. The NRP captures the overall net-effect of tariffs, NTMs, export restrictions (and subsidies), and market price control measures (like administered prices or minimum producer prices). Additionally, due to the heavy data requirements for the computation of the NRP, coverage for some country/commodity combinations in the NRP dataset is very low, especially for LICs and for fruits and vegetables, as opposed to tariff data, which are more comprehensive. ** Annex 5 provides a description of the tariff indicator employed and describes the identification of food groups. Highly processed foods are those identified by Monteiro et al. (2019)417 as “ultra-processed” (NOVA classification 4). *** It should be noted that presented averages mask differences within country groups. For example, lower-middle-income Solomon Islands levies an import tariff of around 10 percent on highly processed foods compared to an average of 14.7 percent in LMICs overall.
Besides tariffs, NTMs can impact agrifood trade and diet affordability and diversity, because producers and traders may have to comply with standards and other regulatory requirements that increase trade costs.r 3 Crucially – and while tariffs in agrifood trade have declined since the Uruguay Round of trade negotiations – NTMs are widespread.3,99,100
To illustrate, recent results on the prevalence of NTMs by product group show that in 2019 close to 80 percent of the total import value of 100 countries with available data were subject to NTMs, with agrifood trade being impacted disproportionally.100 Additionally, estimates of tariff equivalents of NTMs in agrifood trade are often found to be higher than import tariffs. The global average of the tariff equivalent of SPS and TBT – key measures affecting agrifood imports – is estimated at around 15 percent.101,102,103 As for individual food groups of interest in the context of healthy diets, tariff equivalents for SPS and TBT measures combined have been estimated at about 8 percent for broadly defined vegetable products and at almost 14 percent for processed foods (including sugar and confectionary).103
Taken together, these results suggest that NTMs are likely to increase the cost of food to consumers, but it is not clear whether nutritious foods are more severely affected. Additionally, SPS measures are in place for the protection of human, animal, or plant life or health.104 Food safety measures, for example, are implemented to ensure that traded food is safe for consumers, for instance, by imposing maximum residue levels for pesticides or veterinary drugs.3,102 It has also been documented that some NTMs can expand agrifood trade, for example, by boosting consumer confidence through labelling and packaging requirements.102,103 Maintaining and strengthening measures to protect human, animal and plant health, while making their application transparent and based on evidence, is therefore important for safety and predictability of agrifood trade and healthy diets.
Export restrictions mostly target staple foods that are considered important for food security, such as rice, wheat, maize or pulses, and are only seldom applied to fruits or vegetables. For example, in the context of the war in Ukraine and unprecedented high food prices, in mid-March of 2022, Egypt banned the export of wheat, flour, lentils and beans amid growing concerns over food reserves.105 Among 33 countries that implemented export restrictions over 2007–2011, only Jordan imposed an export ban on “fresh vegetables and eggs,”106 with another exemption being Uzbekistan, which introduced an export ban on fruits and vegetables in 2015, but lifted it in 2016.107 Few countries also implemented short-lived export restrictions during the first wave of the COVID-19 pandemic, with Türkiye putting an export ban on lemons for five months, while Kazakhstan first banned exports of different vegetable items before converting the ban into an export quota.108 Given their overarching focus of making staple foods more affordable, export restrictions could lead to lower relative prices of staple foods and therefore a high proportion of such foods in the overall calorie intake of poor households in particular. However, evidence suggests that in the past these measures were not successful at limiting domestic price increases of targeted products.109
Trade and market interventions: market price controls
As outlined in Section 3.1, market price controls include policies such as administered prices used for direct government procurement from farmers. If interventions through public food procurement increase or reduce domestic prices relative to the border price, these generate incentives or disincentives for producers.
Often governments procure food directly from farmers at administered prices for public food stockholding purposes, social protection programmes or meals served in public institutions (see Box 16 in Section 4.2). Policies that establish administered prices are common in LICs and MICs, including major agricultural producers like China and India, but have been largely abandoned by HICs such as the United States of America and the European Union member states.69,110 In the past, public support provided through high guaranteed prices, for example in the European Union, led to excessive public stocks and friction with the European Union’s main trading partners.111
Price controls are frequently accompanied by border measures to sustain prices above world market prices for domestic producers. For example, the price support programme for rice farmers in the Dominican Republic entails maintaining a floor price paid to producers, implemented through a combination of market regulation and tariff rate quotas, with high out-of-quota tariffs.112
If they exceed world prices, such minimum or administered prices would provide incentives to farmers to produce larger quantities than they otherwise would. In many LICs and MICs governments use this instrument with the policy objective of ensuring sufficient supplies of strategic commodities, for food security purposes, and to improve incomes of poor farmers. At the same time, as other trade and market measures that generate price incentives, they distort domestic markets and potentially global trade, affecting the cost of foods. As price controls are predominantly implemented on grains, in particular rice, maize and wheat,71 and also on sugar,110 they often result in a higher supply of these products relative to foods such as fruits, vegetables or legumes.
In many LICs and MICs, these measures are still widespread. Some evidence suggests this may have detrimental effects on dietary diversity. For example, in Egypt, the high domestic wheat procurement price provides strong incentives to farmers to cultivate wheat. This, combined with bread subsidies to bakeries and consumers led to a significant increase in per capita consumption of bread and a higher share of wheat-based products in the overall food supply.113 Similar to other Northern African countries, Egypt’s per capita food supply of wheat products is among the highest in the world: at 146 kg per capita annually, it is more than double the world average, constituting roughly one-third of the overall food supply in calorie terms.90
Fiscal subsidies to producers
The mix of products that is supported through different types of fiscal subsidies to producers (Figure 17), and the process by which policies are implemented, can directly and/or indirectly affect the diversity and quantity of food produced, trade flows and the relative prices that consumers face. These will, therefore, affect the access and affordability of healthy diets (Box 10). The specific impact of a fiscal subsidies is country (context) specific. However, each of these policy instruments have some common positive and negative impacts on healthy diets.
Subsidies on output and (on) factors of production
Subsidies on output and based on factors of production have a direct bearing on farmers’ production decisions. As such, they can impact the quantity, diversity and price of commodities – whether these are for final consumption or are inputs to the food processing and livestock farming industry. Over the past decades, the application of these subsidies has been different across countries; however, in most countries the focus has been – and continues to be – on a handful of commodities (Section 3.1). In fact, the most subsidized commodities, since the 1970s, include staple foods – especially maize, wheat and rice – followed by beef and milk.s
These subsidies have significantly contributed to increasing production and lowering prices of the subsidized staple foods, mainly cereals.85,114 The most significant positive impact of these subsidies has been their contribution to improving food security through higher caloric intake across the world.73,115 Further, by supporting farm incomes, output subsidies and factors of production indirectly supported the development and use of better technology and of new agricultural inputs which enhanced the productivity of the subsidized commodities.116
These subsidies, however, also caused important market distortionst within and across borders.62,117,118 Market distortions affected production, trade and prices of subsidized commodities in ways that would have not usually existed in a competitive market, and have created (relative) disincentives towards producing nutritious foods.74,119 Output subsidies and factors of production have encouraged monocultures in some countries, ceased the farming of certain nutritious products,u and have reduced production of some foods that do not receive the same level of government support (commodities and its derivatesv).73,120,121 These changes in production have direct implications on the price and availability of unsubsidized or less subsidized commodities and their derivatives, which in turn can create negative incentives for people to diversify their diets – especially for the most economically vulnerable.120 The production levels and lower prices of subsidized commodities have also impacted the food industry, which has developed the low-cost, unhealthy inputs that it widely uses (e.g. high-fructose corn [maize] syrup, oils containing saturated fats, etc.).96,122
The most subsidized crops are highly prevalent in most countries’ food supply, are low-priced, and in some countries are consumed at rates well above recommendations (Box 10).123,124,125 When the share of these subsidized commodities, along with food ingredients derived from them, are considered in individuals’ total food consumption, these represent an important portion of people’s diets – especially among the most vulnerable people, including in HICs.120,126,127 For example, a study assessing the impact of the United States of America’s output subsidies and factors of production (covering maize, wheat, soy, rice, sorghum, dairy and livestock) on its population’s consumption found that 56 percent of calories consumed were from the subsidized food commodities, with the share being between 66 percent and 100 percent among those who are less educated, poorer and less food secure.122
Input subsidies usually aim to fill the gaps of underdeveloped or poorly functioning markets, to increase profitability of farming and to diversify and/or to increase the production and consumption of agricultural commodities.128,129 Input subsidies could, therefore, contribute to the availability and affordability of healthy diets, enhancing food security and nutrition.126 Empirical studies show, however, mixed results. On the one hand, some country case studies disclose that large input subsidies for some commodities – e.g. for rice seeds and fertilizer purchases – encouraged higher production, consumption and private investment, which in turn played an important role in transforming the value chain.130
On the other hand, other country case studies show that input subsidies’ policy objectives are not always met, and/or their cost outweighs their benefits, and that the policy instrument is difficult to phase out, and in some cases, it may have inhibited the development of input markets.128,131 The underpinning reasons for these outcomes are related to the process by which these subsidies are provided.132 In certain countries – often in LMICs – input subsidies’ objectives regarding productivity and diversity were not met when the process by which input subsidies were implemented was deficient (e.g. subsidies did not reach the intended beneficiaries or were not accompanied with extension services),131 or when input subsidies had suboptimal funding, encouraged monocultures, or were not nutrition-sensitive.96,130
As for countries where the costs of input subsidies exceeded benefits – notably in MICs and HICs – the mechanism for their implementation (e.g. subsidy coupled to level of production that covers a limited number of products) together with the high amount subsidized, were not only costly and difficult to phase out but also distorted markets or gave an “unfair” advantage to some commodities (e.g. cereals).62,133,134 In this case, the negative impact on diets are similar to those discussed above with regard to output subsidies and factors of production.
The negative impacts of input subsidies may also outweigh their benefits when these subsidies compete for scarce government funds that could be directed to other investments (e.g. infrastructure, R&D, and so on) that, in the long term, may enable rural households to diversify their livelihoods from staple foods and move towards a more diversified healthy diet,120,135 may contribute to boost productivity, and reduce the price and increase the availability of nutritious foods.69
On a positive note, recent studies found that countries that move towards hybrid policies that support market creation for inputs131 have been able to reach a greater number of farmers, while developing a sustainable inputs market, which could facilitate access to quality inputs for all agricultural produce.136,137 This is the case, for example, of input subsidies that use vouchers and private traders,128 or hybrid policies using cash transfers.96
Other subsidies for which non-commodity criteria or production applies
In addition to the subsidies discussed above are lump-sum payments to all farmers, which may include subsidies tied to environmental or landscape outcomes. These subsidies are usually subject to cross-compliance conditions but not linked to the production of specific commodities or livestock numbers or the use of specific factors of production; these are known as decoupled subsidies (Section 3.1). These subsidies can include transfers that contribute to soil regeneration, whose impact on healthy diets will depend on how the subsidy is implemented.138 For example, it can encourage the planting of native species,139 but, in the short to medium term, it may reduce production of some commodities and hence increase their price.140 The impact on healthy diets will also depend on later land-use decisions and the existing agricultural production structure – outcomes will therefore be country specific.141
Decoupled subsidies may also include support to producers to overcome challenges such as compliance with new regulations and to encourage environmentally sustainable production. Empirical studies show that these subsidies increase the level of production but do not significantly change the variety of foods produced by a country.142 In what concerns a healthy diet, the studies gathered suggest that countries that have adopted decoupled subsidies have not been able to meet the demand of nutritious food. For example, in Southern Asia, the movement towards high value fruit and vegetable production systems has been slow relative to the growth in demand.143 In France, despite increase in decoupled subsidies in 2005 and 2014, the performance of the legumes sector has not significantly changed.144 In both cases, lack of infrastructure investments and high transaction costs associated with fruit and vegetable value chains are cited among the primary reasons for the slow supply response. Subsidies with sustainability objectives have, however, contributed to positive environmental outcomes and the availability of safer food. Discussion on policy repurposing towards nutritious and sustainable agrifood systems are part of Chapter 4.
General services support
GSS are public expenditures for the provision of public goods and services that can be designed to create enabling and environmentally sustainable conditions for the food and agricultural sector (Section 3.1). These services connect all economic actors of agrifood systems (Figure 1), support the nexus between producers and consumers, and can be an excellent booster of productivity where levels are low and productivity gaps are significant, which is the case in many LICs. These services include R&D and knowledge transfer, inspection services, agricultural related infrastructure, public stockholding, and food and agricultural marketing and promotion. GSS is critical for the well-functioning of agrifood systems, essential for ensuring food safety and food availability, and can significantly contribute to food price reduction – including for nutritious foods.69 It is important to remember that due to the inadequacy and poor interest given to some nutritious foods over several decades (e.g. indigenous commodities, legumes in France), private sector investment in those foods has been low.144 As for the impact of GSS on production, it is different across services, is highly context specific (Section 3.1), and may present trade-offs. For instance, a service (e.g. inspection) can have a positive impact on food security and food safety, but it might imply a higher food price (e.g. oversight fees) that could threaten affordability of healthy diets, or vice versa. Because of the importance of each of the general services for healthy diets, and for clarity purpose, these are discussed separately hereafter.
Research and development (R&D) and knowledge transfers
Public investment in food and agricultural R&D is essential for global food security, improved nutrition, delivery of affordable healthy diets and environmental sustainability. R&D is one of the drivers of productivity gains, declining commodity prices and the related fall of retail food prices achieved since 1950.145,146 For example, in the case of fruits and vegetables, a study found that without the knowledge acquired through public R&D, the consumption of this food group would have been reduced by more than 27 percent due to higher prices.145 Furthermore, R&D has significantly contributed to the development of farm inputs, new food products, farm technology, improved product information among traders, processors and retailers, and product traceability from farm-to-fork (e.g. block chain technology operated by value chain agents), which increased transparency and trust.147,148,149
Although the benefits of R&D are many,w the impact of R&D on diets depends on the conditionalities that apply to R&D support, the means of implementation and the targeted commodity.150 R&D is generally a joint effort of the private and public sectors,x 151 provided to long-established institutions, most of which are highly concentrated in industries related to cereals (including the most subsidized commodities discussed above under fiscal subsidies to producers).150,152 For example, the World Vegetable Center (covering a wide basket of crops) has a budget of about USD 20 million,153 while the International Rice Research Institute has a grant portfolio of USD 67.5 million.154
Closely associated with R&D are knowledge transfers that are core services for increasing productivity, food safety and the nutritional value of products – specially needed in contexts where it is challenging to meet populations’ micronutrient requirements.146 Knowledge transfer services are critical for the diffusion and adoption of R&D products (e.g. new seeds) and technologies (e.g. satellite data to monitor crop growth).148,155,156 They can also be key to providing generic training and extension advice to farmers (e.g. on sustainable farming techniques, post-harvest loss management, nutrition-sensitive agriculture) and high education on agricultural programmes (e.g. market-oriented services).148,157 For example, in the case of nutrition-sensitive agriculture, these services increasingly involve multiple types of interventions, such as the adoption of biofortified crops along with agriculture-nutrition education,158 fortification of cereals and products together with training to scale up production, which have proven to reduce micronutrient deficiencies (e.g. vitamin A) while increasing household incomes.120,130 These developments, however, are not reaching all producers due to still important gaps in funds, knowledge, technology, means of implementation, coordination of R&D and knowledge transfer service providers, and limited partnerships across stakeholders.159 For example, in the case of fortification, technology gaps are too wide to be effectively applied in small-scale industrial processing.160,161
Inspection service is the enforcement arm of Food Safety Risk Management. This includes ensuring that food products conform to regulations and product safety and quality norms of the entire food chain (inputs and outputs).162 Inspection service is fundamental for healthy diets (Box 10), for food security and food safety, i.e. to reduce the risks of food contamination by, for example, harmful toxins, chemicals, bacteria and other pathogens. Furthermore, inspection can contribute to enhancing the quality of food (including the nutritional value of products), productivity (e.g. rules affecting production losses), and to enhancing consumer trust and awareness.163 In recent years, countries have been investing in tools for communication of good practices, in digital risk-based approaches to improve control for food safety, and in cooperation and collaboration among competent authorities.164,165
That said, significant gaps exist in the adoption of new technologies and in investment of inspection equipment required to access quality scientific services (e.g. capacity to monitor, sample and analyse food products for specific contaminants, and process data for the purpose of risk analysis). Also, in many countries inspection procedures remain cumbersome, costly, and their implementation lack transparency and coherence between different government bodies (e.g. different requirements made by the Ministry of Agriculture and Ministry of Health).164,165 Moreover, in some countries the private sector’s food safety systems are weak,166 and some countries privilege official control of food for export while food for domestic markets is neglected (e.g. food sold in East Africa local markets contained aflatoxin).167
It is important to bear in mind that lack of trust in inspection for local products, or lack of trust in the private sector’s food safety management systems, can deter consumption of nutritious and less expensive local products in favour of imported products (this was the case, for example, of infant foods in Western Africa).168 Coping with those challenges may not come without trade-offs. Compliance with new rules or processes may mean that the food industry will need to bear additional costs for ensuring the safety of their products, which will be passed on to consumer prices. This can reduce the affordability of nutritious foods – affecting poor producers and poor consumers disproportionately. Governments are, therefore, challenged to find the right balance between these two concurrent objectives. A first step to meeting those challenges could be to implement instruments such as FAO-WHO’s Food Control System Assessment Tool, which helps assess the effectiveness of, and better targets limited resources to strengthen, national food control systems – including modernization of inspection service.169
Infrastructure is essential to fostering dietary diversity, food availability, affordability and food safety. Appropriate infrastructure can increase both the quantity and quality of foods available in markets – especially for perishable foods such as fruits144 and fresh fish.170 This is needed to diminish food loss and waste, to reduce economic losses and pressure on the environment, and to build resilience in the face of climate change.y 75,171 Increasing infrastructure at all stages of the value chain also plays a central role in food safety. For example, proper and reliable drying and storage infrastructure is key to reducing carcinogenic mycotoxins (e.g. aflatoxins) in grain, nuts and related dry staple foods; capital-intensive cold chains that meet food safety standards are needed for the distribution of perishable aquatic food.172
Infrastructure is particularly important in countries that depend on access to markets, as well as for countries where the diversity of their food supply depends on their own production, and where post-harvest losses are very high.126,155,171 For example, in the case of food loss and waste, while in sub-Saharan Africa fruits and vegetables loss and waste during post-harvest, processing and distribution have been estimated at 35 percent, in Europe the same figure was estimated at 15 percent.173
Investing in irrigation, roads, technology for storage, low-input food preservation (such as solar drying) and sustainable cooling and electricity have proven to contribute to addressing those challenges and are becoming increasingly necessary due to erratic rain patterns and increasing temperatures.120,135,174 These investments, however, do not necessarily guarantee success in improving dietary diversity, affordability or access to healthy diets. For example, small-scale irrigation in Ethiopia and Tanzania did not improve nutrition,151 and although support to the fruit and vegetable value chains in seven African and Asian countriesz increased exports of those produce, it did not expand fruit and vegetable supply in informal markets.175
Therefore, infrastructure investment needs to be designed to reach rural and remote areas,155,156 growing urban areas, and needs to be adapted to the commodity and the context. For example, food loss and waste varies across products – especially perishable and non-perishable food (e.g. in Africa, losses for non-perishable crops typically range between 1.3 and 7.3 percent, while post-harvest losses for tomatoes, in Kenya, were around 28 percent).176 In terms of products, aquatic food may need the most attention in relation to reducing food loss, as about 35 percent of global harvest in capture fisheries and aquaculture is either lost or wasted every year.78 Furthermore, infrastructure investment may need to be accompanied by other measures such as extension services, support for food and agricultural marketing and promotion of nutritious foods, for rural financial services and, in some countries, subsidies to consumers to increase consumption of healthy diets.135,151 For example, interventions not only require infrastructure and advocacy about the benefits of reducing food loss and waste, but they should be accompanied by investments along food supply chains to ensure behavioural change.177
Public stockholding programmes include the costs of maintaining and managing reserves resulting from market purchase interventions, such as public procurement from farmers and reserves built for food security purposes (Section 3.1). This category does not, however, include public expenditure for buying food stocks. In some countries, these services are part of national food reserves for coping with food emergencies (e.g. food crises in 2007/08) and are considered by some an essential element of a prudent national security policy – particularly in countries facing famines or frequent exposure to shocks (e.g. droughts, floods and conflicts).71 These programmes, however, in some countries are also used to target price behaviour.178 Furthermore, product coverage has largely focused on staple foods, notably rice, wheat, or maize,179 which may skew production away from higher-value products and could be detrimental to diversifying domestic diets towards foods with higher nutritional value.71
Public stockholding success, on ensuring a country’s food security, has been found to rely on programme design. This includes organizational structure and reserve management, the procurement and release of food so it has minimal disruption to regular market functioning,178 and adoption of healthy public food procurement and services policies which support increasing the availability of nutritious foods and developing standards related to foods (e.g. regarding food high in fat, salt and/or sugar, etc.) 180 (see Section 4.2). Some countries are also looking into alternative market-neutral instruments to meet national food security objectives while being less costly and enabling diet diversity. For example, by developing the value chain of indigenous crops such as roots and tubers,178 or by providing cash to the food insecure.71
Food and agricultural marketing and promotion
Food and agricultural marketing (as defined in Section 3.1)aa includes services that are at the core of food environments (Figure 1), encompassing public and private participants involved in all the stages of a product value chain – from supply of inputs of farms to retail markets.181,182,183 For example, these services may include commodity grading schemes or agricultural machinery services. They may be services related to post-harvest losses, lowering transaction costs, facilitating market exchange and trade, and strengthening or expanding supply networks.151,183 Moreover, they can include services to facilitate the sale of nutritious foods in underserved areas,184 or the conservation, processing and other determinant factors for the profitability of products with special requirements such as perishable, bulky or indigenous commodities, among many others.
Food and agricultural marketing services can have an impact on healthy diets through several channels. These can enhance efficiency across the value chain and increase the number of suppliers but also the demand, a combined effect that can trigger competition without decreasing suppliers’ incomes, while providing lower prices for consumers.153,185 For instance, over the past decades cooperatives and producers’ organizations have been cornerstones on the production and sales of farm products.182,186 This has been the case for milk processing through farmers’ cooperatives in Nepal and Uganda which improved milk processing capacity and safety.187,188 In Ecuador, a platform of cooperation helped farmers to achieve higher yields and gross margins, while reducing the use of toxic pesticides, hence increasing supply of sustainably produced food.189
More recently, the food and agricultural sector has witnessed the rise of innovative channels of support adapted to the commodity, the systems of production, the culture and traditions of the producers, and the level of development of the country and the sector.189,190 For example, governments are enabling producers (including small farmers) to meet demand by funding digital innovations that help farmers find vehicles to move their fruits and vegetables to markets (India), and that help farmers add value to products otherwise lost, e.g. tomatoes into tomato paste in Malawi.191 In the European Union, producer organizations channel government support to fruits and vegetables and enable the development of short-food supply chains which, by easing the relation between producers, processors and consumers, are increasing food availability and reducing the price for consumers.192,193
Complementing these services is promotion, which includes activities to inform and reach consumers (e.g. promotion campaigns, participation in international fairs, activities promoting food quality). Services that promote nutritious food, including those that empower consumers to choose healthy diets, are important because the intake of foods that make up a healthy diet (Box 10), or changing consumption patterns, not only depends on price, physical accessibility and availability. Consumption decisions also depend on consumers’ preferences, on their knowledge about nutritious foods and the impact of unhealthy diets on long-term health, and on trust of products in the market 194,195 (not least, trust in the quality [food safety] of traditional/indigenous products). Empirical studies show a strong link between knowledge of nutrition and health (e.g. food-based information through social mass media) and nutritional outcomes.126,130 Furthermore, studies have found a strong association between an individual’s health status and the product promoted.196
For example, promotion of energy-dense foods high in fats, sugars and/or salt significantly increases consumption of these products, and this could led to deteriorating health.197 Although most studies about the effect of the promotion of products’ role in unhealthy diets on consumption have been conducted in HICs and MICs, similar results are predicted for LICs where the consumption of these foods is growing.198,199,200 In fact, in response to the harmful impact of such promotion, countries at the WHA agreed, in 2010, on recommendations to restrict the commercial marketing of foods and beverages of high energy density and minimal nutritional value to children.201 Policies that can create healthy food environments and help achieve healthy consumption patterns are discussed in Section 4.2.
Fiscal subsidies to consumers
Fiscal subsidies to consumers to enable access to food include instruments under social protection programmes (for end consumers) and food subsidies to lower the cost of food (provided to intermediaries). The latter includes transfers to commercial buyers (e.g. millers, processors) and other food value chain actors (e.g. transporters, storage service providers).202 Depending on their design and implementation, these transfers can contribute to food security and nutrition, and have the potential to improve access to healthy diets. These policy instruments are often implemented in the face of crises, economic shocks, policy reforms (e.g. repurposing), and can be part of the broader food and agricultural policy setting.
Food subsidies, unlike the output or input subsidies discussed in the sections above, have the primary objective of making food more affordable and available to consumers. These usually target certain population groups and comprise specific food items.203 For instance, Canada provides food subsidies to wholesale distributors sending perishable foods by air to remote communities, which has reduced the cost and increased the availability of nutritious foods for families in the beneficiary communities.204
Evidence shows that food subsidies that target specific nutrients and nutritious foods in HICs can improve the nutritional status of beneficiaries, but only during the period the subsidy is implemented and the beneficiaries are effectively receiving the subsidy.204 The same study suggests that if the subsidy is designed to have long-term impacts (e.g. by implementing this over long periods), it would allow for sustained changes in dietary patterns and could potentially reduce the prevalence of NCDs in adults.126 In the case of LICs and MICs, studies find that in most countries large-scale food subsidies are directed towards staple foods;96,205,206 this is the case, for example, of the food subsidy that targets rice consumption in India.207 The same studies also revealed that these subsidies have a limited contribution, or no contribution, to improving access to nutritious foods and healthy diets.
Transfers under social protection programmes, which are intended and designed to improve the affordability of food, include in-kind food transfers, food vouchers and cash transfers, and are implemented alone or through a mixed modality. While the impact of these transfers in reducing malnutrition and increasing access to healthy diets are context specific, an increasing amount of evidence reveals several common patterns, namely:
Transfers to consumers that are explicitly designed to have nutritional impacts – i.e. through nutrition-sensitive social protection programmes208 – can increase the consumption of nutritious foods.209 Hence, nutrition considerations must be at the core of the design of any transfer aimed for food security and improved nutrition. This can be accomplished, for example, by ensuring that in-kind food transfers – or other transfers – include nutritious foods and/or fortified staple foods.210 Transfers could also be accompanied with food and nutrition education129,211 which has been the common success factor that helped increase the consumption of nutritious food. For example, Cabo Verde’s in-kind transfer part of its school feeding programme includes diverse nutritious foods (fruits, vegetables, beans and fish) for schoolchildren, and nutrition education for teachers, school staff and cooks.208
Subsidies targeting specific population groups, or the consumption of specific foods that are associated with a specific health policy target (e.g. anaemia reduction), yield better outcomes. Targeting subsidies towards vulnerable households or individuals, such as the lowest income earners or the nutritionally vulnerable, for example, nutrition-specific interventions such as micronutrient supplements (e.g. iron, folic-acid), can enhance the health state of a population as it can improve the nutrition of those who may only have access to healthy diets through social protection programmes, and thus expand the number of individuals with adequate nutritional status.208,212 Thus, targeting subsidies can contribute to reducing fundamental social inequities between low- and high-income consumers which often prevent families from adopting healthy diets and accessing basic services such as health. On the contrary, subsidies to everyone can leave behind the most in need and widen health inequality gaps.129,208 Furthermore, transfers with the specific objective of increasing access to nutritious food (e.g. equivalent to a price reduction of 10–30 percent in fruits and vegetables),180 and especially when accompanied by a food tax (e.g. for sugar-sweetened beverages),213 are expected to bring health benefits such as reduction of deaths from cardiovascular diseases and cancer.214
The implementation of these transfers can be challenging. This is the case when the subsidy does not reach all eligible households, reaches households outside the criteria for inclusion, and has insufficient availability of product variety – especially in LICs that rely heavily on cereals,127 suffer shop closings, or where the programme is affected by corruption (e.g. public officials charged with distributing subsidized grain sell it instead).130,165,215 Tackling these issues is not only important to meet the objectives and ensure sustainability and cost effectiveness of social protection programmes, but also to ensure that these programmes are strong enough to be expanded or adapted – in a timely manner – in the face of shocks and crises.208
Appraisals on the impact and cost of social protection instruments suggest that in areas where there is adequate market functionality, cash transfers could be delivering dietary diversity, and thus micronutrients, more efficiently than in-kind transfers could. 202,211 Evidence also shows that household savings resulting from in-kind transfers are often not used to buy food,209 and in-kind transfers cost nearly three times more to implement than other programmes.211,216 However, in-kind transfers remain essential in remote areas where markets do not function well, have proven to have positive impacts on children’s nutrition through school-feeding programmes, and can also be designed to fill a population’s existing nutrient gaps through, for example, delivery of nutritious foods or of fortified foods.217 For these reasons, in many cases, a mixed approach may bring better outcomes.202 For example, Pakistan’s programme for pregnant and breastfeeding women and children 6–23 months of age provides cash transfer and nutritious foods conditional on their utilization of health and nutrition services.218
Countries are currently exploring multifaceted and innovative approaches in order to enhance the efficiency of subsidies. Specifically, they seek to increase access to nutritious foods and improve dietary diversity in combination with: i) enhancing knowledge, skills and practices; ii) facilitating access to services (health, nutrition, water, etc.); and iii) linking the intervention with an economic activity.219 For instance, in Chile the government developed a digital application to facilitate access to nutritious foods for vulnerable populations, while supporting small local producers and markets.220 These and other new approaches need to be considered in repurposing food and agricultural policy support strategies as further discussed in Section 4.2.
In summary – the challenges and potential policy pathways
Food and agricultural policies affect consumer and food-industry decisions by affecting the availability and affordability of food across all stages of the value chain, from primary production to final consumption, and are interlinked with other systems, such as the health system and the environmental system (see Figure 1). Policies can lead to unbalanced diets that contribute to NCDs when they directly or indirectly encourage production of energy-dense, nutrient-poor monocultures, discourage consumption of nutritious foods (Box 10) or make energy-dense foods high in fats, sugars and/or salt more affordable.199,221
To shift consumption patterns towards healthy diets, and for the food industry to replace harmful inputs such as transfats with nutritious inputs, it is necessary to increase the supply of nutritious foods, to lower their costs to competitive levels, and to implement nutrition-sensitive strategies targeted at both consumers and producers. Thus, fiscal subsidies, trade and market interventions, and GSS need to be analysed for their effects on food supply, prices and consumer choices, and to be tailored to country-specific contexts in order to inform necessary reforms and to ensure well-coordinated multilateral actions (see Chapter 4).
Over the past decades, to improve national food security and support farmers, public support has been highly concentrated on the production of and access to the world’s most consumed staple foods, like rice and wheat, but also sugar, oil, meat and milk (Figure 22). Less support has been provided to foods with higher nutritional value, such as vegetables, fruits and pulses, or indigenous commodities providing the much needed nutrients particularly important in underserved areas. In terms of border measures, governments should strive to reduce barriers and facilitate trade in order to foster the diversity and affordability of nutritious foods, while ensuring that safety of traded food is not undermined. Such changes in border measures could be accompanied by fiscal measures, such as domestic taxes on products high in fats, sugars and/or salt, which are preferable to import tariffs because they affect the overall consumption of a food, not only imported food, and are consistent with WTO rules. Similarly, some forms of market price controls are subject to multilateral trade rules and their implications for affordability of healthy diets need to be analysed carefully before undertaking any policy changes, considering country specificity.
Fiscal subsidies to producers and GSS must include carefully designed mechanisms for implementation and targeting if these are to enhance greater diversity and increase supply of nutritious foods, especially in LICs and LMICs where productivity is still lagging behind and where important gaps exist in the provision of such services. These mechanisms must also ensure that nutritious foods and inputs – whether these are sourced from domestic or international markets – can reach all population groups, especially the most vulnerable, among which are women (Chapter 2). For example, support to producers of nutritious food can be accompanied by nutrient-sensitive social protection programmes and support of food safety and commercialization of neglected and underutilized species that are closer to remote areas. The potential pathways that countries can adopt to make the most of repurposing their policies are discussed in Chapter 4.