Influencing Food Environments For Healthy Diets, Summary

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ACKNOWLEDGEMENTSThe Nutrition and Food Systems Division of FAO is grateful to the Government of Italy for its financialsupport in the preparation and printing of this document.4

INFLUENCING FOOD ENVIRONMENTS FORHEALTHY DIETSINTRODUCTIONFood environments are usuallydefined as the settings withall the different types offood made available andaccessible to people as theygo about their daily lives.That is, the range of food insupermarkets, small retailoutlets, wet markets, streetfood stalls, coffee shops, teahouses, school canteens,restaurants, and all the othervenues where people buy andeat food. These environmentsdiffer enormously dependingon the context. They can beextensive and diverse, with aseemingly endless array ofoptions and price ranges, orthey can be sparse, with veryfew options on offer. Becausethey determine what foodconsumers can access ata given moment in time, atwhat price, and with whatdegree of convenience, foodenvironments both constrainand prompt the consumer’schoice.Food environments areinfluenced by the foodsystems which supply them,and vice versa. Food systemsencompass the entire rangeof activities, people andinstitutions involved in theproduction, processing,marketing, consumptionand disposal of food(FAO, 2013). They includebut are not limited to foodsupply chains. Making foodsystems nutrition-sensitive cancontribute to addressing allforms of malnutrition, as foodsystems determine whether thefood needed for good nutritionare available, affordable,acceptable and of adequatequantity and quality. Howclosely food systems and foodenvironments are interrelatedand interdependent, andthe degree to which externalfactors affect nutritionoutcomes, varies from settingto setting.Many of today’s food systemsand food environments arechallenged in supportingconsumer choices that areconsistent with healthy dietsand good nutrition. Consumersare not making choices basedon nutrition and health, andpoor diet is now the numberone risk factor for deathand disability worldwide(GBD, 2015). Food systems thatdo not enable healthy dietsare increasingly recognizedas an underlying cause ofmalnutrition (GLOPAN, 2016),and malnutrition, irrespectiveof form, has a huge cost.Economic costs associatedwith undernutrition areestimated at 1-2 trillion peryear, about 2-3% of globalGDP (FAO, 2013); the globaleconomic cost of obesityand associated diet-related5non-communicable diseasesis estimated at 2 trillion peryear, about 2.8% of global GDP(McKinsey, 2014). Influencingfood environments forpromoting healthy diets is anemerging strategy to addresstoday’s nutrition challenges.LINKING FOODSYSTEMS, FOODENVIRONMENTS,AND DIETSFood systems also involvethe people and institutionsthat initiate or inhibit changein the system as well as thesocio-political, economic andtechnological environmentin which these activities takeplace (FAO, 2013).1Food systems are shapedby culture and consumerpreferences, as consumerdemand affects supply.The values and beliefsunderpinning people’schoices, influence what kinds1The High level Panel of Experts (HLPE)definition of food systems also includessocioeconomic and environmentaloutcomes of food systems: A foodsystem gathers all the elements(environment, people, inputs, processes,infrastructures, institutions, etc.) andactivities that relate to the production,processing, distribution, preparationand consumption of food, and theoutputs of these activities, includingsocioeconomic and environmentaloutcomes. (HLPE 2014)

of food are produced and howthey are processed, procured,and eaten. Food choices,however, are also shaped byfood systems. The relationshipis bi-directional. This two-waystreet is best viewed atconsumer level via foodenvironments, which are oftendescribed as the “interface” or“link” between food systemsand diets.Herforth and Ahmeddescribe food environmentsas the range of food whichare available, affordable,convenient and desirableto people in a given context(Herforth and Ahmed, 2015),while Hawkes et al. describethe concept as comprised ofthe everyday prompts whichnudge consumers’ foodchoices in particular directions,and which contribute todietary habits and preferenceswhich can have long-termimpacts, especially in children(Hawkes et al., 2015). Both ofthese definitions trace a cleartrajectory from food systemsto food environments to dietchoices, with implications fornutrition.Figure 1 provides a conceptualframework for explaining theseand related links between foodsystems, food environments,consumer choices and diet.Four food supply subsystemscomprise the entire “farmto fork” food chain, namelyagricultural production; foodstorage, transportation, andtrade; food transformation; andfood retail and provisioning.These subsystems influencethe food environments inwhich people make theirdietary choices.How each subsysteminfluences food environmentsincludes but is not limited to: Agricultural productionsubsystems: may affect foodavailability and relativeprices via investmentagendas, for example byprioritizing a small number ofstaple cereals over legumes,indigenous grains, and othercrops. Food storage andtransport subsystems:may encourage or restrictdomestic availability ofaffordable, nutrient-densefoods through export andimport policies or influencetoxin and pathogen-bornecontamination through foodsafety regulations.Figure 1: Conceptual Framework for the links between food systems,food environments and diet qualityDrivers of food systemssuFoodAgriculturalproductionsubsystempply systemFood storage,transport andtrade subsystemFood environmentConsumerNutrientquality &taste ofavailablefoodPhysicalaccessto foodFood retail Food priceSource: GLOPAN, ubsystem

Food transformationsubsystems: may increaseavailability of nutritiousfoods through fortificationand limited processing (e.g.canning), or may reducethe nutrient content of foodthrough heavy processing(e.g. extrusion and additionof free sugars). Food retail subsystems:may increase or reduceavailability of highlyprocessed food relative towhole, nutrient dense foodsthrough food promotion.(Adapted from GLOPAN,2016).Food environments mitigatethe impact of thesesubsystems on the choiceand quality of diets of theindividual through a varietyof factors, including foodlabelling, promotion, pricing,physical access, and nutrientquality and taste of food.Improving alignment betweenall these components – thefour food subsystems andvarious food environmentfeatures is key to reformingthe food system, with theunifying objective being togive better support to foodchoices that are consistentwith healthy diets. As such,food environments supportinghealthy diets can be definedas those that make suchdiets available, affordableand appealing to people,with healthy diets themselvesdefined as: Adequate, comprisingsufficient food for a healthylife. FAO/Asif Hassan Diverse, containing a varietyof food, including plentyof fruits and vegetables,legumes and whole grains. Low in food componentsof public health concern:Sugars and salt consumedin moderation (with all saltiodised) and fats beingunsaturated rather thansaturated and trans fats.Additionally, according to theWorld Health Organization(WHO), the hallmarks of ahealthy diet are abundant,diverse plant foods, limitedor no highly-processed foodssuch as sugar-sweetenedbeverages and processedmeats, and an appropriateconsumption of othernutritious foods aligned withdietary needs for a particularstage in life (WHO, 2015).7High-quality diets also need tobe safe so they do not causefood-borne diseases.This summary providesproposals for influencing foodenvironments for healthy dietsusing production diversity,food safety, food labelling andfood-based dietary guidelinesas possible entry points. It isimportant to note that theopportunities for influencingfood systems and foodenvironments are enormousand largely un-investigated.Readers are referred to thefull on-line publication on“Influencing food environmentfor healthy diets” for detaileddiscussion on the topic(

INFLUENCING FOOD ENVIRONMENTS FORHEALTHY DIETS THROUGH THE PRODUCTIONOF DIVERSIFIED FOODSINTRODUCTIONA core aspect of foodenvironments is the range offood people have availableto them. This availabilityreflects an often extensivearray of processes thatoccur upon leaving the farmgate. However, agriculturalproduction is the necessaryprecursor. Agriculturalproduction influences the foodenvironment directly throughaffecting availability, qualityand affordability of food atlocal and global markets, andindirectly through incomegeneration, social structures,and environmental change.The following briefly discusseshow production of diversifiedfoods can contribute to ahealthier food environment.ACHIEVINGHEALTHY FOODENVIRONMENTSHow does agricultural foodproduction at a globallevel match up with dietaryrecommendations? Theprimary recommendation offood-based dietary guidelinesand diet quality measures is forfood environments to enablea diverse diet that includesfruits and vegetables, legumes,nuts and whole grains. Yetthe current global availabilityshows that production systemsfail to meet nutritional needseven before issues of access,affordability and acceptabilityare considered.The good news is that fruitand vegetable production- especially fruit - has beenincreasing worldwide sincethe 1960s. Legumes have alsobeen increasing steadily sincethe 1980s, following a decadeof decline in productionin 1960s-70s. However, justbecause a particular foodis available, it does notguarantee their acceptanceor appeal by the market northat consumers can affordthem. Therefore, there needs tobe a global dialogue on howto increase the availability offruits, vegetables and legumeson the one hand, and theiraffordability, acceptability andappeal on the other.There is tremendous variationin the type of food madeavailable within a country.At this level, both trade andproduction, become importantbecause national availabilityreflects what is produced,exported and imported, as wellas wasted or used for non-foodpurposes.Countries can grow foodthat are not found in theirdiets or import them, or both.In low-income countries,increasing production diversity8typically boosts the diversityof national food availability.In Nepal, for example, whenthe production diversityincreased, it led to greaterdiversity of national foodavailability. However, asincomes increase, it typicallyresults in a “decoupling”between production andsupply, and trade has agreater influence on nationalsupplies. For example, inChina, as production diversityof vegetables increased, itdid not translate into greatersupply diversity becauseof exports. In Malaysia,production diversity droppedas a result of shifting land tomono-cropping and reducingmixed farming systems, butsupply diversity neverthelessincreased thanks to greaterimports. Increasing the diversityof food availability thereforeinvolves paying attention toboth production and tradepolicies.Policy-makers also need topay attention to what makesup the diversity. More diversitydoes not necessarily translateinto wider nutritional diversity.Importing wheat or rice, forexample, may compensatefor less national diversity but it may not compensatefrom a nutrition perspectiveif locally produced grainsare more nutritious. In fact,modern trade policies have

INFLUENCING FOOD ENVIRONMENTS FOR HEALTHY DIETSSUMMARYtended to introduce morehighly-processed foods thatare high in fat, sugars and salt,which is counter to what isrecommended by food-baseddietary guidelines.Countries with more opentrade policies are more likelyto have food environmentsthat are characterised byultra-processed foods anddecision-makers may haveto put policies in place tomitigate the risks of unhealthyfood environments.THE ROLE OFAGRICULTURALMARKETSAgricultural markets - whichtake food from farm to retail influence if and how the foodproduced by agriculture FAO/Alessia Pierdomenico9makes its way into foodenvironments locally, nationally,regionally and globally. Todate, efforts to strengthenmarkets in low-income settingshave tended to focus on majorstaples and cash crops. Toimprove food environments,more attention is neededto build strong markets thatdeliver a diversity of morenutritious food products tolocal, rural-urban and global

food environments. At alocal level, well-functioningmarkets can ensure thatlocally-produced food boostsdiversity in the local foodenvironment. At a regionalscale, strong markets canensure that people haveaccess to local nutritiousproducts like green leafyvegetables. At a global scale,strong markets mean that theglobal population has accessto nutritious products thatare only produced in specificareas.In practice, strengtheningmarkets often goeshand-in-hand withincreasing specialization ofproduction. While this canboost agricultural yield andeconomic growth, evidencefrom some countries (e.g.Ethiopia and Tanzania) provesthat, where people are relianton local markets, reducingproduction diversity can leadto lower diet diversity. In theseregions, then, agriculturalpolicies and programmesneed to balance specializationand diversification in tandemwith strengthening TIONNot every farmer can or shouldgrow everything. To ensure thatfood environments provide adiversity of nutritious foods ina sustainable way, we need FAO/Marco Longari10

to address how to balancespecialization, mainly forincome, with diversification, fornutrition, environment and riskmanagement. The followingare four potential approachesto enable diversificationalongside specializationtowards healthier foodenvironments.Innovative gardenapproachesDiversified home, institutionaland community gardensare gaining new traction inrural, peri-urban and urbansettings. They often serve asan affordable source of freshvegetables, fruits, and smallstock animal-based products,but also as an educational,social, health, and/orsustainability intervention(e.g. a rooftop garden with anisolation and energy-savingfunction).Mixed or integratedfarming systemsAgriculture has multipleobjectives; from increasingincome to producing food, tomanaging land, to mitigatingand adapting to climatechange. Therefore, smartagricultural managementis crucial to ensure thatagriculture contributes to ahealthier food environmentin a feasible and compatiblemanner with other goals.In mixed or integrated farmingsystems, this is exactly whatfarmers do. They combine11different agricultural practicesand commodities for multiplereasons simultaneously. Thesecan range from controllingpests and diseases, tooptimizing use of inputs (land,nutrients, water), to producinga diversity of products forconsumption and bringingthese products to markets, tominimizing risk and copingwith seasonality. A noteworthyexample is found in floodedrice paddies that are alsoused as fish ponds, providinghouseholds with protein andrice fields with organic matter.Other similar examples includefallow fields that are used forgrazing and provide sources ofmilk and dung and tree cropsthat are intercropped withbeneath-canopy subsistencecrops for soil fertility, fruits, andforage.Several factors currently limitthe scale and potential ofthose systems. Mixed systemsare often knowledge andlabour intense. They needfunctional market linkagesfor several commodities andhave smaller conventionalyields, and as such areconsidered less productivein the short-term. Incentivesthat address those constraintsand support mixed farmingsystems can enhance notonly the health but also thesustainability of our foodenvironments.

Genetic resourcemanagementPlant and animal geneticresources underpin fooddiversity. Managing thosegenetic resources, in termsof conservation and accessfor use and innovation,is crucial for creating anenabling environment for foodproduction diversification.Community seed bankssafeguard and create optionsfor diversification and futureuse.Strengthening valuechains for multiplecommoditiesMost investments aimed atstrengthening value chainsin low-income settings, havefocused more on value chainsof major staples and cashcrops, and less on facilitatingthe diversity of more nutritiousfoods to penetrate marketsor on making them moreaffordable and desirable toconsumers.Two recent examples thattake a holistic approach tostrengthening value chainsinclude:i. Harnessing entrepreneurialideas for nutritious food inthe marketplace throughthe Global Alliance forImproved Nutrition (GAIN).The marketplace empowerslocal social entrepreneurswith promising ideas onseed funding, businesscapacity and networkingthat would widen theaccess of nutritious food inlocal markets. The selectionof ideas goes through apeer-review, where localentrepreneurs submittheir ideas to a regionalmulti-stakeholder committee.ii. Multiple chain approachessuch as linking farmers withschool meal programmesor retailers for a diversity ofproducts through improvingcold chains in remotesettings would improve thelivelihoods of farmers whileguaranteeing nutritiousmeals for school children.CONCLUDINGRECOMMENDATIONS Monitor trends in diversity ofnutritious foods in the foodenvironment, in agriculturalproduction and trade toidentify key leverage pointsfor action. Address the overall shortagein availability, affordabilityand acceptability invegetables, fruits, legumesand nuts. FAO/Ruth Charrondiere12

FAO/Oliver Bunic Enact policies that helpmanage the balancebetween agriculturalspecialization anddiversification, includingthose policies that: Formulate complementarypolicies to mitigate therisks of trade policiesto unhealthy foodenvironments.For detailed discussion of thistopic, refer to the full on-linepublication on “Influencingfood environments forhealthy diets” (available strengthen local marketsfor nutritious foods-- create greater coherencebetween domesticagricultural policy, tradepolicies and policies topromote healthy foodenvironmentsBox 1: Production of diversified foods - key messages-- support initiatives thatenable diversificationalongside specializationsuch as innovative gardenapproaches, mixedfarming systems, geneticresource management,and multi-chainapproaches. Balancing specialization and diversification in agriculturalproduction is key to ensure that food environments provide adiversity of nutritious foods and are sustainable. Current availability at a global level indicates that productionsystems are failing to meet the nutritional needs of people evenbefore issues of access, affordability and acceptability areconsidered. There is a need to produce and increase access anddemand for more vegetables, fruits, legumes and nuts. To do so governments, public and private actors should:1) strengthen local markets for nutritious foods, 2) creategreater coherence between domestic agricultural policy, tradepolicies and policies that promote healthy food environments,3) support initiatives that enable diversification such as innovativegarden approaches, mixed farming systems, genetic resourcemanagement, and value chains that benefit multiple commoditiessimultaneously.13

INFLUENCING FOOD ENVIRONMENTS FORHEALTHY DIETS THROUGH FOOD SAFETYINTRODUCTIONThe food environmentinfluences people’sconsumption choices andnutritional status. Foodsafety issues can affecthealth directly by makingpeople sick (primary diseasepathway resulting fromhazard ingestion). Theycan affect health indirectlywhen food scares leadpeople to change their foodconsumption behaviour (foodfear pathway). This can leadto additional indirect effectssuch as a drop in incomes ofworkers in agri-food chains,or a reluctance to offer foodthat is perceived as risky. Athird pathway is the effectsof disease control attemptson food and nutrition security(disease control pathway),either by condemning unsafefood or by controlling animalhosts, which can lead tocurbing the availability of aparticular type of food.Food-borne diseases (FBD)can be defined as anyillnesses caused by ingestingcontaminated food ordrink. The most commonclinical presentation isgastrointestinal symptoms,but FBD can also lead tochronic and life-threateningconditions includingneurological, gynaecologicalor immunological disordersas well as multi-organ failure,cancer and death. Illness mayalso cause the malabsorptionof nutrients or other effectsthat impair nutritional statusof the individual. Worldwide,millions to billions of casesof FBD occur each year ofvarying severity.The first global andcomprehensive estimate ofFBD was published in 2015.The report found that FBDhad been currently greatlyunderestimated and thatmost FBD are due to microbialpathogens and food-borneparasites (rather thanchemical hazards); and thatthe highest burden of FBDfalls on developing countries,with the highest incidences inAfrica. However, there is greateruncertainty about the healthburden of chemical hazards.GROUPS MOSTVULNERABLE TOFBDCertain groups are morevulnerable to FBD. Thesegroups can be summarisedby the acronym YOMPI, thatis, the Young, the Old, theMalnourished, the Pregnantand the Immunosuppressed.In developing countries, thereare important interactionsbetween malnourishmentand FBD. One multi-country14study found 25% of stuntingwas attributable to repeatedepisodes of diarrhoea. Eachadditional episode in the first24 months of life, increases therisk of stunting by roughly 5%.FBD has important implicationson women’s resilience andvulnerability. For example,pregnant and lactatingwomen are especiallyvulnerable to a range ofFBD, especially listeriosisand toxoplasmosis. Culturealso affects the relativeconsumption of risky food.In some countries, womenconsume more low-valueoffal and men, more highvalue muscle meat. Offalconsumption has beenfound to be a risk factor fordiarrhoea. In Africa, menhave more access to meatbecause they eat in barsthat serve meat and alcohol.Consumption in these placesis associated with increasedrisk. A similar pattern is seenwith fish-borne diseases inChina, Vietnam and Korea.TRENDS IN FBDMost FBD are caused bypathogens. Recently, therehas been an overall sharp fallin infectious diseases, whilenon-communicable diseases,and especially diseasesassociated with overweightand obesity, have seen an

INFLUENCING FOOD ENVIRONMENTS FOR HEALTHY DIETSSUMMARYupward trend. From thisperspective, we might hopefor a decline in FBD. However,countries and regions withgood data on FBD (EuropeanUnion and United Statesof America) have seen nochange or deterioration inthe number of cases of most(but not all) FBD over the lastdecade.FOOD SAFETY ANDHEALTHY FOODENVIRONMENTSmore expensive than stapleThe following outlines thecritical role that food safetyplays in ensuring a healthyfood environment.control methods involve the1. Food availability: Most FBDmay also motivate changesfoods. FBD can reduce foodavailability if contaminatedfood is destroyed and ifculling of animals. The lattermay also reduce farmerincomes. Concern over FBDresult from consuming freshin agri-food systems, resultingmeat and vegetables, whichin lower availability of fresh,are more nutritious and oftenlocally-produced andunprocessed food. FAO/Giuseppe Bizzarri15

2. Food scares: Hazards3. Food standards: Foodfood safety is less common,associated with food scaresstandards have an important,and not likely to influenceare not a major cause ofbut not decisive, influence onhealth either through theillness and death, becausereducing FBD in developeddisease or nutrition pathway.typically only dozens orcountries (where privateThere are economic andhundreds of people arestandards are increasinglysocial challenges to usingaffected. The burden ofimportant). In developingthis strategy for promotingendemic FBD takes a muchcountries there is often littlefood safety.higher toll on the population.compliance with standardsHowever, food scares haveand thus their impact iscountries, modern retaila potentially larger effectdifficult to generally associated5. Retail: In developedon health through nutrition4. Public information: Inpathways because millionscontrast to provision ofwhich tends to create anof people may change theirnutritional information,unhealthy food environment,diets as the result.provision of information onbut as a general rule, is safe.with more processed food(Some types of retail arealso associated with higheravailability of fresh food.)In developing countries,modern processed foodappears to be less safe thanits equivalent in developedcountries, while the relativesafety of food from modernretail and traditional isunclear.6. Household production:Ensuring the safety of foodthat is grown and consumedby farm household is verychallenging. There are tradeoffs between encouraginghealthy food environmentsthrough increasinghome production of freshvegetables and animalsource foods and ensuringall food consumed byhouseholds is safe. FAO/Tang Hongwen16

FAO/Alessia Pierdomenico7. Provision of foodprogrammes such as schoolmeals or food for work:these programmes have thepotential to make greatercontributions to attainingfood safety and a healthyfood environment eventhough there are tradeoffs, such as food whichis highly nutritious andpalatable may also be moreexpensive with a higher risk ofcontamination.8. Trade: The relationshipbetween attaining foodsafety and a healthy foodenvironment throughtrade is a complex one. Indeveloping countries, tradedfood is generally safe butmay be more processed andless nutritious as a result.RECOMMENDATIONSFOR IMPROVINGFOOD SAFETY A “farm to fork” approachis best for identifyingcontrol points. An importantprinciple of food safetymanagement is that risksmust be managed alongthe “farm to fork” pathwayand that some risks are mosteffectively managed on thefarm. The United Kingdom,Iceland and Denmarkdramatically reducedpathogens found in foodproduction by stringentcontrols along the valuechain, with an emphasison reducing disease in theanimal reservoir rather thanin the retail product. Risk-based approachesrather than hazard-basedones. Studies from17developing countries showthat hazards are commonlyfound in food but the risk ofthis occurring is not alwayshigh. For example, milk inKenya is often contaminatedwith bacteria but becausemore than 99% of milk isboiled, the risk to consumersis not necessarily high.Focusing on risk to humanhealth, rather than presenceof hazards allows for betterallocation of resources. Where the informalsector predominates,professionalize don’tpenalize. In developingcountries, “farm to fork”approaches are lessapplicable. However,successful approaches havecombined capacity buildingof the informal sector withthe provision of incentives tofurther motivate behaviour

change. For example, untilthe late 1990s street foodsvending in South Africawere perceived as unsafeand most decision-makerswanted it outlawed. Publicopinion shifted thanksto a combination ofevidence, policy advocacyand programmes toimprove hygiene. As aresult, improved streetfood vending to supportlivelihoods and nutritionwas supported and wellperceived by all. Encourage the uptake ofappropriate technology.Where value chain actorsare not using food safetytechnologies, simpleinnovations such as foodgrade containers orchlorinated water can resultin substantial improvementsto food safety and quality. Improve food safetygovernance. Manygovernments in developingco

with healthy diets. As such, food environments supporting healthy diets can be defined as those that make such diets available, affordable and appealing to people, with healthy diets themselves defined as: Adequate, comprising sufficient food for a healthy life. Diverse, containing a variety of food, including plenty

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