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Redirecting The Diet Transition: What Can Food Policy Do?: Lawrence Haddad

This article discusses the changing diets in developing countries as incomes rise and populations urbanize. People are consuming more calories, fats, sugars and salts, leading to issues of "over-nutrition" like heart disease and diabetes, in addition to persistent under-nutrition problems. The drivers of these diet changes include rising incomes that cause people to consume more animal products, processed foods and sugars. Food prices have also changed due to technology and policies, making unhealthy foods relatively cheaper. Urbanization concentrates advertising and encourages consumption of prepared foods outside the home. The article examines what food policies around production, marketing, retailing and consumption could help redirect diet changes towards better health outcomes.
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0% found this document useful (0 votes)
32 views16 pages

Redirecting The Diet Transition: What Can Food Policy Do?: Lawrence Haddad

This article discusses the changing diets in developing countries as incomes rise and populations urbanize. People are consuming more calories, fats, sugars and salts, leading to issues of "over-nutrition" like heart disease and diabetes, in addition to persistent under-nutrition problems. The drivers of these diet changes include rising incomes that cause people to consume more animal products, processed foods and sugars. Food prices have also changed due to technology and policies, making unhealthy foods relatively cheaper. Urbanization concentrates advertising and encourages consumption of prepared foods outside the home. The article examines what food policies around production, marketing, retailing and consumption could help redirect diet changes towards better health outcomes.
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Development Policy Review, 2003, 21 (5-6): 599-614

Redirecting the Diet Transition: What Can Food


Policy Do?
Lawrence Haddad∗
The diets of consumers in the developing world – rich and poor, rural and
urban – are changing. More calories, saturated fats, added sugars and
added salts are being consumed, resulting in ‘over-nutrition’. Combined
with lower physical activity levels these changes are causing increased
levels of chronic diseases such as heart disease and diabetes. However, the
shifts are taking place in the presence of persistent under-nutrition
problems, creating a co-existence of under- and over-nutrition. This article
identifies the drivers of these changes, and asks what food policy (including
policies directed to production, marketing, retailing and consumption) can
do to re-direct the changes towards better health. The policy trade-offs
inherent in the co-existence of under- and over-nutrition are highlighted.

Where good data on food consumption are available they show that the availability and
intake of foods that are risk factors for chronic diseases – such as cardiovascular
disease, diabetes, and some forms of cancer – are increasing rapidly in both urban and
rural areas and across all income groups in developing countries. Increases in
overweight and obesity rates in the developing world show similar patterns (see Popkin
1998, 2001; Guo et al., 2000a). The co-existence of a double burden1 of under-nutrition
and ‘over-nutrition’2 adds to human suffering and economic costs (see Popkin et al.,
2001 for estimates of these costs for some Asian countries). It also complicates the
design of food policy.
What can food policy do to redirect the transition in diets towards healthier
outcomes? This article reviews the drivers of changes in diet and then reviews the
potential of both demand- and supply-side food policy options to influence the drivers.


Director, Food Consumption and Nutrition Division, International Food Policy Research Institute,
Washington, DC ([email protected]). He wishes to thank Mary Arimond, Marie Ruel, Amalia Waxman,
Rajul Pandya-Lorch and seminar participants at IFPRI, WHO, OECD, Cornell University and USDA/ERS
for their many helpful comments and suggestions on this article. All errors are the author’s.
1. See WHO website (www.who.int/nut/db_bmi.htm) for data on the population co-existence of underweight
and overweight and see Garrett and Ruel (2003) for the co-existence in the same household.
2. In a scientific sense the term ‘over-nutrition’ lacks consensus. In this article we use the term as useful
shorthand for excess consumption of added sugar, processed meats, red meats, starch from refined grains
and potatoes, dairy products, trans isomers of fatty acids (found in partially hydrogenated vegetable oils
found in some margarines and shortening), saturated fat, cholesterol, and overall calories – no matter the
source – which leads to overweight and obesity. The term over-nutrition is problematic in that it focuses
on excess consumption of some diet components, but what is displaced from the diet by these unhealthy
foods matters as well. In particular, the consumption of fruits and vegetables, nuts and pulses, poultry and
fish, healthy oils and fats, and whole grains are thought to be health-promoting and increased intakes
should be encouraged (see WHO/FAO, 2002; Willett and Stampfer 2002; McCullough, 2002).
 Overseas Development Institute, 2003.
Published by Blackwell Publishing, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.
600 Lawrence Haddad

The article ends by highlighting the difficult challenges posed to food policy design by
the co-existence, linkages and trade-offs between under- and over-nutrition.

Drivers of diet and nutrition trends

The drivers of consumption trends include (a) income growth, (b) changes in relative
prices caused by technological, institutional and policy change and (c) the socio-
economic and activity changes associated with urbanisation.

Income growth

We know that as income grows, consumers want to diversify out of cereals and other
starchy staples. Data from USDA (Regmi, 2001) on how food expenditure responds to
increases in income (food expenditure-income elasticities) across a number of
developing countries show that the poorest countries have the highest elasticities. Fish,
then dairy and then meats have the highest values followed by fruit and vegetables, oils
and fats and lastly cereals. Elasticities may increase in the short term; for example, data
from China (Guo et al., 2000b) show that the income elasticities for pork and oil
increased between 1989 and 1993, more so at the lowest income levels, especially for
edible oil.

Relative prices

Basic economics tells us that if the relative price of a foodstuff increases, demand for it
will decrease. How have the relative prices of different foodstuffs changed over time?3
In the United States, the relative prices of dairy products, fats and oils, eggs, meat,
poultry and fish, and sugar and sweets have dropped dramatically over the period 1982-
97, as has the price of non-alcoholic beverages (dominated by carbonated sweetened
soft drinks) (Putnam and Allshouse, 1999). Future projections of the internationally
traded prices for non-staple non-fruit and non-vegetable goods, whenever available,
indicate a further decline in their prices relative to cereals (Delgado et al., 1999).4
More analyses need to be undertaken from a health perspective of past trends in
producer and retail food prices. For example, we do not have consumer food price
trends by fat content or, even better, by type of fat content. Such trends would help
identify the main sources of any decline or increase in the price of fat or added sugar –
obviously important for policy formulation. In addition, there need to be more studies
linking price trends to health outcomes. There are many linking under-nutrition
outcomes to price changes (for example Pitt and Rosenzweig, 1986), but few linking

3. One price that we do not examine here is the wage rate, which has risen for occupations that tend to be less
physically demanding. This, of course, is the other side of the coin, but one which, for now, we ignore
with respect to what food policy can do.
4. Preliminary simple regression analysis of FAOSTAT’s producer price series (no retail prices were
available) for Nigeria, South Africa, India and China did not demonstrate any significant systematic
differences in relative price increases by food category, with the exception of China where oils low in
saturated fats (soybean, sunflower, rapeseed, and sesame seed) posted significantly higher price increases
over the 1976-95 period compared to palm oil which showed one of the lowest price increases over that
period.
Redirecting the Diet Transition: What Can Food Policy Do? 601

rates of chronic disease or levels of obesity to relative price changes, controlling for a
range of other factors. One of the few such studies to do so, using US data, suggests that
40% of the growth in weight of the US population between 1976 and 1994 was due to
technology-based reductions in food prices (see Lakdawalla and Philipson, 2002;
Philipson and Posner, 1999).
Technology may be one important source of change in the relative prices of foods
that pose a chronic health risk; institutional change is another. Examples of the latter
include (a) trade policy governance and (b) changing food distribution mechanisms. An
illustration of the first is the entry of China into the World Trade Organization, expected
by many (for example, Fang and Beghin, 2000) to lead to a 20% decline in the prices
paid by consumers in China for soybean oil and related products. More research is
needed from a health perspective on how trade liberalisation will affect the prices of
different foods that represent different health risks.
An illustration of institutional policy changes, fuelled in part by technology
changes, is the rapid transformation of food retailing in Latin America. Reardon and
Berdegué (2002) report that the percentage of food distributed by supermarkets in retail
outlets in the region grew from 10-20% in 1990 to 50-60% in 2000, driven by
liberalisation of financial flows and developments in inventory management
technology. These changes are also happening in Asia and Africa (Reardon et al., 2003).
Do these supermarkets provide poorer consumers with increased access to more
unhealthy processed foods (for example, those with high levels of trans fatty acids)? Do
they also provide increased access to fresh fruit and vegetable products and other
healthy diet components? What happens to the choice sets of those who do not use
supermarkets? These issues have not been investigated yet. More research is needed to
identify the trade-offs between healthy foods and healthy profits.5

Urbanisation

Urbanisation is proceeding rapidly in the developing world. Urbanisation is marked by a


reduction in physical activity for the majority of the labour force. The density of
residence of urban populations also lowers the per person cost of mass-media
advertising, where the spending power of food manufacturers and processors certainly
outweighs that of public health authorities. The urban environment is also marked by a
greater physical distance between places of work and of residence, and by smaller
household sizes. In this environment, where time is scarcer, at least for those gainfully
employed, and where the fixed costs of food preparation are higher in smaller families,
more food tends to be purchased outside the home, even for poor households.
Good data from the developing world are hard to obtain but foods purchased
outside the home tend to be more processed and prepared. If so, they will tend to be
higher in salt and fat and will often be fried, sometimes using oil that has been refried –
a particularly unhealthy diet component because of the high concentration of trans fat.
These foods are often purchased from street vendors, so-called ‘street foods’. Street
foods are a significant source of food (and income generation) for many urban dwellers,
both in terms of energy intake and food expenditure. In some settings, this may be

5. Reardon and Berdegué (2002) note that profit margins are highest on fresh fruit and vegetables, but are
also high on dairy and processed foods.
602 Lawrence Haddad

particularly true for poorer urban dwellers compared to the more wealthy group. A
recent Accra-wide study (Maxwell et al., 2000) finds that households in the poorest
expenditure quintile obtain on average 31% of their total calories away from home,
compared to 22% for the top quintile (see Figure 1).

Figure 1: Calories from food away from home


(% of total), Accra 1997

6 1.6

3 1.4 30
27 .5 28.8
2 4.3 22 .5
20 .2
1 5.1
10

income group 1 2 3 4 income group 5


(low ) (high)
per capita incom e percent of calories from meals aw ay from home

MSource: Maxwell
axw ell et. et al.
al., 2000 (2000).

Tinker, in her study of street foods in seven countries of Asia and Africa, shows
expenditures on street foods ranging from 16% in Manikgani (Bangladesh) to 50% in
Ile-Ife (Nigeria), and higher street foods expenditures among the poorest quartiles in
both Bangladesh and the Philippines (Iloilo) (Tinker, 1997). Very little information is
available on the contribution of street foods to the daily nutrient intake of consumers. In
the Philippines, commercially prepared foods were found to contribute 25% of the
energy intake of urban working women and 45% of their fat intake (Bisgrove and
Popkin. 1996). In the US, data from the Department of Agriculture (Lin et al., 2000)
show that the saturated fat content of foods consumed at home has dropped steadily
over the 1980s and 1990s, whereas the fat content in fast food restaurants and in schools
has remained high (see Figure 2).

Figure 2: % of calories from saturated fats by


location of consumption, US
16
15
14
13
12
11
10
9
8
home restaurants fast food sc hools other public
plac es

1987-8 8 1 990 1995

Source: Lin et al. (2000)


Source: Lin et al. (2000).
Redirecting the Diet Transition: What Can Food Policy Do? 603

Location clearly matters, but does it matter when price and income are controlled
for? That it does is clearly shown by a modelling exercise for China, where food
consumption shifts due to rural-to-urban migration were modelled, controlling for prices
and income levels (Huang and Bouis, 1996). The results are presented in Figure 3.
Interestingly, in this case, urbanisation seems to have led to a large increase, all things
being equal, in the consumption of fruit, a moderate increase in the consumption of
meat, fish, milk and eggs, and a moderate decline in the consumption of all other foods.
Clearly, one cannot generalise too much about the urban experience before more studies
of this type are undertaken.

Figure 3: % change in consumption caused by rural-to-urban


shift, controlling for income and prices, China, 1991

125

26

grain meat, fish, edible oil vegetables fruit


eggs, milk
-33 -19 -20

% change due only to urbanization-large and capital cities

Source: Huang and Bouis (1996).

What can food policy do?

The rationale for public action

Table 1 summarises the rationale for public action to influence the diet transition
towards a healthier outcome. Perhaps the most obvious rationale is information
asymmetry between producers and consumers about what is healthy and what is not.
There may also be negative externality effects if health care resources are directed away
from infants to middle-aged individuals, and in terms of the intergenerational
transmission of obesity from mother to baby (see Parsons et al, 2002). There will also
be a case for public intervention if private sector incentives result in poorer consumers
being priced out of access to healthier food options, especially basic processed foods.
604 Lawrence Haddad

Table 1: The case for public policy intervention


to improve diet quality

Rationale for public action Example of broad areas in which public intervention
may be justified
Underprovision of ‘public If generation of affordable healthy food is not available to
goods’ poorer consumers
Externalities not captured Negative externality if obesity of mothers is risk factor for
child obesity. Health care costs diverted from prevention
Information asymmetries Case for providing healthy alternatives. Case for labelling;
nutrition education
Capital market failure Investing in anti-low birth weight interventions
Universal access and equity Obesity is linked to more marginal groups in US, UK
concerns
Health insurance market failure Prevention and treatment of chronic diseases

Food policy options

Options emanate from the supply side and the demand side, although success will
obviously be enhanced via the effective interaction of both. Table 2 summarises the
food policy options available to moderate dietary fat intake, based on US experience
(see Sims, 1998; Ralston, 2000). Although focused only on dietary fat and only on US
policy instruments, the table highlights several points. First, there are many stages in the
food system where policy can act – both on the supply side and on the demand side.
Second, many of the instruments may have small effects – either because behaviour is
hard to change in the desired direction or because there are off-setting effects (for
example, moving to lower-calorie foods, but consuming additional portions: Sims,
1998). This is a rather sobering conclusion and one that should be kept in mind during
the process of policy formulation throughout the developing world. Third, several
instruments have ambiguous effects on fat intake – either because they have not been
evaluated (for example, harmonisation of fat descriptors between regulatory agencies)
or because their direct effects may be overwhelmed by their indirect effects (for
example, restrictions on beef imports may result in a reaction from domestic beef
producers and a search for new outlets for beef products). The table represents a menu
of options that need to be evaluated if their impacts are to be maximised in the desired
direction.
Redirecting the Diet Transition: What Can Food Policy Do? 605

Table 2: Food policy instruments for influencing dietary fat

Stage of the Types of policy Examples used in the dietary fat issue Effectiveness
food system instrument in controlling
fat intake
Food Commodity Feed grain subsidies for feedlot animals Negative
production price subsidies/ Dairy price supports Negative
supports
Import/export Export incentives for US vegetable oil Uncertain
quotas Restrictions on beef imports Uncertain
Food Meat grading Beef grading (changes from choice to Positive
processing standards select)
‘Standards of ‘Standards of identity’ changed for low- Positive
identity’ fat milk and yoghurt
Food labelling Food label descriptors (e.g. ‘low fat’, etc.) Quite positive
changed for fluid milk, ice cream
Food Marketing Changes in milk marketing orders Negative
distribution orders for dairy
and Food labelling Use of ‘% lean’ claims on ground beef Slightly
marketing negative
Restaurant labelling of menu items with Slightly
‘low fat’ claims positive
Food Harmonisation between the FTC and Uncertain
advertising FDA on ads using fat ‘discriptors’
Food Food labelling Fat descriptor information on food label Positive
consumption Dietary Dietary guidelines Positive
information Food Guide Pyramid Quite positive
Commodity Promotion of cheese, ice cream, milk, Negative
promotion beef, pork
boards
Source: Adapted from Sims (1998).

Supply-side interventions

(i) More public investment in technology to deliver high-productivity, low-cost


vegetables and fruits and low-fat livestock products to poorer consumers. The bulk
of agricultural technology development in high-value commodities such as
livestock and fruits and vegetables tends to be undertaken by the private sector for
larger farms. The high cost of cold chain systems reduces access by small farmers.
Increasing the productivity of fruits and vegetables and lower-fat livestock products
and reducing the transactions costs of delivering them to growing markets are an
important area in which agricultural research and development can have a larger
health impact.
(ii) Eliminate price incentives on growing high-fat foods and relax quantity restrictions
on growing healthier foods. The commodity composition of these kinds of price
606 Lawrence Haddad

and quantity instruments reflects the economic, social and political importance of
the various crops and growers’ associations and the small and large industries that
rely on them. Whenever the welfare of small sub-groups is weighed against the
broader interest, the politics of hurting a small but powerful group will usually
outweigh the smaller negative impacts on a much vaster set of individuals (Nestle,
2002). When small welfare losses result, over time, in a large cumulative disease
burden, the economics of such trade-offs needs to be revisited.
(ii) Evaluate food trade policy from a health perspective. GATT and the World Trade
Organization use a number of agreements to navigate health issues, including the
Sanitary and Phytosanitary (SPS) Agreement and the Trade Related Intellectual
Property Rights (TRIPs) Agreement. Can these Agreements be used to regulate the
health content of food imports? Past experience suggests ‘yes’, if scientific risk
assessments show the danger (Millstone and van Zwanenberg in this volume).
Beyond obvious health-related trade instruments, can the health community
influence the trade community in much the same way as the labour and
environment communities have done? Do we know whether the commodity-
protection profiles of different countries are pro- or anti-health? If we did, would
the health community be able to influence trade policy? If it could (which must, at
this point in time, be considered improbable), are there non-health downsides for
poor farmers and consumers from an altered pattern of trade? These issues have not
been explored to date, and this is surely an area for future research as the
percentage of food consumed from trade increases.
(iv) Impose tougher standards on the fat content of food away from home and in
schools. In the US, for example, the menus in many public schools fail to meet US
Department of Agriculture dietary guidelines (Brownell, 2002a, b).
(v) Reduce malnutrition in utero. The so-called ‘Barker Hypothesis’ posits that
maternal dietary imbalances at critical periods of development in the womb can
trigger an adaptive redistribution of foetal resources (including growth retardation).
Such adaptations affect foetal structure and metabolism in ways that predispose the
individual to later cardiovascular and endocrine diseases (Barker, 1998). The
correlation between low birth weight or early childhood stunting and later
cardiovascular disease and diabetes may arise from the fact that nutritional
deprivation in utero, or in early childhood, ‘programmes’ a newborn for a life of
scarcity. The problems arise when the child’s system is later confronted by a
higher-fat, higher-sugar diet, in combination with lowered activity patterns. If this
hypothesis is borne out (and evidence is accumulating both for and against) it will
serve to remind us that one food policy option for attenuating the impacts of the
diet transition is to reduce intra-uterine growth retardation. For example, based on a
balanced review of the evidence as of 2000, Popkin et al. (2001) conclude that in
China approximately one-third of diabetes can be traced back to low birth weight
and stunting in infancy, with this percentage declining in 2020, on the assumption
that low birth weight and stunting will decline. There are a number of interventions
to address low birth weight at term, ranging from the immediate (for example,
improving the food intake quantity and quality of adolescent girls and expectant
mothers and improving the quality of pre-natal care) to the underlying (for
example, improving women’s status relative to men’s in terms of resource
allocation decisions).
Redirecting the Diet Transition: What Can Food Policy Do? 607

Demand-side interventions

(i) Increase the relative price of unhealthy choices. This is an option that those
familiar with anti-smoking campaigns might find appealing. It often underlies
discussions of what food policy can do to increase the healthiness of the diet
transition (for example, Guo et al., 1999). However, it is difficult in practice to
identify a food for which an increase in price will not reduce access to healthy
components of a diet – components that in a developing country context may be in
short supply. Examples in Figures 4 and 5 illustrate this for US data on meat and
edible oil consumption. As Figure 4 shows, an increase in the price of meat does
have a negative impact on fat and cholesterol intake, but it also has a negative
impact on a wide range of diet components that are crucial to diets, especially those
of infants and women, such as iron and calcium, which are not found in high
densities in non-animal source foods (Huang, 1996). For the same demand system
estimates, Figure 5 shows that an increase in edible oil prices does decrease fat
consumption and increase the consumption of nearly every other diet component
because of a substitution towards other foods. This is more in line with the kind of
results we might be seeking. However, in a developing country context, edible oil is
often used to increase the energy density of infant diets.

Figure 4: Responsiveness of nutrients (%) to a 1% increase


in price of meat, US price elasticities
0.1

0.064

0.05

0
energy

protein

fat

carbohydrate

cholesterol

calcium

phosphorous

iron

potassium

sodium

vitamin A

thiamin

riboflavin

niacin

vitamin C

-0.025
-0.05 -0.041
-0.027
-0.025
-0.009 -0.078-0.08 -0.076 -0.074-0.072
-0.1 -0.091 -0.096

-0.15 -0.14 -0.135

Source: Huang (1996).


608 Lawrence Haddad

Figure 5: Responsiveness of nutrients (%) to a 1% increase


in price of oil, US price elasticities

0.067
0.054
0.05
0.045
0.036
0.027 0.028 0.027
0.021
0.017
0.009
0 -0.001
energy

protein

fat

carbohydrate

cholesterol

calcium

phosphorous

iron

potassium

sodium

vitamin A

thiamin

riboflavin

niacin

vitamin C
-0.021

-0.056
H uang, 1996
Source: ibid.

(ii) Clearer information about product contents. Food labelling can help in reducing
information asymmetries, but it can often be confusing, it is obviously of limited
value in areas where literacy is weak, and it may be better at discouraging certain
types of behaviours perceived as risky than encouraging healthy behaviour (for
example, Verbeke and Ward, 2001 on BSE in Belgian beef).
(iii) Better awareness about consequences of poor diet. A number of initiatives have
been employed in developing countries to raise awareness of the causes and
consequences of poor diet. These include a mass media campaign to reduce
overweight in Brazil; dietary guidelines for nutritional well-being in China; and
school-based training for improving diet and activity levels in Singapore (Doak,
2002). Evaluations of the effectiveness and cost-effectiveness of these attempts to
change behaviour are badly needed.

Policy trade-offs accentuated in a developing country context

Policy formulation on diet change in the developing world must build on the evidence
accumulated in the industrialised world. However, the developing country context is
very different and policy-makers must remember that:

• Food consumption deficits are still widespread. When looking for foods to
discourage the consumption of, remember that many groups require the other
nutrients contained in the food (for example, the micronutrients in livestock).
• Certain groups of individuals, for example infants, will need to consume even
foods that might otherwise be discouraged, for example, edible oils.
• The capacity to influence preferences via the public sector is likely to be lower
than in the industrialised world. Whether the imbalance between public and
Redirecting the Diet Transition: What Can Food Policy Do? 609

private sector power to communicate nutrition messages is growing in the


developing world is an open question, but with multinationals backing much of
the nutrition messaging, one would not be surprised to see the public sector
caught on the back foot (Hawkes, 2002).
• On the supply side, anything done to discourage the consumption of a locally
produced food considered harmful to health above some cut-off will harm the
income-generating ability of many smallholder farmers. They may not have the
political strength of industrialised country farmers, but the economic impact on
the rural economy of an attempt to alter consumption could be large.
• Many developing countries are desperate to increase foreign direct investment,
not to discourage it. Attempts to discourage foreign supplies of foods that are
designated ‘less healthy’ will have employment and livelihood consequences
that need to inform any decision taken.

The uniqueness of food

Finally, it is important to note that food represents a class of commodities that is


difficult to influence in a predictable manner. In particular, the temptation to apply the
model that was so successful in curbing tobacco consumption (World Bank, 1999) to
food should be resisted. Comparisons may be more valid in some countries with
powerful judicial systems for those who can take advantage of them (for example, the
US and the recent lawsuits taken out against fast-food retailers). But even in the
industrialised countries there are some important differences between the two situations
– i.e. poor diets are not the same as a smoking habit. First, there is a difficulty in
identifying the ‘offending product’. Second, with tobacco, there are no obvious
consumption trade-offs with positive outcomes as outlined above. Third, there are fewer
obvious private externalities (there is no such thing as ‘secondary eating’). Finally, there
is a broader constituency for food farmers than for tobacco farmers.
Because of these and other differences, the ‘triggers’ for strong public action are
not yet in place (Kersh and Morone, 2002). Table 3 is adapted from Kersh and Morone
(2002) and it lists the ‘triggers’ for public action in health and assesses their strength in
the US as applied to the obesity problem there. The authors conclude that only the first
three of seven triggers have been tripped: social disapproval, evidence from medical
science and the evidence of self-help groups. Such constructs help us to remember that
evidence is only one ingredient in the formulation and implementation of public health
policy.
610 Lawrence Haddad

Table 3: ‘Triggers’ for successful government regulation


of private behaviour when a ‘political window’ opens

Trigger Comments Power of obesity triggers in US


Social disapproval Recognition by society as There is a popular disapproval of
a ‘bad thing’ obesity
Medical science Role is to challenge myths There is strong evidence linking diet to
obesity and obesity to chronic disease
Self-help For example, Alcoholics Overeaters Anonymous, Weight
Anonymous Watchers
Demonise the user Fearing the drug culture Obesity does not play on fears. No
evidence of trigger yet
Demonise the For example, Big No ‘Big Chocolate’ yet. ‘Fast Food
provider Tobacco Nation’ gaining consciousness. No
evidence of trigger yet
Mass movement Protests, rallies No evidence of anti-obesity campaigns
(possibly the opposite, re: accepting
body image). No trigger yet
Interest-group action Lawyers and lobbyists Yet to be achieved. No trigger yet
Source: Adapted from Kersh and Morone (2002).

Information and analysis gaps

Research in the area of the diet and nutrition transition in developing countries is in its
infancy. Most of the work has been spent documenting it and analysing its causes, and
much of it has had to make do with crude food data (national supply, not household-
level availability or individual intake). Very little research has focused on policy
analysis. The following areas deserve much more attention from the research
community.

• There is a need to use existing nationally representative household survey data


systematically to chart trends in the availability of ‘bad’ food components.
These datasets are available for a large number of countries, but are solely used
to estimate poverty rates.
• The location of consumption and the health content of that consumption need
to be better connected, with more data collected on the characteristics of the
points of sale, whether they are street-food vendors or supermarkets.
• Food price elasticities need to be generated that are disaggregated enough to be
policy-relevant (for example, ‘meat’ is not useful, but ‘high saturated fat beef
products’ might be).
• The trade-offs in terms of the consumption changes of different diet
components of different population subgroups resulting from the change in the
price of a single community need to be spelled out, as do the implications for
smallholder income generation.
Redirecting the Diet Transition: What Can Food Policy Do? 611

• There need to be more evaluations of non-price interventions to change diets,


both in terms of quality and quantity.
• There has to be more research on the investments and institutional innovations
that smallholder farmers need to link up with growing domestic and
international markets for healthy foods.
• More research needs to be done that links trade policy with health outcomes,
perhaps via the linkage of computable general equilibrium models (CGEs) and
micromodels of individual welfare outcomes (for example, Cogneau and
Robilliard, 2000).
• Research on the policy process and the role of information will be useful to
help us to understand why the public health response to chronic disease has
varied in terms of effectiveness.
• More research needs to be done on identifying institutional mechanisms for
win-win public-private partnerships (for example Buse and Walt, 2000) to
reduce the amount of unhealthy fat and added sugar entering into the
developing country food supply.
• Too much of the evidence cited in this article has come from one country,
China. A similarly concerted effort needs to be undertaken in other large
countries for which there are indications that the diet transition is accelerating
– for example, India, Brazil, Indonesia, South Africa and Nigeria.

Conclusion

The diet transition in the developing world seems to be accelerating. It seems to be a


transition towards an increased burden of chronic disease. It is increasing human costs
in terms of mortality and the disease burdens. It is increasing economic costs in terms of
lower productivity. It is driven by changing preferences fuelled by growing incomes,
changing relative prices, urbanisation, changing food choice options fuelled by changes
in food technology, and changes in the food distribution systems; and by a legacy of
low birth weights from the previous generation. Is there a case for public investment in
efforts to influence the transition towards increasingly healthy outcomes? The existence
of information asymmetries and negative externalities suggests that this is so.
What can food policy do? We have identified a number of options from the food
supply and food demand sides. These options have had mixed success in the
industrialised countries. The policy trade-offs in the developing world are even more
complicated. For example, efforts to overcome over-nutrition might well undermine
efforts to overcome under-nutrition. The public health anti-smoking policy model offers
some insights, but it should not be leaned on too heavily; food is not tobacco. There are
plenty of areas in which additional technical research is needed to assess competing
risks and to help develop policy options, and we have outlined some. But there is also a
very great need for research to engage actors in the policy process underlying the diet
transition. In a debate where so much is at stake – market shares, profits, livelihoods,
and life itself – there is a potentially powerful role for the generators of balanced
evidence to bring different actors to the table. This may help to improve the decision-
making processes underlying the attempts of food policy to redirect the diet transition
towards healthier outcomes.
612 Lawrence Haddad

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