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R U R A L 21
The International Journal for Rural Development 3 | 2020
VOLUME 54
ISSN 1866-8011
D 20506 F
Changing times,
changing diets
PROJECT PLANNING AGRICULTURE CLIMATE CHANGE
Combining local best practices The myth of Africa’s A vital role for
with state-of-the-art knowledge ageing farmers agroecology
rural21.com
2 EDITORIAL
Dear Reader,
Many of you will be familiar with the 2019 publication people, e.g. via income
Food in the Anthropocene, in which the EAT-Lancet transfers, investments in
Commission described the link between nutritional targets inclusive income growth,
and environmental sustainability. In brief, the study argues increased productivity in ag-
that diets and food production will need to change in riculture or nutrition-smart
order to improve health and avoid damage to the plan- fiscal policies, this by no
et, emphasising that people will have to eat more fruit, means implies that people
vegetables, nuts and seeds, legumes and whole grains while will really integrate it in
reducing the consumption of ruminant meat in particular. their daily meals. For this
Setting out from this, the authors presented a proposition brings us straight back to the
for a global reference diet. first issue, the human factor.
Whereas it is undisputed that the recommendations of the As their disposable income
Lancet Commission point in the right direction, the ques- rises, more and more people in low- and middle-income
tion remains how the world population can be urged to countries start favouring the so-called Western style diet –
take precisely this course. For the recommendations raise a with high amounts of refined carbohydrates, saturated fats,
number of tricky issues. First of all, there is the human fac- sugar and salt and a high share of processed foods. This in
tor. People’s food choices are by no means dictated solely turn results in more and more countries being confronted
by the aspect of health. What we eat depends crucially on with the double burden of malnutrition, a phenomenon
the culture that we have grown up in, the traditions that characterised by the coexistence of undernutrition and mi-
we maintain and what we believe in. How we prepare our cronutrient deficiencies on the one hand and overnutrition
daily meals is determined by factors such as time, cost and and obesity on the other.
availability of food. The latter in turn depends largely on
supply chains, markets and trade. And then there are social So these are complex contexts which call for complex
norms and the degree to which media and marketing answers. Our authors and interview partners show what
professionals influence choice. So many emotions come to level of knowledge we are at and where there is a need for
play, while rationality assumes a lesser role. further research. They give examples of how the negative
effects of changing consumption patterns can be addressed
This leads us to the second problematic issue, that of by multi-sectoral and multi-stakeholder action, but also of
scientific evidence. While studies have revealed that the new opportunities that changing dietary habits offer
the intake of the food recommended above is inversely farmers and agripreneurs. And they highlight how tradi-
associated with the risk of developing hypertension, type tional but frequently underutilised and undervalued food
2 diabetes or cardio-vascular diseases, our knowledge of can contribute to tackling the nutritional problems of the
precisely how diets are systematically linked to nutritional modern world.
adequacy, human health and environmental health remains
very limited. We also know little about which policy We wish you inspiring reading.
interventions – be it on the supply or on the demand side
– are really suited to govern globalised sustainable food On behalf of the editorial team,
production and consumption systems.
Then there is issue number three: affordability. Even if
we assume that the proposition for a global reference diet
presented by the Lancet Commission is the right one for
the health of the people and the planet as a whole, we still
face the problem that nearly 1.6 billion people around the
You can find the latest information on COVID-19 at
world simply can’t afford such a diet. And even if we were www.rural21.com
to succeed in making healthy food more affordable to all
Partner institutions of Rural 21
IN THIS ISSUE 3
Imprint
Rural 21 –
The International Journal for Rural Development
CONTENTS
Published by:
DLG-Verlag GmbH
FOCU S
Frankfurt, Germany
04 Changing times, changing diets
Advisory council:
Dr Reinhard Grandke, DLG
08 Healthy diets – a privilege of the rich?
Petra Jacobi, GIZ
Martin Koppa, HELVETAS
Ueli Mauderli, DEZA
10 Towards sustainable diets and planetary health –
lessons from early research and knowledge gaps
Editorial committee:
Dr Michael Brüntrup, DIE
12 Tackling the double burden of malnutrition
Dr Manfred Denich, ZEF
How to counter the effects of the nutrition transition in Cambodia
Dorothea Hohengarten, GIZ
Karl-Martin Lüth, DLG
Prof Dr Matin Qaim, University of Göttingen 15 “Reducing malnutrition levels calls for concerted efforts”
Dr Detlef Virchow, Plan International An interview with Jane Wanjiru Wambugu, Kenyan Ministry of Agriculture
Editor in chief / Berlin office:
16 Civil society’s engagement for better nutrition – the case of Namibia
Silvia Richter, s.richter@dlg.org
Editorial staff / Frankfurt office: 18 Helping ‘local favourites’ join the race for healthier diets
Olive Bexten, o.bexten@dlg.org Tapping the potential of traditional vegetables
Ines Lechner, i.lechner@dlg.org
Angelika Wilcke, a.wilcke@dlg.org 21 Insects for dinner?
Editorial assistance: ProciNut project's results
Mike Gardner
Translated by:
24 Small fish with a big potential
Christopher Hay, Tazir International Services
26 The trend towards healthy diets – an opportunity for farmers and
Cover photo: agri-entrepreneurs
Robert Haidinger/ laif
Design & Layout: 29 Nutrition and health: farming women in Kenya’s Murang’a speak out
Andrea Trapani, DLG-Verlag
Editorial office, distribution, advertising:
DLG-Verlag GmbH OP IN ION
Eschborner Landstraße 122
60489 Frankfurt, Germany 32 Eat less meat – if only it were that simple
Printed by:
Brühlsche Universitätsdruckerei GmbH & Co KG
35396 Gießen, Germany IN T E RN AT ION A L P LAT FORM
Rural 21 is published four times a year. 34 Lifesavers from the air
The subscription rate is EUR 33.– (Germany), EUR
Drones delivering blood and medical supplies to remote areas in Rwanda
37.– (EU countries), EUR 51.– (non-EU countries)
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All rights reserved. The contents may not be
36 Community-led climate change adaptation – insights from a project beyond
translated, reproduced in whole or in part, nor may the norm
information be passed on to third parties without
permission of the publisher. Please direct all
correspondence to the editor in chief. SCIE N T IF IC WORLD
The opinions expressed by the authors are not
necessarily those of the publisher or the editor. The
39 The myth of Africa’s ageing farmers
editor retains the right to make editorial changes.
42 The potential of agroecology to build climate-resilient livelihoods and food
systems
Photo: Jörg Böthling
4 FOCUS
Changing times,
changing diets
Diets are the great equaliser. Depending on who you are, where you live and the amount of resources at your disposal,
diets can either hinder or promote human and environmental health. Overall, diets are changing for various reasons,
particularly in rapidly transitioning low- and middle-income countries. If trends in these countries follow those in high-
income contexts and countries, fragile health systems could be overwhelmed and burdened with a new host of complex
diseases. How can low- and middle-income countries leapfrog over the mistakes made in high-income countries and
ensure that dietary changes are moving in a direction benefiting both human and planetary health?
By Jessica Fanzo and Isabella Sarria
W hat people choose to eat and the way
they eat and interact with food looks
different depending on who someone is, where
The importance of diets begins foundationally,
for it is necessary for humans to survive, have
energy and perform everyday tasks. Overall
diversity and safety. But people’s food choic-
es are not solely influenced by health. Where
individuals and their families originate from
someone is or where they come from. Despite health and bodily functions that determine influences their culture, traditions and beliefs,
these differences, food and diets are an essential overall well-being are highly dependent on which in turn bears on the way they choose,
part of who we are as humans and individuals. the composition of diets and their adequacy, prepare and view food. Traditions and culture,
RURAL 21 03/20 5
have a vast array of choices, while others have
very few. From money to accessibility to val-
ues, people prioritise distinct things when de-
ciding what to eat and the best way to interact
with food. Part of understanding why people
make certain diet choices therefore requires an
understanding of the resources, constraints and
aspirations that influence those choices, but
also the immediate built and food environ-
ments where people live and purchase foods
and their influence on food choice.
As people adapt to the environment they are
surrounded by, they become limited to only
certain food options for which the food supply
bears. Ultimately, these choices will be a prod-
uct of what is available and accessible to them.
Accessibility, price, taste and convenience are
all aspects of food that influence the diets dif-
ferent people consume. Brands, certifications,
advertising and marketing also matter and can
influence choice. Factors that influence di-
ets are highly dependent on the incomes of
households and the spectrum of development
of countries. Rural diets can also be quite dis-
tinct and different from urban diets because
the types of food vendors and food availability
on hand change dramatically with geography.
Countries with major cities have greater access
to good food options, giving people a larger
selection of dietary choices, but at the same
time, more exposure to energy-dense foods
with limited nutrients.
Customs and beliefs influence what people
choose to eat as does knowledge of food and
nutrition. Changing social norms and media
can influence food purchases. These types of
exposures show that people are not only a
product of their own individual choice and
beliefs in what they choose to eat but are im-
pacted by society and cultural trends.
Photo: Bilderbox.com
How are diets changing?
in turn, also shape the types of diets that people surrounding environments play a role in the
eat. A person’s daily relationship with food is kind of crops and animals grown and raised. In Over the last decades, diets in low- and mid-
complex and depends on several factors, such turn, the functionality of supply chains, trade dle-income countries (LMICs) have been
as cost, time and availability. Diets are there- and markets influences the types of foods indi- changing in both positive and negative ways.
fore not only a solitary concept, but are instead viduals have access to, and for many countries, On the positive side, diets are more diverse
connected to many parts of life, and under- this is a significant contributor to economic in the types of foods people consume that are
standing those connections is the first step in growth. available in the food supply. Dietary variety is
understanding dietary habits. associated with increased dietary quality be-
cause it broadens the sources of the vitamins,
Diets also have an interconnected relationship Why do people make certain choices minerals and macronutrients that fuel and
with the surrounding environment and societ- about the diets they consume? protect your body for optimal human health.
ies. It is a two-way street: just as the environ- There are other positive trends. The intake of
ment influences food and dietary choices, the Every individual makes different choices for trans fats, a type of industrialised fat that is dele-
way societies produce, process, distribute and different reasons regarding food and diets, but terious for health, has declined in some regions
manipulate food affects the environment and some people have more options and more of the world. One trend that has both positive
natural resources. Landscapes, ecosystems and resources when making these choices. Some and negative implications is that over the last
6 FOCUS
two decades, in many middle-income coun- types of animal foods and products in demand years, with most countries increasing the ener-
tries of Latin America for example, people are vary depending on the geography, the culture gy, protein, fat and food weight of their food
eating away from home, in more restaurants. and religious beliefs, to name a few influenc- supply. Yet in this period, the compositions
ing factors. Consumption of processed meat of countries’ food supplies have become more
On the negative side, people are consuming (those types that are salted and cured) has also similar to one another and some of the more
more highly-processed packaged foods, such increased in all regions of the world. While indigenous, local foods have since been ne-
as cookies, chips, crackers and sweets, which animal-source foods are typically rich in es- glected and marginalised.
tend to be high in added sugars, sodium and sential nutrients that promote good health and
unhealthy fats and low in dietary fibre and nu- nutrition, some of these foods are associated Trade is and will continue to be important
trient density. These types of foods now com- with increased risk of cardiovascular disease for the diversity of diets in that trade increas-
prise a significant share of many diets around and cancer. In addition, production of some es the availability of different types of foods,
the world because they are widely available, animal-source foods has detrimental impacts extends the number of days that food prod-
cheap and intensely marketed. In many up- on the environment when consumed and pro- ucts are available and influences the affordabil-
per-middle- and lower-middle-income coun- duced at high levels. ity of foods. While trade has moved so many
tries of Asia and Africa, there has been a sig- different types of foods around the world, it
nificant growth in sales of packaged foods over sometimes does so at the expense of local pro-
the last 20 years. In addition to foods, which Why are diets changing? ducers and traditional food systems. In addi-
beverages are consumed is also a health con- tion, when food and beverage products such
cern. While the number of kilocalories pur- With growing urbanisation, globalisation and as sugar-sweetened beverages and highly-pro-
chased from sugar-sweetened beverages is trade liberalisation, food systems have become cessed foods become cheaper, the consequenc-
highest in high-income countries (HICs), more interconnected, with longer and increas- es could be harmful to human health.
many low- and low-middle income countries ingly complex food supply chains involving
have had a significant increase in their sales many diverse actors who engage across many Globalisation shapes food environments – the
over the last decade. These highly processed different links of the chain. Connected food physical, economic, political and socio-cultural
foods and sugary beverages have been associ- systems offer consumers the possibility to ac- surroundings, opportunities and conditions that
ated with adverse health outcomes including cess a basket of diverse foods all year long, create everyday prompts, shaping people’s di-
overweight, obesity, type-2 diabetes and car- expanding their food choices and protecting etary preferences and choices – notably through
diovascular diseases. them against seasonal shortages. Efficiency the expansion of supermarkets and hypermar-
has been the motto for the global food sys- kets. The rapid spread of more supermarkets
The demand for animal-source foods is also in- tem: the food supply has been increasing in as well as fast food restaurant chains to every
creasing in many places in the world, but the terms of quantity and quality over the last 50 country in the world influences consumer be-
RURAL 21 03/20 7
haviour and food consumption patterns. While Why are changing diets necessary? provide significant health and environmental
the “supermarket revolution” offers consumers benefits.
a wider range of products at a lower price than With diets now a top risk factor for morbidity
traditional retailers, it also can spur significant and mortality globally, it is necessary to ensure Choices made by high-income countries in
organisational changes across the whole food that the world’s population can access and af- how they produce food and what foods con-
supply chain. Furthermore, the revolution is ford a healthy diet. Future dietary transitions sumers choose to eat will have more severe
shifting the locus of power and decision-mak- are projected to negatively impact human impacts on those people living in low-income
ing from farmers and producers to traders and health. This will be felt most in lower-middle countries who do not have the resources to
retailers, and from governments to the private income countries, where diets are changing adapt quickly to the rapid onset of environ-
sector and multi-national corporations. most rapidly. Increasing consumption of fruits, mental changes stemming from food systems.
vegetables, nuts and seeds, legumes and whole They are also limited in their options to access
Food prices dictate dietary shifts as well. Un- grains would improve human health in most of or afford healthy diets. In the next decade, we
predictable changes in food prices have a the regions of the world. need all hands on deck for widespread, large-
significant impact on the poor because they scale changes. Governments, business and civil
spend a higher proportion – 50 to 80 per cent At the same time, diets will need to be more society all have a responsibility to ensure that
– of their entire income on food. Poor popu- environmentally sustainable if we are to tack- everyone has access to healthy, equitable foods
lations, particularly those living in deeply rural le climate change in a serious way. By 2050, that provide the greatest benefit for human
areas, often only have access to mainly cere- global greenhouse gas (GHG) emissions from and planetary health.
al-, root- and tuber-based diets, while costly food production are expected to increase by
animal-sourced foods, fruits and vegetables 50 to 80 per cent as a result of increases in
are hardly affordable for them. With income population size and dietary shifts. Land used Jessica Fanzo is a Bloomberg Distinguished
growth, consumers are able to diversify and to grow food will need to expand to meet Professor at Johns Hopkins University, Baltimore/
shift diets towards those less dominated by sta- those dietary shifts of a growing human pop- USA and serves as the Editor in Chief of the Global
ples, to those that include more fruits, vege- ulation, which will result in additional GHG Food Security Journal.
tables, animal-source foods and dairy as well emissions from deforestation and biodiver- Isabella Sarria is a student at Johns Hopkins
as more oil and more processed and packaged sity loss, with potential additional stress in University majoring in Public Health Studies.
foods. Consumer awareness can also generate sub-Saharan Africa. From the diet perspec- Contact: jfanzo1@jhu.edu
demand for certain types of foods including tive, reducing consumption of ruminant red
certain brands, food safety standards and even meat in particular in regions where con-
higher quality foods that meet certain health sumption of said foods is above the nutrition- Photos (from left to right):
and environmental criteria. al recommendations would most potentially 1-6 Jörg Böthling; 7-8 Bilderbox.com
Photo: Jörg Böthling
8 FOCUS
Nearly 1.6 billion people around the World cannot afford a diet meeting the standards of the EAT-Lancet reference diet.
Photo: Jamie Martin/ World Bank
Healthy diets – a privilege of the rich?
A healthy and diversified diet is the best antidote against hidden hunger. But by no means everyone can afford such a
diet – quite apart from the fact that there is no uniform definition of it. Our author shows what affordability is like around
the world and which approaches can lead to a world free of hidden hunger.
By Kalle Hirvonen
D eficiencies in iron, zinc, vitamin A and
other micronutrients can have serious
negative health consequences for both chil-
countries and often equated a healthy diet
with the one consumed in the Mediterranean
region, motivated by the finding that average
diet that is reasonably flexible to accommodate
most dietary traditions around the globe. The
Table shows the Commission’s recommend-
dren and adults. It is estimated that more than life-expectancies are higher in that region than ed ranges of intake for the major food groups
two billion people world-wide suffer from elsewhere. Another branch of this work de- considered for an adult consuming 2,503 calo-
micronutrient deficiencies – a condition also fined healthy diets using national food-based ries/day. Like most national dietary guidelines,
known as hidden hunger because even mild dietary guidelines that provide recommended the Commission proposed consuming a di-
or moderate deficiencies that do not show intakes from different food groups taking into verse range of fresh or lightly processed foods
visible symptoms can be harmful. The risks of account local dietary habits and food availabil- while limiting the intake of red meats, sugary
hidden hunger are elevated for young children ity. Unfortunately, neither of these approaches products, and saturated fats and oils.
and pregnant women for whom micronutrient is well suited to study this question in many
needs are relatively higher. The 2008 Lancet low- and middle-income countries, where the While many experts continue to debate the
report estimated that more than one million bulk of the world's poor people reside. First, scientific merits of the EAT-Lancet diet, the
children die every year because of micronutri- the Mediterranean diet does not align with the reference diet opened up new options for ex-
ent deficiencies. The best antidote against hid- dietary habits and preferences in Africa, Asia ploring the affordability question. In a recent
den hunger is a diverse diet rich in fruits, veg- or Latin America. Second, only a handful of study published in the Lancet Global Health,
etables, pulses and animal-source foods (meat, countries in these regions have developed their we calculated the cheapest means of meeting
poultry, fish, eggs and dairy). own national food-based dietary guidelines. the EAT-Lancet dietary intake recommenda-
tions in the reference diet in 159 countries, to-
An important development in this regard was gether representing 95 per cent of the world’s
What defines a healthy and diverse diet? the formulation of the planetary healthy diet population. Using standardised retail price data
by the EAT-Lancet Commission in early 2019. collected under the International Comparison
But can everyone afford a healthy and diverse The Commission was tasked to define a set of Program, we worked out that for the median
diet? Studying this question is made difficult by diets that limit diet-related disease risks and country, the cost of the EAT-Lancet reference
the fact that there is no universal agreement on minimise the environmental harm caused by diet was 2.89 international dollars based on 2011
what defines a healthy and diverse diet. Earlier our food choices. The outcome was a prop- purchasing power parity exchange rates. This
research in this area focused on high-income osition for the world’s first global reference may not sound a lot, but it exceeds the dollar
RURAL 21 03/20 9
1.90 international poverty line set by the World (storage, transport, and processing). There is
Content of the EAT-Lancet reference diet
Bank by more than 50 per cent. The true cost also scope for designing nutrition-smart fiscal
is likely to be higher because these estimates do Serving/day policies that favour healthy foods and tax un-
Food group
not include costs associated with acquiring and grams kcal healthy foods.
preparing the food – household activities that Rice, wheat, corn, and other 232 811
often fall onto women. Comparing the esti- Potatoes and cassava 50 39 Finally, making healthy foods affordable is un-
mated daily costs against available incomes, we Dark green vegetables 100 23 likely to be sufficient. Growing numbers of
calculate that nearly 1.6 billion people around Red and orange vegetables 100 30 people in middle- and high-income countries
the world cannot afford such a diet (see Figure). Other vegetables 100 25 consume excessive amounts of refined carbo-
In sub-Saharan Africa and South-Asia, the two All fruits 200 126 hydrates, saturated fats, sugar and salt – ingre-
regions hosting the most of the world’s poor Whole milk or equivalents 250 153 dients that elevate the risk of obesity, cardio-
and malnourished people, the estimated cost Beef and lamb 7 15 vascular diseases and various types of cancer.
exceeded the available incomes for 57 per cent Pork 7 15 Worryingly, we start to see similar unhealthy
and 38 per cent of the population, respectively. Chicken and other poultry 29 62 dietary patterns emerging among affluent con-
Eggs 13 19 sumers residing in low-income countries. This
Fish 28 40 calls for more investments in nutrition edu-
Making healthy food affordable is not Dry beans, lentils, and peas 50 172 cation and more stringent regulation in food
enough Soy foods 25 112 marketing so as to make consumers more
Peanuts 25 142 aware of the health implications of their di-
Our research suggests that the world’s poor Tree nuts 25 149 etary choices.
cannot afford a healthy and diverse diet – a Palm oil 6.8 60
finding that has been confirmed by a number Unsaturated oils 40 354 A world free of hidden hunger can be achieved,
of recent country-specific studies from Africa Dairy fats 0 0 but it requires global commitment – and a lot
and Asia. So what can be done? First, the large Lard or tallow 5 36 of work.
All sweeteners 31 120
observed disparities in affordability are mostly
Total n/a 2,503
driven by the highly unequal global distribu-
Source: Willett et al. (2019)
tion of income. Thus, raising the incomes of Kalle Hirvonen is a Senior Research Fellow at
the poor is a necessary condition for improving the International Food Policy Research Institute
diets. Targeted income transfers in the form of Second, there is also scope to reduce the prices (IFPRI), based in Addis Ababa, Ethiopia. This article
cash, food or vouchers can improve diets in re- of nutrition-rich foods. Fresh fruits, many veg- was based on research done together with Yan Bai
source-poor settings if coupled with effective etables and healthy animal-sourced foods like (Tufts University/USA), Derek Headey (IFPRI) and
nutrition communication strategies that nudge milk, eggs and fish are often very expensive, William A. Masters (Tufts University).
households to allocate more of their food bud- especially when compared to calorie-rich but Contact: k.hirvonen@cgiar.org
get on nutrition-rich food items. A longer-run micronutrient-poor grains and tubers. In poor
strategy involves investments in sectors of the countries, the high cost of these nutrition-rich
economy that promote job creation and inclu- food stems from low farm-level productivity as
References: www.rural21.com
sive income growth. well as inefficiencies in the post-harvest stage
Affordability of the EAT-Lancet reference diet across the globe
Source: Hirvonen et al. (2020)
10 FOCUS
Towards sustainable diets and planetary health: lessons from
early research and knowledge gaps
In 2019, the EAT-Lancet commission launched a thought-provoking report proposing the “planetary health diet”. The
idea was to formulate a diet that is both healthy and environmentally benign in terms of limiting societies’ environmental
footprints. So far, however, we know far too little about how governments and other stakeholders can cost-effectively
govern globalised sustainable food production and consumption systems. Our authors summarise recent research
on measuring health and environmental impacts of such systems as well as related policy interventions and propose
ingredients of a future research agenda.
By Jan Börner and Ute Nöthlings
H uman diets and the corresponding food
systems have a strong environmental im-
pact and play an elementary role in meeting the
planetary boundaries of greenhouse-gas emis-
sions, cropland use, water use, nitrogen applica-
tion, phosphorus application and biodiversity
losses. Without change in dietary patterns and
bio-based feedstock demand across the globe,
the environmental footprint of human con-
sumption will permanently exceed planetary
boundaries and thus undermine the capacity
of ecosystems to support human societies. At
the same time, dietary intake is strongly asso-
ciated with human health in that it has to be
nutritionally adequate and limit the risks of
common non-communicable diseases, i.e. dis-
eases that are not transmissible directly among
people, such as heart diseases, many types of
Photo: Bilderbox.com
cancer, and diabetes.
The concept of sustainable diets integrates pose elements of a research agenda that sup- Only few studies have so far explored indi-
across these human and environmental health ports evidence-based decision-making towards vidual dietary intakes regarding indicators of
dimensions of dietary patterns by defining as sustainable food and biomass production and environmental health, which would allow to
sustainable “… those diets with low environ- consumption systems. directly link environmental footprints of indi-
mental impacts which contribute to food and vidual diets with health outcomes. A number
nutrition security and to healthy life for present of tools are being developed, nonetheless, to
and future generations. Sustainable diets are Diets, health and the environment trace the footprints of aggregate consumption
protective and respectful of biodiversity and data back to its origins, e.g. TRASE, which
ecosystems, culturally acceptable, accessible, Suboptimal dietary intake increases mortal- stands for “Transparent supply chains for sus-
economically fair and affordable; nutritionally ity and reduces disability-adjusted life years tainable economies”. TRASE enables analysts
adequate, safe and healthy; while optimizing world-wide, with high sodium intake, low in- to calculate detailed spatially explicit emission
natural and human resources.” (FAO, 2010) take of whole grains and low intake of fruits footprints for agricultural production across
being the leading dietary risk factors. For ex- a whole value chain from a supply side per-
In 2019, a planetary health diet (also called the ample, meta-analyses of epidemiological stud- spective. The SHARP database (Sustainable,
EAT-Lancet reference diet) was proposed as a ies show that intake of whole grain, vegetables, Healthy, Affordable, Reliable and Preferable),
general dietary pattern to optimally align di- fruit, nuts and fish are inversely associated with on the other hand, adopts a demand-side per-
etary health effects and environmental impacts risk of type 2 diabetes, hypertension, cardio- spective to inform consumers in the Euro-
considering global food system linkages. De- vascular diseases or early disease risk markers, pean Union about environmental impacts of
spite the attention raised by the EAT-Lancet as well as with disability-adjusted life years or their dietary patterns in terms of greenhouse
proposal, a number of critical reactions from mortality. Intake of red meat, processed meat gas emission and land use. Still, many envi-
academia and civil society pointed to consid- and sugar-sweetened beverages is positively as- ronmental impacts of diets across the world
erable knowledge gaps in the way of designing sociated with such negative health outcomes. cannot be assessed due to data gaps. As a re-
food systems, or more broadly, bio-based pro- However, our knowledge remains limited sult, researchers studying the impact of dietary
duction and consumption systems that holisti- with regard to how diets are systematically behaviour on environmental health often rely
cally address planetary health outcomes. Here linked to environmental health, nutritional ad- on highly aggregated data and modelling ap-
we summarise key knowledge gaps and pro- equacy and human health. proaches.RURAL 21 03/20 11
Importantly, studies linking self-selected diets biomass systems. Two separate factors may The way forward
and nutritional quality suggest that an envi- be at play. First, technological innovation in
ronmentally friendly diet is not necessarily food and biomass production has to some ex- The scientific evidence on the current mis-
healthy. Clearly, dietary energy and meat in- tent enabled land users to comply with effec- match between health requirements, dominant
take are paramount to mitigate diet-related tive environmental regulations, while keeping diets and planetary boundaries is overwhelm-
environmental impacts. But, net outcomes food prices low. Second, especially in parts of ing. And yet, our knowledge about what con-
are determined by the choice of meat replace- the world currently witnessing the lion’s share stitutes globally accessible dietary options that
ments and potential spill-over effects towards of agricultural expansion into natural ecosys- minimise the environmental and social impacts
non-food consumption. Still, adherence to the tems, land use and conservation policies were of production is limited. Even less evidence
planetary health reference diet was found to shown to exhibit comparatively low levels of exists on how globalised food and biomass sys-
be inversely associated with chronic disease effectiveness. As a result, supply-side interven- tems can be governed towards providing such
risk, and some country specific adaptions have tions have so far arguably done rather little to diets. A research agenda to overcome these
already been developed. In fact, food-based change consumer behaviour. knowledge gaps should address the following
dietary guidelines (FBDG) are usually coun- non-exclusive lists of challenges:
try-specific recommendations of wholesome Instead, a growing body of academic literature
diets for populations or population groups. As deals with the impact of consumption on pro- Improve the data base linking dietary
such, they include general rules advising food duction, resource use and land use patterns. choices including non-food biomass
choice taking a range of aspects into account. Bruckner et al., for example, demonstrate how consumption to local and global im-
Although sustainability criteria are increasingly changing non-food biomass consumption pat- pacts in key planetary health outcome
considered, not all FBDG have included such terns in the EU have resulted in an increasing dimensions, i.e. human and environ-
aspects yet, and there is evidence that adop- land footprint of EU consumption outside EU mental health as well as socio-cultural
tion of FBDG with specific public health tar- boundaries. Popular initiatives to influence impacts.
gets does not necessarily support environmen- consumption choices via increased transparen- Improve system understanding focus-
tal health. Clearly, regional and target group cy in food and biomass value chains have since ing on nexus relationships between
specificity of sustainable diets need to be more been promoted by both civil society and private health and environmental impacts of
widely addressed by future research. sector organisations. However, there are lim- food and biomass production and con-
its to what can be achieved through voluntary sumption.
behavioural changes informed by value chain Build a systematic evidence base on
Effective policies lacking so far transparency. The still small number of studies the effectiveness of governance mea-
evaluating sustainability certification schemes sures in affecting food and biomass
Knowledge gaps about health and environ- point to highly context-specific impacts. consumption and production deci-
mental impacts notwithstanding, governments, sions.
civil society and the private sector around the Some countries have instead experimented Expand analytical system boundaries to
world are implementing policies and pro- with demand-side policies, such as taxes on study the role of non-food economic
grammes to govern food and biomass system unhealthy food components with ambiguous and policy factors in driving food and
dynamics. Equally important in affecting these results. The Danish fat tax, for example, was biomass system outcomes.
system dynamics are policies and socio-eco- abandoned after two years in 2013 for diverse, Improve regional and sectoral aggre-
nomic drivers that emerge in other sectors, including political, reasons. It was found to gation of modelling and simulation
such as the non-food industry, infrastructure have had a positive, but minor, effect on pub- tools and the empirical basis for their
and finance. Often, the resulting and frequent- lic health. parameterisation in order to inform
ly incoherent policy and incentive mix driving decision-makers with policy-relevant
the behaviour of actors along all food and bio- So far, the academic debate on dietary health scenario analyses.
mass value chains does not result in the desired impacts synthesised above takes place largely Mainstream the planetary health per-
behavioural outcomes. detached from research on the effectiveness of spective in the developing context and
supply- and demand-side interventions to in- stakeholder-specific policy recommen-
Commonly, a distinction is made between ternalise social and environmental externalities dations and dietary guidelines.
governance of the demand versus the supply of food and biomass systems. An exception is
side of food and biomass systems. Tradition- the growing empirical literature on consumer
ally, economists have argued that negative so- choice architecture, which points to a series of Jan Börner is a Professor at the Institute for
cial and environmental externalities from these promising and low-cost intervention options Food and Resource Economics & Center for
systems be ideally addressed by supply-side to nudge customers towards both healthier and Development Research at the University of Bonn,
policies, such as regulations, taxes or subsidies environmentally more sustainable consump- Germany.
imposed by governments. This intervention tion choices. This includes, for example, traf- Contact: jborner@uni-bonn.de
logic assumes that once food prices reflect the fic light labels on food packaging that indicate Ute Böthlings is a Professor at the Department
actual social and environmental costs of pro- health and environmental risks to induce more of Nutrition and Food Science at the University of
duction, end-consumers will automatically ad- sustainable consumption decisions. Bonn.
just their behaviour towards more sustainable, Contact: noethlings@uni-bonn.de
though not necessarily healthier, consumption Below we highlight key ingredients of a future
patterns. It may surprise, at first glance, that research agenda that addresses gaps and missing
there is little empirical evidence confirming links between the research fields summarised
References: www.rural21.com
this conjecture in the context of food and here.12 FOCUS
In the MUSEFO Project, women in care groups learn about topics like mother, infant and young child nutrition.
Photo: Dominique Uwira
Tackling the double burden of malnutrition
Many low- and middle-income countries are confronted with the phenomenon of nutrition transition. Using developments
in Cambodia as an example, our authors demonstrate the consequences this has for people’s health and the attempts
being made to address the issue.
By Dominique Uwira and Nicole Claasen
T he pace of change in demographics and
public health has quickened in recent
years. Among other factors, urbanisation, eco-
be observed in Cambodia. At the same time,
activity patterns shift towards a more sedentary
lifestyle, leading to a higher energy intake and
resulted in increased consumption of these
products, often also driven by aggressive food
marketing adapted to the local context.
nomic growth and technological inventions a lower energy expenditure in general.
have brought about changes in populations’ Against this background, two simultaneous
health and nutrition status which are described mechanisms within the context of globali-
by the US American nutrition and obesity re- How globalisation and the nutrition sation have an effect on dietary choices and
searcher Barry Michael Popkin with five broad transition interrelate consumption habits: dietary convergence (ho-
nutrition patterns, ranging from collecting mogenisation of diets with high consumption
food (1), through famine (2), receding famine The phenomenon of the nutrition transition is of animal-source foods, edible oil, sugar, salt
(3), nutrition-related non-communicable dis- the result of a number of demographic, eco- and low intake of a variety of staples and fibre;
eases (NR-NCD) (4) and, lastly, to behaviour nomic, social and behaviour changes that affect mainly driven by price) and dietary adaption
change (5). The shift between the patterns 3 to daily life in Cambodian society. Globalisation (increased consumption of brand-name pro-
5 is synonymous, for many, with the term nu- and the implementation of market-oriented cessed foods and meals eaten outside the home
trition transition, and its associations between agricultural policies during the last decades together with changes in household’s eating
nutrition and health are shown in the Figure. have led to a more liberal global agricultural behaviour; mainly driven by time constraints,
marketplace, which enabled food trade, higher advertising and availability). The change in
The rapid shift between the end of famine foreign direct investments and the expansion Cambodia is being brought about by the trend
and overeating along with the emergence of of transnational food companies. Thus, global- that fewer and fewer traditional healthy dishes
NR-NCD can be found in many low- and isation affects the availability of and access to are being self-prepared as more food is pur-
middle-income countries, including Cam- food by changing the way it is produced, pro- chased from outside the home, where it is
bodia. This pattern shift comes along with a cessed, procured, distributed and promoted. difficult to control ingredients and cooking
dietary shift from traditional, starchy, low va- This has led to major changes in the country’s procedures. Ultra-processed convenience food
riety, low fat and high-fibre diets towards di- food culture, with significant shifts in dietary has become readily available even in the most
ets with increased low-quality fat, sugar and patterns and individual nutritional status. High remote areas, where it relieves busy mothers
refined carbohydrates, and processed foods foreign direct investments in processed foods increasingly entering the workforce of their
– the so-called Western diet, which can also made them available on local markets, which already heavy burden at home.RURAL 21 03/20 13
Apart from globalisation, other factors such same year. Six of the top ten causes of disabili- ince found prevalence of impaired glucose tol-
as modernisation, urbanisation, and contin- ty-adjusted life years (a measure of overall dis- erance (preliminary stage of diabetes), diabetes
ued economic growth paired with increased ease burden, expressed as the number of years and hypertension of 10 %, 5 %, 12 % (SR) and
household income and wealth have ampli- lost due to ill-health, disability or early death) 15 %, 11 %, 25 % (KC) respectively. These
fied these dynamic shifts in everyday lifestyle, in Cambodia in 2017 were NCDs, with re- findings were unexpected to this degree as
dietary intake and physical activity patterns markable increases in the burden of strokes and Cambodian society, in particular in those two
amongst the Cambodian population. The shift diabetes over the last decade. areas, is relatively poor and the lifestyle is fairly
from traditional diets to Western-style diets traditional. Two-thirds of the study partici-
has been a key contributor to increased obesity In terms of consumption patterns during the pants with diabetes as well as half of the par-
rates in this Southeast Asian country. As in- complementary feeding period, a study con- ticipants with hypertension were unaware of
come continues to rise, individuals can afford ducted by Pries et al. (2017) showed that a their condition – an alarming result given the
an abundance of high-calorie convenience considerable proportion of the children aged negative long-term effects of these conditions
foods whilst at the same time becoming less six to 23 months in Cambodia’s capital Phnom left untreated. As obesity prevalence in Cam-
active, leading to increases in obesity and obe- Penh were fed with infant formula and pow- bodia is quite low, genetic susceptibility to di-
sity-related chronic illnesses such as diabetes dered milk. Drinks containing high amounts of abetes and metabolic adaptions to early nutri-
and heart disease. sugar (soft drinks, fruit drinks, chocolate-based tional deprivations during the Khmer Rouge
or malt-based drinks) were consumed by up time were considered as possible explanations
to 20 per cent of the children aged 12-23 for the study’s findings.
The double burden of malnutrition – months. Within the same age group, com-
a particular challenge for Cambodia mercially produced snack foods were the third
most commonly consumed food group, with Addressing all forms of malnutrition
The new dynamics and the altered nutrition a preference for savoury snack foods, such as with a multisectoral and multi-level
situation have led to an emerging twofold chal- chips or crisps. In the study sample, snack foods approach
lenge called the double burden of malnutrition, were more commonly consumed than micro-
meaning that undernutrition - described by nutrient-rich fruits and vegetables. The results In order to address the problem, the Deutsche
wasting, stunting and micro-nutrient deficien- indicate that regular consumption of commer- Gesellschaft für Internationale Zusammenar-
cies - and overweight or obesity coexist within cially produced snack foods is very common beit (GIZ) launched the Multisectoral Food
the same generation and household, and even in children under the age of two years in the and Nutrition Security (MUSEFO) Project in
among the same individuals throughout their urban setting of Phnom Penh. Mothers said the two provinces Kampong Thom and Kam-
lifetime. In the specific case of Cambodia, the the main reasons for feeding this type of food pot in 2016. Activities are carried out in the
double burden of malnutrition is characterised to their children were that the child liked the health, nutrition, WASH (water, sanitation
by high prevalence of child stunting (32.4 %, snack food and demanded or cried for it. 21.5 and hygiene) and agriculture sectors at house-
2017) and anaemia in women of reproductive per cent of them also believed these snacks hold, village, provincial and national levels.
age (46.8 %, 2016), whilst NCD rates were si- were healthy for their child.
multaneously estimated to account for 64 per With policy advice at national level, the proj-
cent of all deaths in 2016, and communicable, A study conducted in a rural community in ect supports the integration of food security
maternal, peri-natal and nutrition conditions Siem Reap (SR) province and in a semi-urban and nutrition aspects in national policies and
accounted for 24 per cent of all deaths in the community in Kampong Cham (KC) prov- guidelines. This has resulted in the country’s
2nd National Strategy for Food Security and
Nutrition (NSFSN, 2019–2023) acknowledg-
Patterns 3 to 5, illustrating the nutrition transition ing the double burden of malnutrition within
the Cambodian context and declaring the pro-
Urbanisation, economic growth, technological changes for work, leisure, motion of healthy diets and nutrition-sensitive
food processing, mass media growth
food value chains as priority actions, among
Pattern 3 Pattern 4 Pattern 5 others. Food policy changes are seen as a major
Receding Famine Degenerative Disease Behavioural Change option for improving nutrition, but they will
not be adequate without shifting the culture of
• starchy, low variety, low • increased fat, sugar, • reduced fat, increased
eating. Therefore, the project has created care
fat, high fibre processed foods fruit, veg. CHO, fibre groups at local level that provide a platform for
• labour-intensive work/ • shift in technology of work • replace sedentarianism women to meet on a regular basis and learn
leisure and leisure with purposeful changes
in recreation, other activity
about mother, infant and young child nutri-
tion, childcare and hygiene practices, focusing
on interpersonal behaviour change communi-
MCH deficiencies, obesity emerges, reduced body cation. The leaders of the care groups, who
weaning disease, bone density problems fatness, are community-based health volunteers, meet
stunting improved bone health regularly with project staff for training and su-
pervision. They are responsible for continuous
Slow mortality decline Accelerated life expectancy, Extended health ageing, training and coaching of the care group mem-
shift to increased NR-NCD, reduced NR-NCD bers in care group sessions and during home
increased disability period
visits. In the sessions, the group leaders share
MCH = Mean Corpuscular Hemoglobin; CHO = carbon, hydrogen, oxigen Source: Popkin, 2002
insights on nutrition and health and encour-14 FOCUS
age participants to put their newly acquired THE MANY FORMS OF MALNUTRITION
knowledge into practice at household level
and within their community. Training and Malnutrition occurs in different forms – it is a collective term that includes undernutrition (underweight,
empowering people, in particular pregnant stunting, wasting), micronutrient deficiencies and overweight and obesity, often leading to nutrition-re-
and breast-feeding women, and supporting lated non-communicable diseases (NR-NCD), disproportionately affecting the poorest, minorities and
people most vulnerable to food insecurity. Wasting, defined as low weight-for-height, indicates a recent
efforts of citizens working together to change
and severe weight loss due to acute undernutrition, while stunting is defined as low height-for-age and
their communities and regain food sovereignty
results from chronic undernutrition which is usually associated with poor socio-economic status, poor
is key. In addition, nutrition-sensitive agricul- health and inappropriate child feeding early in life. A child suffering from underweight, measured as low
tural activities are implemented using seasonal weight-for-age, might be wasted, stunted or both. Overweight and obesity on the other hand are defined
calendars combining agricultural practices with as an excessive fat accumulation. Persons affected by this condition are too heavy for their height.
nutrition and health information and practical
cooking recipes for young children. The sea-
sonal calendars are supporting farmers to iden- Response Plan. The CNCDA has just been are some key interventions that can be consid-
tify the right timing and techniques for culti- awarded its first grant by the Solidarity Fund ered for most of those countries. Overnutrition,
vation and harvest. on NCDs and COVID-19, which was officially and especially obesity, have been largely ignored
launched mid-July 2020 by the NCD Alliance. in national nutrition and health strategies with-
The MUSEFO Project looked into possibil- Activities in the 2020 Action Plan include: in those countries that are still characterised by
ities to promote healthy snacking options. It high prevalence of undernutrition. Keeping in
worked together with food vendors from the Identify and recruit champions to raise mind the tremendous long-term public health
target areas to develop recipes for healthy awareness of key messages and advo- and economic consequences that come along
snacks such as brown rice waffles with morin- cate for greater attention to NCDs. with the double burden of malnutrition, rapid
ga, purple sweet potato smoothies or ice cream Produce evidence-based policy briefs policy and programme shifts are needed to ad-
with pink dragon fruit and unsweetened co- to provide information to deci- dress all forms of malnutrition. It is well-known
conut milk. The recipes were tested with the sion-makers who support key advoca- from high-income countries that the treatment
target group and are currently compiled in a cy priorities. and management of NR-NCDs is extremely
recipe booklet for the wider population. Produce written content and dissem- expensive. Low- and middle-income countries
inate key messages via social media are particularly challenged regarding allocating
channels and other communication funds within their health budgets for treatment
Forming of an alliance to fight NCDs platforms. options as they are already struggling to pro-
Produce fact sheets on NCD risk fac- vide for primary preventive undernutrition
Beyond the activities of the MUSEFO Proj- tors and main diseases in Cambodia. care. Currently, prevention efforts are the only
ect, GIZ has established the Cambodian NCD Identify ways to increase the involve- feasible approach to address the upcoming ep-
Alliance (CNCDA). The CNCDA was offi- ment of people living with NCDs and idemic of NR-NCDs in countries affected by
cially launched in March 2019 to call for great- document lived experiences of NCDs. the double burden of malnutrition. Progressive
er action to tackle the rising burden of NCDs, Expand and diversify CNCDA mem- changes in government policies at national and
and build a new platform for collaborative ac- bership by establishing connections alignment with subnational levels, law regula-
tion. The mission of CNCDA is to put NCDs with key stakeholders across multiple tion and enforcement, alongside shifts in local
firmly on the political agenda, by joining forc- sectors. food systems, from production to marketing,
es with those working on NCDs and their risk purchasing and consumption as well as individ-
factors to build a platform for collaborative ual behaviour changes are of the essence when
advocacy and a common agenda to acceler- Policies and food systems must change it comes to improving the way people grow
ate action and mobilise resources necessary to food, work, eat, move and enjoy life.
prevent and control NCDs among the Cam- Many low- and middle-income countries have
bodian population. The CNCDA is currently seen substantial economic growth in the last
an informal alliance, with its secretariat based decades, with rising income and therefore in- Dominique Uwira is Advisor for Deutsche
in Phnom Penh. So far, the CNCDA has 22 creased purchasing power of the consumers Gesellschaft für Internationale Zusammenarbeit
members consisting of civil society, bilateral along with changing lifestyles, making them (GIZ) in the Multisectoral Food and Nutrition
and multilateral agencies, academia, research- particularly susceptible to the nutrition tran- Security (MUESEFO) Project in Cambodia. Her
ers, relevant ministries and government agen- sition. The food industry plays a major role in focus lies on the SUN Donor Network Co-ordination
cies, patient groups and people living with the structural flaws that affect the most vul- and Social Behaviour Change Communication.
NCDs who share its mission and vision. nerable groups the hardest. With new glob- Nicole Claasen is Policy Advisor with Deutsche
al actors such as transnational agri- and food Gesellschaft für Internationale Zusammenarbeit
The CNCDA has developed its first annual businesses, including global and local food and (GIZ), working for the Cambodian Council
Action Plan to provide a framework for NCD beverage producers and food service compa- for Agricultural and Rural Development. The
prevention and control activities. The focus was nies, but also local food retailers increasingly scope of her work encompasses multi-sectoral
initially on accelerated action on the prevention influencing food production and subsequent coordination, subnational integration and advocacy
of NCD risk factors and sustainable financing food purchases, the challenges posed for obesi- work for food security and nutrition in Cambodia.
for NCDs. However, the impact of the re- ty and NR-NCD prevention are great. Contact: Nicole.Claasen@giz.de.
cent COVID-19 pandemic has shifted it with
the CNCDA now calling for the inclusion of While the manifestation of the nutrition tran-
References: www.rural21.com
NCDs in the national COVID-19 Preparedness sition differs across countries and regions, thereYou can also read
