Food systems as syndemic drivers
For all their past successes in feeding human populations and improving their health and life expectancy, the current food systems are becoming more industrialised, globalised, and dominated by large actors capable of economies of scale and of maintaining long supply chains. These systems are now also becoming the source of failures that are impossible to ignore. Although sufficient food is produced to meet the dietary energy requirements of the global population, undernutrition and micronutrient deficiencies still affect more than a third of the world’s population.89 Agricultural systems tend to favour energy-rich staple food production, without sufficient attention to nutrient-rich foods. In many regions, vegetables, fruits, and animal-source foods are often expensive or inaccessible, resulting in monotonous diets low in nutritional quality. Furthermore, ultra-processed foods are a key driving force in the global obesity pandemic; nearly 2 billion people are overweight or have obesity.34 The food system is also driving unprecedented environmental damage, contributing up to 29% of anthropogenic greenhouse-gas emissions and causing rapid deforestation, soil degradation, and massive biodiversity loss.52, 90
A fundamental reorientation of food systems is required — superficial repairs at the edges will not deliver the global outcomes needed for the 21st century.91 Momentum at the global and local level is building for this fundamental change. Conceptualising the current food systems as a major driver of The Global Syndemic could contribute to that momentum by articulating common drivers and interactions of obesity, undernutrition, and climate change and in the identification of double-duty and triple-duty actions that address them.23, 92
Global meat production has increased 4–5 times from 71 million tonnes annually in 1961 to 318 million tonnes in 2014, and is projected to increase further to 455 million tonnes in 2050.93 This increase reflects growth in demand from both global population increase and an increase in per-capita consumption from 20 kg to 43 kg per person per year from 1961 to 2014, linked to growing incomes and changing dietary preferences. 93 This level of production and consumption of red meat is a substantial driver of The Global Syndemic.
Although animals are an integral part of many well-functioning agroecological systems and permanent pastures on which animals graze can be important carbon sinks, livestock production is a major contributor to climate change (19% of all greenhouse gasses94). The greenhouse gasses are related to methane emissions from enteric fermentation, nitrous oxide emissions from manure and fertiliser application, and the considerable inputs required to grow cereal and oilseed crops for use as livestock feed in industrial livestock farming.95 Livestock also use approximately 70% of global agricultural land and are a prime driver of deforestation.93, 95 Intensive production systems also contribute substantially to localised pollution through effluents and air pollution.
The links between excess meat consumption and obesity and related NCDs are also well known. Excess meat consumption can contribute to obesity.96, 97 Red meat consumption (particularly processed meat) is associated with increased risk of NCDs including cardiovascular disease,98 type 2 diabetes, 99 and some cancers.100
Animal-source foods, including meat, provide a rich source of highly bioavailable micronutrients, especially for young children, and make an important contribution to high quality diets when consumed in moderation.101 In many regions, livestock production is also an important contributor to livelihoods, household income, and national wealth, and in semi-arid and arid areas there are often few other productive land uses. However, production of feed for livestock can divert food away from direct human consumption, and threaten food security and the livelihoods of populations displaced by the expansion of crop land for feed production, which is also an important cause of deforestation.
The manufacture of ultra-processed foods and sugary drinks is based on inexpensive commodity ingredients such as sugar, flours, and oils, often with multiple preservatives, colourings, and flavourings. These products are typically energy-dense and nutrient-poor, and offer excessive amounts of energy, fat, sugar, or sodium.102 Examples include snack products such as chips or crisps, ready-to-eat cereals, sugary drinks, and confectionery. By design, these products are highly palatable, cheap, ubiquitous, and contain preservatives that offer a long shelf life. These features, combined with aggressive industry marketing strategies, contribute to excessive consumption and make these products highly profitable for the food, beverage, and restaurant industry sectors that are dominant actors in the global food system.73, 103 The governance systems that created the operating conditions that favour large companies that produce ultra-processed food and beverage products include: subsidies for their commodity ingredients, deregulated business operating environments, weak or ineffective accountability systems for the human health and environmental externalities that result from their production and marketing, and industry’s privileged access to policy makers and decision makers to maintain these business operating conditions. This constellation of policy incentives reinforces the existing food system that produces cheap products with high profit margins through long, complex global value chains.66
Although not all ultra-processed foods are unhealthy, a high intake of these food and beverage products is linked to poor diet quality, obesity, and diet-related NCD risks.73 These products (eg, cheap instant noodles and biscuits) might also contribute to undernutrition and micronutrient deficiencies by displacing more nutritious whole foods. The high consumption of commercial snack foods is common in the diets of infants of complementary feeding age in several LMICs.104 For vulnerable groups, especially infants and children living on marginal-quality diets, ultra-processed food and beverage products can contribute to both obesity and stunting.62, 105
Food processing is generally considered to have a relatively small environmental effect compared with other stages of the food supply chain, such as agricultural production or transportation. For example, in the UK, food manufacturing and packaging is responsible for 19% of total food chain greenhouse-gas emissions, with agricultural production (at the farm level) accounting for much of the remainder.106 However, this figure overlooks the environmental effects generated across all stages of the food system by ingredients that are eventually used in ultra-processed foods. In Australia, ultra-processed food consumption is estimated to contribute more than a third of the total diet-related environmental effects; 35% of water use, 39% of energy use, 33% of carbon dioxide equivalents, and 35% of land use.107 If dietary trends continue, per-capita greenhouse-gas emissions from empty calories are estimated to nearly double by 2050.108 Therefore, reduction of ultra-processed food consumption is a priority for reducing the environmental effects of the food system.
Growing consensus on the need for healthy, sustainable food systems
The number of authoritative reports that have called for fundamental changes to food systems to make them healthier, more sustainable, and more equitable is large and growing rapidly.23, 68, 91, 109, 110, 111, 112, 113, 114 The timely and concurrent publication of several reports in the early years of the UN’s Decade for Action on Nutrition has created an invaluable consensus that radical changes to the food system are urgently needed. The opportunities and recommendations arising from these reports to promote planetary health include developing sustainable and healthy cities, encouraging more resilient health systems and disaster preparedness, reducing food waste, preserving ecosystems, and redirecting harmful subsidies in the food, agriculture, fishery, and energy sectors.115 Many of these recommendations relate directly to reduction of greenhouse-gas emissions and implementation of effective climate adaptations.
The primary collective authority for climate change are the parties to the UN Framework Convention on Climate Change (UNFCCC). This international agreement has a process to update the science through regular IPCC assessments and progressively gain commitments from Member States to reduce greenhouse-gas emissions. However, the IPCC does not make recommendations for specific actions, and, under the 2015 Paris Agreement that complements the UNFCCC, Member States or national governments are left to define their own targets and how they will achieve them. Furthermore, the incorporation of agriculture into government actions and targets has been highly contested and very sluggish.
Double-duty or triple-duty actions for food systems
A wide variety of food systems exist within which transformations are needed. They span the traditional food systems, with local production and markets, low-level processing, poor storage, low diversity, little marketing, and low quality and safety standards, through to the modern food systems, with global production sites, multiple access points, high-level processing, secure supply lines and storage, high diversity, abundant marketing, and high safety standards.91 Transformation should be based on the principle that food systems, regardless of variation between countries and regions, must promote health, environmental sustainability, social and health equity, and economic prosperity.
As a starting point to identify double-duty or triple-duty actions to create healthy, sustainable food systems, we examined the degree to which existing recommendations for improving nutrition and physical activity could also support climate change mitigation or adaptation. The Commission identified 66 reports published by UN agencies and independent groups between 2007 and 2017, related to obesity, undernutrition, climate change, or physical activity. Of the most recent reports with high-authoritative impact (n=11), a subset of reports (n=5) presented 255 specific recommendations for governments (appendix p 13).
The individual recommendations for governments were extracted from the five reports and categorised into overarching domains for nutrition or physical activity. We used the domain structure of the two most recent high-level reports, the High-Level Panel of Experts on Food Security and Nutrition’s Report on Nutrition and Food Systems 201791 and WHO’s Global Action Plan on Physical Activity 2017.116 Many of the recommendations were replicated across reports. Therefore, the main recommendations were condensed into 36 across 10 domains for nutrition and 74 across 16 domains for physical activity. Two commissioners with climate change expertise provided indicative ratings on the condensed set of recommendations according to their likely effects on mitigation of, or adaptation to, climate change (Table 1, Table 2; appendix p 14).
Table 1 Nutrition recommendations, drawn from High Level Panel of Experts Nutrition and Food Systems Report, scored for potential effects on climate change mitigation and adaptation
|Potential climate change effect|
|Strengthen the integration of nutrition within national policies, programmes, and budgets|
|Strengthen the integration of nutrition within national policies, programmes, and budgets||5||5|
|Improve nutrition literacy and the nutrition workforce capacity||4||2|
|Strengthen global cooperation to end malnutrition and hunger|
|Increase official development assistance and avert famines by strengthening local food systems||4||5|
|Address the effects of trade and investment agreements on food environments and diets|
|Ensure that trade and investment agreements favour more sustainable food systems||2||2|
|Address the nutritional vulnerabilities of particular groups|
|Ensure that vulnerable and marginalised groups can achieve an appropriate and nutritious diet||2||3|
|Improve nutritional outcomes by enhancing women’s rights and empowerment|
|Ensure that laws and policies provide men and women equal access to resources||2||2|
|Strengthen rural women’s participation at all levels of policy making for Food Security and Nutrition||2||3|
|Create an enabling environment for breastfeeding||2||1|
|Recognise and address conflicts of interest|
|Ensure transparency and accountability mechanisms to prevent and address conflicts of interest||2||2|
|Protect nutrition sciences against undue influence and corruption||2||1|
|Improve data collection and sharing of knowledge on food systems and nutrition|
|Promote research on food systems and food demand||2||2|
|Improve the availability and quality of multisectoral information systems that capture nutrition-related data||2||2|
|Invest in systems for knowledge sharing among stakeholders in the food supply chain||3||5|
|Enhance opportunities to improve diet and nutrition outcomes along food supply chains|
|Support the production of nutritious, locally-adapted foods||3||3|
|Protect and enhance nutritional value along food supply chains||2||2|
|Improve the quality of food environments|
|Implement policies that make healthy foods more accessible and convenient and restrict advertising of unhealthy food||3||2|
|Regulate health claims on food and adopt a front-of-pack food labelling system||2||1|
|Strengthen national food safety standards and surveillance systems||1||1|
|Institute policies that implement the International Code of Marketing of Breast-milk Substitutes||1||1|
|Create consumer demand for nutritious food|
|Develop guidelines for healthy and sustainable diets||2||2|
|Implement economic and social policies that increase demand for nutritious foods and lower demand for nutrient-poor foods||3||2|
|Ensure that social protection programmes, such as school feeding, lead to improved nutritional outcomes||2||1|
|Promote food cultures, including cooking skills and the importance of food in cultural heritage||2||2|
Key for rating of recommendations on mitigation and adaption: 1=no effect; 2=small effect; 3=moderate effect; 4=average effect; 5=substantial effect.
Table 2 Abbreviated recommendations for physical activity and indicative potential for effect on climate change
|Potential climate change effect|
|Implement communication campaigns to raise awareness of the benefits of physical activity|
|Develop a national communication campaigns on the benefits of physical activity||2||2|
|Support partnerships between health and other sectors to promote physical activity||2||2|
|Implement mass-participation initiatives and provide access to physical activity experiences|
|Implement accessible events, providing opportunities to be active in local public spaces||2||2|
|Strengthen training of health and non-health professionals in opportunities to develop an active society|
|Include training on physical activity in professional development of staff in health and non-health sectors||2||2|
|Collaborate with road safety experts to strengthen stakeholders’ understanding of approaches to improve road safety||3||1|
|Promote active and public transportation through policies and infrastructure|
|Support community-influenced transportation and urban planning policy and regulations that promote active and public transportation||4||1|
|Support evaluation of transportation and urban planning policies and interventions to assess effects on health and environment||4||1|
|Promote policies that create highly connected, safe neighbourhoods that are accessible using active and public transportation||3||3|
|Support the strengthening of road safety legislation and interventions||2||1|
|Strengthen access to recreational spaces and facilities for all|
|Promote policies enabling access to open spaces and sports facilities||2||2|
|Evaluate effects of open spaces on health and environmental benefits||3||3|
|Implement marketing restrictions on unhealthy food and beverages in and around open public spaces and sports facilities||2||1|
|Strengthen frameworks to promote physical activity in and around buildings and facilities|
|Support building designs and regulations prioritising universal access and physical activity among users||2||2|
|Strengthen provision and enjoyment of physical education and active recreation|
|Strengthen national leadership, policy, and guidance to promote physical education and active recreation for children||2||1|
|Promote walk and cycle to school programmes||3||2|
|Implement physical activity assessment, advice, and referral into health and social care services|
|Implement protocols in health and social care for patient assessment, brief advice, and referral for physical activity, including for vulnerable groups||1||2|
|Enhance provision of, and opportunities for, physical activity in wide-ranging work and leisure settings|
|Promote national guidance, and implementation of workplace health programmes to increase physical activity among employees||1||1|
|Partner with government and the sports community to strengthen provision of universally accessible opportunities for active recreation||2||2|
|Evaluate the effectiveness of fiscal instruments to promote physical activity||1||1|
|Strengthen programmes to increase physical activity in the least active groups|
|Implement policies and programmes to increase physical activity among older adults, the least active, and disadvantaged groups||1||1|
|Implement whole-of-community initiatives to promote widespread participation in physical activity|
|Implement whole-of-community approaches to promote physical activity, and share guidance, resources, and experiences||2||2|
|Strengthen leadership, governance, and policies to increase physical activity|
|Strengthen high level leadership, strategic planning, and guidance for physical activity||2||2|
|Strengthen action plans on physical activity and maximise cooperation across relevant sectors||2||2|
|Enhance monitoring and accountability for physical activity|
|Strengthen comprehensive population surveillance of physical activity and its determinants||2||2|
|Strengthen research and evaluation capacity and strengthen innovations for policy solutions to increase physical activity|
|Provide funding for institutions to undertake physical activity research and evaluation||1||1|
|Strengthen knowledge sharing on physical activity to advance research, policy implementation, and resource use||1||2|
|Escalate advocacy efforts to increase action at multiple levels, targeting key audiences|
|Strengthen collaborative partnerships to support engagement for increasing physical activity||2||2|
|Strengthen financing mechanisms to support action and policies to increase physical activity|
|Develop long-term, dedicated financing mechanisms to support physical activity||2||2|
Key for rating of recommendations on mitigation and adaption: 1=no effect; 2=small effect; 3=moderate effect; 4=average effect; 5=substantial effect.
Most of the nutrition recommendations had at least a small potential to affect climate change, and some offered substantial potential (table 1). The Commission found that reframing recommendations to create healthy and sustainable diets would considerably strengthen their ratings. The existing nutrition recommendations that we identified offer great opportunities to promote double-duty or triple-duty actions. However, the multiple benefit outcomes from implementing the recommendations must be more strongly emphasised by governments to promote climate change mitigation.
Investment needed to improve nutrition
Financial costs are often highlighted as a barrier to implementation of recommendations. The World Bank has estimated that an additional investment of $70 billion over 10 years would be needed to achieve the WHO global targets for stunting, anaemia in women, exclusive breastfeeding, and upscaling the treatment of severe wasting by 2025.117 These estimates show that achieving the task is possible by addressing the underlying determinants and implementing nutrition-specific programmes. Similar analyses from the World Bank could also include estimates of the resources required to achieve the WHO targets of no increases in adult and childhood obesity, and address the climate change consequences of our current food system.
Estimating the potential costs and impacts of achieving obesity prevention policies is challenging, but the experience of Mexico is instructive. Bloomberg Philanthropies invested in civil society actions and research over several years to achieve greater public awareness of the need for policy actions for reduction of the prevalence of diabetes and its complications, to press for measures such as taxes on sugary drinks and junk food, and more generally for social change that supports action on food and obesity (panel 7). Mexico’s approach of providing philanthropic funding to consumer and health non-governmental organisations (NGOs), to create public pressure for healthy policies, and to researchers, to evaluate their impact, could be applied in many other countries with adequate civil society and academic capacity. An investment of $1 billion from philanthropic and other sources could plausibly support 100 countries to apply Mexico’s approach to hasten the global implementation of recommended food and nutrition policies to support obesity prevention. A focus on policies with double-duty or triple-duty actions would further facilitate a return on investment.
Mexico provides an example of how mobilisation of civil society can generate commitment to policy change — in this case the introduction of a national tax on sugary drinks. The Alliance for Healthy Food, a coalition of civil associations, social organisations, and professionals concerned about the epidemic of overweight and obesity in Mexico, had a key role in mobilising public support and government commitment to implementation of a tax on sugary drinks in 2014. The Alliance launched a multipronged communications campaign to raise public awareness of the risks of sugary drinks, engaged directly with members of Congress, and entered into dialogue with the Ministry of Finance. These efforts coincided with a policy window as Mexico’s elected President and legislature supported the adoption of a sugary drinks tax to raise revenue within a broader fiscal reform agenda.15
The Alliance campaigned for a 20% tax on sugary drinks to decrease consumption. After fierce opposition from the food and beverage industry, Mexico’s Government passed a 1 peso per litre sales tax on Jan 1, 2014, that effectively increased the cost of sugary drinks by 10%. The tax was part of a suite of anti-obesity measures implemented after 2014, which included standards for healthy school meals, front-of-pack nutrition labels on packaged foods, and a ban on certain junk food advertisements aimed at children. Efforts by the food and beverage companies substantially weakened the marketing and front-of-package labelling system that reduced the overall effectiveness of Mexico’s obesity prevention policies. An evaluation of the average effect of the sugary drinks tax between 2014 and 2016, found that consumers reduced their sugary drinks purchases by 7·6%. The effect was greatest among low-income households that reduced their sugary drinks purchases by 11·7%.118
Substantial investment in civil society action would greatly encourage the achievement of the objectives of the Decade of Action on Nutrition and the SDGs, as well as offering an important counterweight to the enormous commercial investments focused on promoting sales of obesogenic products and opposing public policies for healthier food environments.119 For example, Coca-Cola intends to invest more than $10 billion to promote business growth in India, China, and the Philippines alone.120
Voluntary, quasi-regulatory, and regulatory approaches to improving food systems
Experience from public-private partnerships involving voluntary actions with weak monitoring and accountability structures indicates that these partnerships tend to lose the support of civil society and have limited impacts. One such example is an analysis of the UK Public Health Responsibility Deal (appendix p 17). The Partnership for Healthy America provides a demonstration of partnership arrangements with the food industry that have stronger accountability structures, through agreed targets for reductions in calories and the provision of healthier foods.121 These agreements with industry incorporate an external, independent evaluation, and the outcomes of the partnership are included within Partnership for Healthy America’s annual reports.122
In the UK, Public Health England has taken engagement with the food industry a step further by conducting a structured product reformulation for sugar. Through this process, the government sets targets to reduce total sugar volumes sold by food category (appendix p 22). Such quasi-regulatory approaches could be important steps in achieving healthier food environments, provided that governments are prepared to implement regulation when industry actions are inadequate.86
The best example of a strong regulatory approach comes from Chile, where the extraordinary commitment of politicians, led by Senator Dr Guido Giradi, has seen a step change in international best practice for a combined portfolio of food labelling, taxation, and regulation of marketing (panel 8). Academia and civil society organisations have strongly supported these policies, but the hallmark of Chile’s progress is its political leadership, which compares favourably with the progress seen in New York City during Michael Bloomberg’s years as mayor.123
Three-quarters of Chileans are either overweight or have obesity. As a physician and later in my role as Senator, since 2006, this health issue has been of great concern to me. Since assuming the Presidency of the Senate’s Health Commission in 2011, I have sought to tackle this challenge head-on, by exploring a law capable of dealing with the — not always obvious — underlying causes, such as the marketing strategies promoting unhealthy foods.
Key to bringing this discussion into the Senate was forming a strategic alliance with the research community, spearheaded by Dr Ricardo Uauy, one of the world’s leading nutrition specialists. This alliance provided the evidence base and credibility necessary to garner the support and momentum for change.
Before even contemplating any specific proposals, one of the first challenges encountered was how to define unhealthy food and identify its negative health impacts. Our second challenge was to harness this evidence to effectively demonstrate that there was a need for a law to tackle the issue. This was not without a great deal of resistance, of course. The food industry, marketing companies, and politicians of the opposition alike, all claimed that there was no valid basis for the law.
These challenges prolonged the process of passing of the law, so much so that it wasn’t until after four years of Senate discussions, including on traffic light labelling of foods versus warning labels, that the law was finally approved in 2012. The journey had only just begun — we still needed to obtain the signature of the President and define regulatory norms (including a nutrient profile system and warning label format).
The Chilean President at that time, Sebastián Piñera, faced enormous pressure from the food industry and subsequently vetoed the bill. With several other Congressmen, we staged daily demonstrations, posters-in-hand emblazoned with messages including “Our President, selling out the health of our children”, at the gates of the Presidential Palace. The pressure was fierce, and ultimately led to the reinstatement of the law. However, after a further year of discussion, the Ministry of Health proposed a weak set of regulatory norms inconsistent with the law’s original aim.
In 2014, Michelle Bachelet became President, supported by the political coalition of which I am a part. She swiftly halted the approval of the regulatory norms proposed by the previous government, and formed a new Committee drawing on the participation of academia, government, and civil society to propose new regulatory norms consistent with the original spirit of the law. This was met by strong opposition from the Finance and the Agriculture Ministers and propagated by extensive media coverage. In response, a group of Senators pledged that they would leave the President’s coalition if the law was not approved. This unwavering conviction finally secured the approval of the regulations in June, 2015, allowing for their gradual implementation over the 3 years that ensued.
I am pleased with the law and all that we have achieved, but conscious that its enforcement will require both continuous monitoring by society and accountability from policy makers. The rigorous evaluations underway will certainly improve the law’s application, and I am thrilled that several countries are following Chile’s lead towards better regulation.
Contributed by Senator Dr Guido Giradi, Chile.