Management HW8

Importance of government policies and other inﬂuences in transforming global diets W Bruce Traill, Mario Mazzocchi, Bhavani Shankar, and David Hallam The Second International Conference on Nutrition, organized by the Food and Agriculture Organization of the United Nations and the World Health Organization, will take place in November 2014. In 1992, the First International Conference on Nutrition declared, “Hunger and malnutrition are unacceptable.” Twenty-two years later, it is timely to revisit the state of global nutrition and examine the forces that have brought change to diets worldwide. Calorie availability has increased throughout the world, even in the least-developed countries, where per capita availability has grown by 10%. As a consequence, the proportion of undernourished people has fallen, yet obesity has emerged as a major public health concern, primarily in developed countries but also among the growing middle classes in middle- and low-income countries. Globally, the nutrition transition has been aﬀected by increased intakes of livestock products, processed foods, and fast foods.

These changes are most readily explained by economic growth, urbanization, and globalization. International trade and liberalization of investment have been the key policy drivers of dietary change.

© 2014 International Life Sciences Institute INTRODUCTION The Second International Conference on Nutrition, orga- nized by the Food and Agriculture Organization of the United Nations and the World Health Organization, will take place in November 2014. The period since the First International Conference on Nutrition, held in 1992, has seen signiﬁcant changes in global nutrition. While the number of undernourished has remained between 800 and 900 million, 1its share of the world population has fallen. The number of overweight people worldwide, however, has leapt to over 1 billion from levels so low even most developed countries did not consider them worth counting in 1992. 2 The aim of this article is to describe and discuss the dietary and nutritional changes that have occurred since the 1992 International Conference on Nutrition byattempting to untangle the multitude of factors that have contributed to such changes, with particular reference to the role and importance of public policies that inﬂuence food prices and/or food availability, particularly agricul- tural policies (e.g., reform of the Common Agricultural Policy), trade and investment policies (e.g., the Uruguay Round Agriculture Agreement), and consumer-oriented policies (e.g., domestic and international food-assistance programs). To this end, a wide range of literature, from detailed global trade models to country-speciﬁc descrip- tions of change, has been utilized. The evidence has been analyzed through an economic lens, although the approach used for identiﬁcation and assessment was much broader than the traditional neoclassical econom- ics approach. Figure 1 diagrams the framework for the discussion of dietary change presented here. The inﬂu- encing factors are divided into two broad sets. One set, Aﬃliations:WB Traillis with the Department of Food Economics and Marketing, University of Reading, Reading, UK.M Mazzocchiis with the Department of Statistical Sciences, University of Bologna, Bologna, Italy.B Shankaris with the Leverhulme Centre for Integrative Research in Agriculture and Health and the School of Oriental and African Studies, University of London, London, UK.D Hallamis with the Trade and Markets Division, Food and Agriculture Organization (FAO), Rome, Italy.

Correspondence:WB Traill, Department of Food Economics and Marketing, University of Reading, PO Box 237, Reading RG6 6AR, UK.

E-mail: [email protected], Phone:+44-118-378-8389.

Key words: diet, food, globalization, policy bs_bs_banner Nutrition Science↔Policy doi:10.1111/nure.12134 Nutrition Reviews® Vol. 72(9):591–604591 categorized as “trending factors,” captures the important developments over the last 20 years in technology, glo- balization, population, urbanization, and other sociode- mographic factors such as the increased participation of women in the workforce. Another set includes the range of government policies that impinge on diets. These are divided into trade policy, domestic policy relating to agri- culture and food, and consumer policy. Both sets of factors inﬂuence food consumption and dietary quality via two pathways. One pathway operates through “income eﬀects,” wherein sociodemographic trends or govern- ment policies induce changes in income and its distribu- tion, thereby inﬂuencing people to change their consumption patterns. The second pathway operates through food prices, food availability, and consumer food preferences, all of which can be altered by trends and policies. Changes in food consumption (operating in con-junction with other determinants) have implications for both over- and undernutrition.

BACKGROUND: DIETARY CHANGE As the Chicago Council on Global Aﬀairs 3acknowledges, the shift from early death due to communicable diseases and undernutrition to later death from chronic noncom- municable diseases often associated with overnutrition is primarily a story of technological, social, and economic success. In developed countries, deaths from diet-related noncommunicable diseases have fallen steadily, 2and life expectancy is little, if at all, diminished by being obese. 4 However, it is an incomplete success for the many coun- tries where rural and child hunger remains common and where advances in healthcare systems have yet to dimin- ish the adverse health eﬀects of overnutrition. Such coun- Figure 1Inﬂuences on food consumption. Nutrition Reviews® Vol. 72(9):591–604 592 tries are aﬀected by what has become known as the double burden of malnutrition. Indeed, it has become apparent that diet-related noncommunicable diseases are emerging increasingly among lower- and middle-income groups in less aﬄuent countries, 5and death rates from noncommunicable diseases are much higher, for example, in Burkina Faso and Bangladesh, than in the United Kingdom. 3Table 1 uses data from FAOSTAT to show how calorie availability has progressed between 1992 and 2007 (latest available data). FAOSTAT tracks national-level calorie availability only. This shortcoming in capturing nutrient intakes is well recognized in the literature and is fully acknowledged here. However, the value of these data lies in their provision of comparable data across countries and over time, with global coverage.

The data show that, quite uniformly, for regional aggre- gates, per capita availability has increased by between 100 and 200 calories per capita per year; in the least- developed countries, there has been a per capita increase of 10.4%.

The increase in available food energy has been accompanied by changes in the composition of the diet.

The process appears to follow a pattern involving two main stages 6: the “expansion” eﬀect, which results mainly from an increase in energy intake, largely from cheaper foodstuﬀs of vegetable origin, 6and the “substitution” eﬀect, which follows a shift from primarily carbohydrate- rich staples (cereals, roots, tubers) to vegetable oils, animal products (meat and dairy foods), and sugar.

Culture, beliefs, and religious traditions can inﬂuence the extent to which animal products are substituted for veg- etable products and the speciﬁc types of meat and animal products consumed. 5FAOSTAT data suggest even the least-developed countries have reached the second stage as per capita energy intake from the following sources has grown: sugar,+45%; animal products,+25%; meat,+31%; vegetables,+25%, and vegetable oil,+20%. Major increases in per capita calorie intake from animal prod- ucts also was observed in China (+75%) and India (+24%). Globally, the share of food expenditure on cereals and tubers fell from almost 40% in the 1980s to just over 20% in 2005. 7The demand for processed foods follows asimilar pattern of rapid growth, particularly in middle- and low-income countries, as shown in Table 2.

KEY TRENDS DRIVING FOOD CONSUMPTION Figure 1 shows the key drivers of change in global food consumption patterns and assesses their importance.

Food price trends and their impact Figures 2A and 2B chart the overall Food and Agriculture Organization of the United Nations (FAO) Food Price Index 8along with the indices of international prices of individual commodities. International food prices were largely stable (with a gentle decline) from 1991 until 2003, having declined for a considerable time before this period. The food price inﬂation that began in 2003 turned into a full-blown inﬂationary crisis in 2007–2008, which, after a brief respite, has since continued. Thus, while the overall Food Price Index in Figures 2A and 2B shows a marginal decline in the 1990s, it doubled in the next decade. Sugar prices have been highly volatile since 2005, and cereal, oil, and dairy prices have escalated rapidly since 2007. For example, the cereal price index, the most important component of the index from the perspective of food security and energy provision, surged from a value of around 100 in early 2005 to 270 in early 2008.

Meat price changes have been much more modest in comparison. Global prices for processed food and bever- ages are not available, but data from Thomson Reuters’ Datastream for the United States and the European Union (EU) suggest that prices of soft drinks, snacks, and confectionary have fallen most sharply since 1992, par- ticularly in relation to prices of fresh fruit and vegetables.

The limited coverage of these data, however, prevents global generalizations.

The impact of price changes depends on individual and cross-price elasticities. Regmi and Gehlhar 9show that own-price elasticities for unprocessed foods are highest (in absolute terms) for fruit and vegetables and meat and lowest for cereals and oils and fats. Green et al. 10con- ducted a systematic review of almost 3,500 elasticity esti- mates worldwide and conﬁrmed that elasticities for all food groups are generally higher in low-income countries than in high-income countries and, within countries, are higher in low-income groups than in high-income groups.

They also found elasticities in low-income countries to be highest for meat (95% conﬁdence interval:−0.83 to −0.73), ﬁsh (−0.80 to−0.74), and dairy (−0.84 to−0.73) and lowest for cereals (−0.66 to−0.56) and fats and oils (−0.65 to−0.54). In high-income countries, the patterns are similar, but with lower magnitudes: elasticities are Table 1Regional per capita calorie availability, 1992 and 2007. a Geographic region 1992 2007 Least-developed countries 1,957 2,162 World 2,634 2,798 Africa 2,300 2,462 North, Central, and South America 3,005 3,216 Asia 2,477 2,668 Europe 3,253 3,406 Oceania 3,079 3,182 aData from FAOSTAT.

Nutrition Reviews® Vol. 72(9):591–604593 relatively high for meat (−0.66 to−0.54), ﬁsh (−0.67 to −0.55), and dairy (−0.66 to−0.54) and relatively low for cereals (−0.48 to−0.36) and fats and oils (−0.48 to−0.35).

Thus, for most of the period studied, prices were relatively stable and, as a result, had limited impact on consumption, but the decline in the price of meat relative to the price of cereals and other foods since the early 2000s, combined with a higher price elasticity for meat, may partially explain the shift toward meat in the diet in several developing countries. Similarly, the relative decline in the prices of processed foods has contributed to the increased consumption of these foods. Lakdawalla and Philipson 11emphasize the importance of reductions in the overall price of food relative to other goods in stimulating overnutrition. Other authors 12,13 attribute overnutrition to the relative aﬀordability of energy-dense foods with added sugars and fats compared with healthier diets composed of lean meats, whole grains, and fruit and vegetables. It may be too simplistic to state that healthier foods have become more expensive relative to unhealthy foods, particularly since the increasing relative attractive- ness of ready-to-eat foods as a source of energy becomes apparent when the opportunity cost of cooking time isfactored into the comparison. In the last two decades, an increasing proportion of fruit and vegetables has been aﬀected by value addition through processing (washing, peeling, cutting, microwavable packaging, etc.). When the price trends for such value-added produce are compared with those for processed snacks, thereby maintaining the level of convenience constant across the two sets, the relatively expensive nature of healthier foods is con- ﬁrmed. 14 Although arguments about the role of food prices in overnutrition patterns have been framed largely in the context of the developed world, particularly the United States, they are also relevant for low- and middle- income countries undergoing nutrition transition, par- ticularly the urban areas. In addition to the many processed foods that are increasingly available in devel- oping countries, street foods (often high in fats, salt, and sugar) may provide inexpensive energy with a low time cost of preparation.

In relation to undernutrition, the general fall in the price per calorie should be considered beneﬁcial. By the same token, recent food price increases are cause for concern. Poor consumers cope with rising food prices by switching from preferred to lower-quality staples or by Table 2Average growth rates (expressed as percentages) of sales per capita for selected food categories, 1998–2003. a Geographic region Oils & fats Breakfast cereals Ready meals Dried foods Dairy products High-income countries France 0.7 4.4 4.2 0.9 3.2 Germany−2.6−0.5 2.6 1.4 1.6 Japan−2.0 2.0 4.7−1.7 0.7 Singapore−0.4 7.4 1.0 1.0 2.1 United Kingdom 0.7 0.6 5.5 3.1 1.4 United States−1.2 0.2 4.7 0.3 2.7 High-middle-income countries Brazil 22.6 7.5 15.9 14.7 12.0 Chile−0.2 9.1 2.8−1.4 2.5 Czech Republic 0.9 12.5 10.9 11.4 4.5 Hungary 7.2 16.5 10.5 8.2 8.9 Mexico 8.1 13.1 12.3 19.3 8.3 South Africa 8.9 2.5 1.8 6.4 4.7 South Korea 4.4 8.7 4.5 4.1 3.6 Turkey 0.0 0.7−2.6−3.3 1.5 Low-middle-income countries Bulgaria 3.7 15.3 5.8 5.2 5.9 China 10.6−0.6 2.3 9.8 14.8 Columbia 3.9 9.3 7.2 9.3 11.6 Morocco 2.4 15.0 4.0 4.0 4.8 Philippines 5.9 9.9 2.7 9.9 8.9 Romania 29.8 28.2 35.0 37.7 27.7 Russia−3.3 2.8 9.6−3.5 2.1 Low-income countries India 3.9 10.1−1.7 9.0 8.2 Indonesia 5.3 9.4 8.1 2.4 13.4 Ukraine 20.4 21.5 13.3 13.4 11.2 Vietnam 13.6 180.9−1.1 29.5 9.5 aData computed using information presented in Regmi and Gehlhar, 8based on the Euromonitor International database, 2003. Nutrition Reviews® Vol. 72(9):591–604 594 cutting back on relatively expensive nonstaple sources of calories such as meat, fruit, and vegetables. Reliance on cheap and energy-dense convenience foods or street foods may increase in urban areas. Dietary diversity and micronutrient intakes may be casualties in this process.

Although the crisis is recent, a substantial body of evidence from across the world is beginning to accumu- late, conﬁrming these patterns. The World Food Pro- gramme’s application of rapid assessment tools to gauge the eﬀect of the crisis on food security showed reduced dietary diversity in Haiti, Nepal, and Niger. 15In Liberia, the World Food Programme found substitution of cassava for rice following the crisis, as well as an overall reduction in protein sources and vegetable con- sumption. In Palestine, households were found to have reduced milk and meat consumption due to the crisis.

D’Souza and Jolliﬀe 16found that the food price crisis in Afghanistan resulted in substantial reduction in real percapita food consumption, calorie intake, and dietary diversity.

Trends in income and impact on diet Income is a well-recognized determinant of calorie intake and dietary quality, and economic growth is the obvious pathway toward reducing malnutrition. 17Table 3 shows the world average real per capita income rose by 2.1% per year between 1992 and 2010. 18It rose fastest in middle- income countries (above 3% between 1990 and 2009) and slowest in heavily indebted poor countries (just above 1% over the same period) and in the wealthiest countries (between 1.4 and 1.5%).

Income elasticities approximately mirror own-price elasticities (i.e., similar magnitude, opposite sign). They are much higher in low-income countries than in middle- or high-income countries, with average values for all food A B 0 50 100 150 200 250 300 Jan-90 Mar-91 May-92 Jul-93 Sep-94 Nov-95 Jan-97 Mar-98 May-99 Jul-00 Sep-01 Nov -02 Jan -04 Mar-05 May-06 Jul-07 Sep -08 Nov-09 Jan -11 Food Price Index Meat Price Index Dairy Price Index Cereals Price Index 0 50 100 150 200 250 300 350 400 450 Jan-90 Feb-91 Mar-92 Apr-93 May-94 Jun-95 Jul-96 Aug-97 Sep-98 Oct-99 Nov-00 Dec-01 Jan-03 Feb-04 Mar -05 Apr -06 May -07 Jun-08 Jul -09 Aug-10 Food Price Index Oils Price Index Sugar Price Index Figure 2Fluctuations in international food price indices between 1990 and 2010. A,FAO international food price indices for cereals, meat, and dairy products (nominal prices, 2002–2004=100).B, FAO international food price indices for oils and sugar (nominal prices, 2002−2004=100). Data from the FAO Food Price Index. 8 Nutrition Reviews® Vol. 72(9):591–604595 estimated at 0.73, 0.60, and 0.34 for the three respective income levels. 19 Thus, consumption response to 1% growth in per capita incomes is more than twice as large in low-income countries than in high-income countries.

Furthermore, income elasticities for animal products, processed foods, and eating out are much higher than those for cereals and other staples at all income levels.

Thus, income growth generates a shift toward animal products and a larger demand for processed products and food away from home, 20 especially in the transition between low and middle income levels, while at higher income levels, demand for luxury goods (including health) becomes more prominent, and consumption of meatandfatsisreduced. 21These patterns are consistent with cross-country developments in the distribution of undernutrition and obesity and help to explain why obesity is concentrated in the wealthier part of the popu- lation in low- and middle-income countries yet is high in low-income groups of aﬄuent economies. Data on the evolution of income distribution are incomplete, but the trend in many developing countries seems to be toward a reduction in disparities. However, strong inequalities (i.e., a Gini index above 40) are still associated with under- nourishment rates well above 10% in African and South American countries. In recognizing income growth as perhaps the most important factor in inﬂuencing malnu- trition, it is important to also acknowledge the signiﬁcant causal link between nutrition (health) and economic growth 22in poor countries; thus, income growth is not a genuinely exogenous contributor to better diets.

Food systems: development and impact on diet Food systems in middle- and low-income countries have changed dramatically over the past 20 years. Multina-tional retailers have followed multinational food manu- facturers, soft drink companies, and fast food chains into food and drink sectors in virtually all countries and have introduced the types of supply-chain controls pre- viously seen only in the developed world, such as tight vertical coordination, centralized purchasing and distribution, private standards, product diﬀerentiat- ion, and sophisticated marketing. Domestic ﬁrms, driven by competition and learning from new market entrants, have followed suit. From an analytical perspec- tive, it is diﬃcult to determine whether observed changes in supply chains caused dietary change or were a response to growing consumer demand for soft drinks, fast food, and packaged groceries linked to general economic development, but there is plenty of circumstantial evidence that multinational ﬁrms have created demand as well as satisﬁed it. 23Such ﬁrms also provide employment and generate income, which mul- tiplies through the economy and brings its own nutri- tional change.

The rapid expansion of supermarkets in develop- ing countries, examined by Reardon and Berdegue, 24 Reardon and Swinnen, 25Weatherspoon and Reardon, 26 and Reardon et al. 27in a series of articles, happened in response to a number of forces, many of them intercon- nected: rising incomes (also associated with higher own- ership of consumer durables such as refrigerators and cars, which facilitate supermarket shopping); urbaniza- tion; greater female participation in the labor force (increased opportunity cost of time); and the desire to emulate Western culture, spurred on by the globalization of media and advertising. 28In Latin America, supermar- kets deliver 50–60% of retail food sales. 27This trend is mirrored in Southeast Asia, Eastern Europe, and Central Europe, followed closely by Africa, which is led by South Table 3Gross domestic product per capita, based on purchasing power parity (converted to constant 2005 international dollars). a Country grouping 1992 2010 Yearly growth Low income 738 1,127 2.4% Middle income 3,048 5,998 3.8% High income 24,866 33,119 1.6% Heavily indebted poor countries 899 1,197 1.6% Latin America & the Caribbean 7,376 10,117 1.8% Least-developed countries: UN classiﬁcation 807 1,334 2.8% East Asia & Paciﬁc 4,095 8,725 4.3% Middle East & North Africa 6,629 9,132 1.8% North America 31,431 41,908 1.6% European Union 20,664 27,555 1.6% OECD members 22,931 30,112 1.5% South Asia 1,266 2,914 4.7% Sub-Saharan Africa 1,535 2,041 1.6% World 6,797 9,889 2.1% Abbreviations: OECD, Organization for Economic Co-operation and Development; UN, United Nations.aData adapted from World Development Indicators, World Bank (2012). 18 Nutrition Reviews® Vol. 72(9):591–604 596 Africa, where a “spectacular” rise of supermarkets has occurred since 1994. 27 The continuing spread of multinational food and soft drink manufacturers and fast food franchises has also been well charted. 7,29,30 Global inﬂows of foreign direct investment (FDI) in the food sector have increased from less than $10 billion in 1992 to over $40 billion in 2007. 30 Wilkinson 31shows that US investments in Mexico have concentrated on convenience and highly processed foods, especially snacks, beverages, instant coﬀee, mayonnaise, and breakfast cereals. However, as pointed out by Regmi and Gehlhar, 9such products are amenable to foreign investment because they are not location speciﬁc; tech- nology and capital are mobile in the world food economy, whereas primary processed products, such as fresh or frozen meat, frozen and canned fruit and vegetables, and dry milk powder, are more closely associated with their production location and can be readily exported. Thus, it would be a surprise if FDI was not concentrated in highly processed products.

Fast food chains and soft drink companies have also been blamed for unhealthy eating habits in developing countries. Pingali and Khwaja 32 charted the growth of McDonald’s restaurants from 951 stores in the Asia Paciﬁc region in 1987 to 7,135 in 2002; since then, the numbers have continued to rise, though more slowly.

Pepsico, another global food and beverage corporation (main brands Pepsi and Frito-Lay) trebled its sales outside North America and Mexico between 2000 and 2007. 23 Of potentially far greater importance for diets are the domestic food manufacturers, including fast food and soft drink ﬁrms, that have sprung up to imitate global brands at much lower prices, thereby generating much higher sales. 33 International trade increases the availability of foods and provides a further competitive impetus for the mod- ernization of domestic competitors. Between 1992 and 2009, the total trade in food and agricultural products more than doubled, from $40 billion per annum to $80 billion (UN Comtrade database). The share of processed food in food and agricultural exports grew from 54% to 69% for high-income countries and from 49% to 67% for Asia between the 1970s and 2000s. 34 The main impetus for this was the declining cost of moving prod- ucts around the world, which resulted from technological developments in transport, handling, and information technology. 35 Preferences for Western foods are said to have been encouraged by imports displacing traditional staples, beginning in the era of colonization (see, for example, Thow and Snowdon 36). More recently, sophisticated mar- keting activities of global food manufacturers, soft drink companies, and fast food chains have been highlighted aschanging preferences toward Western foods: Hawkes 37 noted that “marketing aims to develop in consumers the habit of drinking or eating the product regularly.” To this end, children and young adults have been particular targets of marketing that aims to change consumption habits over the long term. 37 Methods include targeted television and web advertising, sports and event sponsor- ship, products targeted at local tastes, and special oﬀers/ price promotion for market growth. 32,37,38 Limited evidence suggests that supermarkets (and convenience stores) have reduced the prices of packaged foods relative to fresh produce, particularly in the early stages of supermarket penetration in a country. 39A study in Brazil found supermarket prices for packaged foods to be as much as 40% lower than prices in traditional outlets.

By contrast, fresh fruit and vegetables were more expen- sive in supermarkets. 40,41 Supermarkets and large manu- facturers are said to work “symbiotically”: the latter are able to supply the large volumes (at high standards) demanded by the supermarkets, which in turn are able to deliver a market for the manufacturers’ products. 42The economies of scale on both sides enable the delivery of reduced prices for processed products.

Supermarkets and multinational manufacturers further inﬂuence consumption by oﬀering a wide variety of previously unavailable products, 39,43 including refriger- ated products, especially dairy items. Provided there is a market for such products (which there must be, or they wouldn’t continue to be available for sale), the supermar- kets, again in a symbiotic relationship with large manu- facturers, can inﬂuence consumption of diﬀerent product categories.

In developed countries, snacking has been associated with increases in energy intake. 44There is limited empiri- cal evidence from developing countries, but the tendency toward consumption of snack foods, largely associated with increased availability, is reported for urban India, 33 where rapid increases in consumption of biscuits, salted snacks, and prepared sweets (between 1987–1988 and 1999–2000, intakes of these products rose from close to zero to 68 g, 45 g, and 13 g per capita per day, respec- tively) also have been observed. Vepa 33suggests that pro- cessed foods, mainly in the form of snack products, may represent as much as 1,000 kcal in the daily diet of high- income consumers.

In summary, processed foods now account for 80% of global food sales, and, although spending is still low in developing countries, it is increasing rapidly. In addition, spending on food service accounts for 22% of food budgets in Brazil and Indonesia, and 15% of urban food spending in China. 7The impact of all these changes on nutrient intakes has not yet been conﬁrmed, even in developed countries, but processed foods, fast foods, and soft drinks have all been linked to nutrition transition and Nutrition Reviews® Vol. 72(9):591–604597 the obesity epidemic, and are likely to be equally involved in widening the girths of the expanding middle classes in poorer countries. Whether they have increased the avail- ability of aﬀordable, safe, and palatable energy to the chronically hungry has not been researched.

Impact of other trends A number of other factors have been linked to aspects of dietary change since 1992. Agricultural growth, for example, has been shown to have a strong impact on calorie availability and malnutrition reduction, especially in highly malnourished populations. 45The strong links found between public agricultural investment and growth in the agricultural sector 46and between agricul- tural growth and calorie supply and nutrition suggest a lost opportunity to improve nutrition over the last 2 decades by investing in agriculture.

Perhaps most important, though diﬃcult to separate from other changes associated with economic develop- ment and changes in food systems, are the various inﬂu- ences associated with urbanization, which include more sedentary lifestyles and growth in the participation of women in the workforce. 47Between 1990 and 2010, the global urban population topped the rural population, rising from 42% to 51%. The urban population has doubled in low-income food deﬁcit regions, such as Africa and China, and has increased by 20% in Europe and 30% in North America (FAOSTAT, 2012). In China, the urbanization that took place during the 1990s has been associated with an increased intake of edible oils, animal foods, and caloric sweeteners, a reduced intake of fresh foods (especially vegetables), and an increased intake of processed foods. 48Among the causes of dietary shift during the urbanization process is the existence of price diﬀerentials between urban and rural areas. 49 Between 1992 and 2009, the female labor force increased by 20% in countries belonging to the Organisation for Economic Co-operation and Develop- ment (OECD), an increase of about 48 million women.

Low-income and lower-middle-income countries have experienced 58% and 46% growth, respectively, which represents about 156 million women entering the work- force.

18These dynamics of females in the workforce have potentially conﬂicting eﬀects on nutritional status. Some authors have suggested a causal relationship between maternal employment and rising childhood obesity rates, mainly based on US data, 50but recent studies have found the eﬀect of maternal working hours on children’s diets to be very limited 51or even positive. 52The evidence from developing countries, though scarce, suggests that increased female participation in the labor force has posi- tive eﬀects on children’s nutritional status. 53 IMPORTANCE OF AGRICULTURAL, TRADE, AND FOOD POLICIES IN INFLUENCING DIETS In this section, the importance of various policy develop- ments over the past 20 years in determining dietary changes is examined. As indicated in Figure 1, policies can inﬂuence diets through their eﬀects on prices, food avail- ability, food preferences, and incomes. Policy measures may have domestic and/or global implications; for example, a measure that increases domestic farm produc- tion of some commodity may lower domestic consumer prices and, at the same time, lower the demand for imports or expand exports. If the country is large enough, this would lower the global price of the commodity, with implications for producers and consumers in other countries.

Trade policy reform The major achievement in the past 20 years has been the signing of the Uruguay Round Agreement on Agriculture (URAA) in 1994. This represented the ﬁrst time food and agriculture were speciﬁcally addressed in multilateral trade agreements. Bound tariﬀs were introduced, and a tariﬀ reduction formula was adopted, though it was applied by most countries in ways that minimized the reduction in applied tariﬀs. The URAA also included commitments to reduce export subsidies and, perhaps most importantly, introduced rules governing domestic agricultural support.

Subsequent progress in addressing concerns about nontariﬀ barriers was made with the Sanitary and Phytosanitary Measures Agreement and the Technical Barriers to Trade Agreement of the newly created World Trade Organization (WTO) in 1995. The Doha Round has thus far failed to further capitalize on progress, and frustration with the stalled multilateral talks has contrib- uted, in part, to the creation of over 200 regional agree- ments notiﬁed with the WTO, together with various bilateral treaties. As part of the WTO, the Trade-Related Investment Measures Agreement has facilitated substan- tial progress in the liberalization of investment, which has freed up FDI and has restricted discrimination against foreign-owned ﬁrms. In addition to increasing the volume of international trade, liberalization has changed the relative prices of food groups and increased the range of products available to consumers. Changes in relative prices and in availability induce changes in food con- sumption and diets, but they can also have longer-term nutritional implications by helping to shape consumer preferences. 54,55 However, arguably the most important impact of multilateral trade agreements has been their eﬀect on incomes, both farm and nonfarm; the ability to specialize has facilitated global eﬃciency in sourcing, Nutrition Reviews® Vol. 72(9):591–604 598 thereby enabling production and processing of agricul- tural and food products in regions that have a compara- tive advantage – most frequently, developing countries.

This has increased food availability, kept prices down, and stimulated job creation and rapid global economic growth for most of the past 20 years, all of which have been major drivers of dietary change.

Trade economists have used partial and general equi- librium models to simulate the impact of trade liberaliza- tion. These models study the distributional consequences of reform on diﬀerent types of farmers as well as on the prevalence of poverty within and between countries at diﬀerent stages of development (e.g., Anderson et al. 56).

Of course, both income and price aﬀect food consump- tion, as discussed in the previous section.

The review articles by Anderson 35and Anderson et al. 56 summarize ﬁndings from the World Bank’s LINKAGE model and from various other Global Trade Analysis Project applications: trade-related policy reforms in the agricultural sector added around 1% annu- ally to the gross domestic product of developing coun- tries and 0.7% to that of developed countries, beginning in the mid-1980s. In developing countries, the value added by agriculture is 4.9% higher than it would have been without agricultural and trade policy reforms.

Prices tend to be modeled as a by-product of analyz- ing farmers’ incomes and production, and they are often unreported, as is their impact on consumption. URAA- induced reform has tended to raise world food prices by reducing incentives for overproduction by the major developed countries, 57,58 notably the United States and members of the EU, though this has come about mainly through domestic policy reforms (e.g., lowering of inter- vention payments and a move to direct payments to farmers) rather than removal of tariﬀs, and the magnitude is likely quite small. 59 Increased prices help exporting countries but (at least in the short run) harm importing countries. Within countries, the urban poor lose if food prices increase (at least in the short run). However, there are opposing forces for farmers in developing countries, given that the vast majority are both sellers and buyers of food, depending on the season. In the longer run, price changes in developing countries feed through labor markets to inﬂuence incomes of even the landless poor.

For example, the World Bank 7reports a study of Bangla- desh that suggests the average landless poor household loses from an increase in rice prices in the short run but gains in the long run as wages rise over time.

Overall, evidence indicates the price-induced impact of trade liberalization on consumption and diets has been modest. The World Bank has estimated that even com- plete trade liberalization would raise prices of agricultural commodities by only 5.5%, and, thus, such results as the URAA’s achievement of only partial liberalization areunlikely to have resulted in signiﬁcant dietary change.

Under full trade liberalization, prices of processed foods would rise by only 1.3%. 7,60 The transmission of world price changes to domestic price changes is frequently below 50% 7; thus, the already small impact of liberaliza- tion on international food prices is likely to be further muted by low price transmission, resulting in only minimal impacts on local prices and diets.

WTO trade reforms are complemented by a prolif- eration of regional and bilateral agreements; indeed, 248 regional trade agreements formally reported to the WTO are currently in force. In general, these agreements involve not only tariﬀ removal but also harmonization or mutual recognition of standards to remove nontariﬀ bar- riers. More than one-third of global trade is between countries that have some form of reciprocal regional trade agreement. 7,61 The implications of regional agree- ments are not, in principle, diﬀerent from those of mul- tinational agreements.

Although models indicate relatively minor price changes for agricultural commodities, trade liberalization may have induced other, less quantiﬁable changes in food supply systems. 62,63 Thow and Snowdon 35relate the cau- tionary tale of how exports of unhealthy by-products of sheep (mutton ﬂaps from New Zealand) and poultry (turkey tails from the United States) found their way into the hearts (via the stomachs) of Fijians and Samoans before imports were eventually banned. In India, market liberalization in the mid-1990s stimulated a rapid increase in imports of low-priced vegetable oils, 64which corresponded with a simultaneous increase in consump- tion. It also stimulated a switch in the type of oils con- sumed, away from traditional peanut, rapeseed, and cottonseed oils and toward imported palm and soybean oils. These developments may also, at least in part, be attributed to domestic policy decisions about what prod- ucts to prioritize. Indeed, Drewnowski and Popkin 65 argue that the nutrition transition typically begins with major increases in imports of oilseeds and vegetable oils.

Nontariﬀ barriers The Sanitary and Phytosanitary Agreement and the Tech- nical Barriers to Trade Agreement were intended to stop the creeping use of nontariﬀ barriers as protectionist replacements for reduced tariﬀ barriers. In requiring the adoption, wherever possible, of international standards and speciﬁcally referencing the Codex Alimentarius Commission, these WTO agreements raised the impor- tance of Codex standards and politicized them. In the 2002 Codex Evaluation, 66member states were surveyed, and two-thirds of high-income country respondents and 90% of low-income country respondents found Codex standards very important to their food exports, while Nutrition Reviews® Vol. 72(9):591–604599 more than 80% of country respondents in all income classes found them very important for ensuring the safety of food imports. In addition to public standards such as Codex, private standards have been developed as a result of the globalization of supply chains. Gereﬃ and Chris- tian 67 cite Kentucky Fried Chicken, McCain Foods, McDonald’s, and Wal-Mart as examples of global food corporations who set their own standards for their supply chains.

By contributing to a reduction in the use of nontariﬀ barriers as trade barriers and promoting conﬁdence in import standards, public as well as private standards have eﬀectively increased the availability and diversity of food products traded and consumed. The principle by which removal of nontariﬀ barriers makes a wider range of foods available at lower prices and, hence, enhances diver- sity of diets was described by the European Commission 68 in justifying the use of the mutual recognition principle in the creation of the Single Market: “European consum- ers can thank the principle of mutual recognition for the increase in the range of products on sale at ever- decreasing prices. Selling their products on a market which covers half a continent enables businessmen to make economies of scale and hence reduce their costs, to the greater beneﬁt of the man in the street. Freedom of movement, as achieved through mutual recognition, attacks national rules which tie consumers to a given product, e.g., by laying down a particular composition for this or that foodstuﬀ. This type of rule, apart from arbi- trarily depriving consumers of the opportunity to dis- cover the specialities and traditional products of other Member States, whose composition diﬀers from that laid down by the law of the importing country, prevents the interpenetration of markets – to the detriment of both business and consumers.” Thus, public and private stan- dards could be argued to promote the globalization of diets, although it is unknown whether this has been assessed quantitatively.

Liberalization of international investment Between 1991 and 1999, 1,035 changes (across all sectors) were made to FDI regulations worldwide. Many of these changes happened within the context of trade agreements and investment treaties: the number of bilateral invest- ment treaties rose from 181 in 1980 to 1,856 in 1999. 64 Investment liberalization has inevitably led to the spread of multinational enterprises at all stages of the food chain, with implications for diets as discussed above.

The speciﬁc role of policy as opposed to other forces promoting globalization has not been adequately quanti- ﬁed, though Traill 28found openness to inward FDI to be an important stimulus to the spread of supermarkets in middle- and low-income countries. More commonly,assessment is based on case studies. For example, as part of the North American Free Trade Agreement, Mexico abolished many restrictions on foreign investment in the Mexican Foreign Investment Act of 1993, and between that year and 1999, American food processing investment in Mexico more than doubled – to $5.3 billion – and Wal-Mart de Mexico is now the largest retailer. 64 Eﬀect of liberalization of agricultural policy on domestic consumption In the OECD countries the period since 1992 has been marked not only by a reduction in overall levels of support but also by signiﬁcant movement from a reli- ance of producers on market price support to the use of other forms of support that have progressively been delinked from production levels. Market price support, by setting a ﬂoor for prices received by producers for certain commodities and thereby driving a wedge between domestic and international prices, has long been implicated in the overproduction of protected commodities. A movement toward alternative forms of support that eliminate the direct link to production levels of speciﬁc crops, such as area-based payments, has gone a long way to restore the link between production and international price signals. Martini 69 estimates a “production impact” index for support relative to the baseline of 1991–1993. He reports that the EU has made steady progress in reducing the production impact of support, which in 2008 was only 38% of 1991–1993 levels. However, Japan and Korea, at 57% and 98% of 1991-1993 levels, respectively, have made less progress.

Since support for agricultural policies in OECD coun- tries has traditionally involved raising prices paid to pro- ducers by keeping consumer prices high, reform has had the eﬀect of lowering consumer prices, hence tending to raise consumption. Farm prices, however, are often only a small fraction of ﬁnal prices paid by consumers. In the EU case, Schmidhuber 70computed that, in aggregate, the pre-reform policy-induced impact of agricultural support amounted to only about 5% of consumer food expenditure. Thus, agricultural policy reform has likely had a limited price-induced impact on diet in the EU (and in other developed countries), although the eﬀect of policy on the mix of commodities produced and made available in the market may, in turn, shape diets. Rickard et al. 71simulated the removal of support to farm com- modities in the United States over the 1990s and early 2000s and found a minimal impact on calorie intakes.

They also found that, as US policies have become less distorted over the 1990s and 2000s and commodity prices have become less important in determining con- sumer prices, the ability of agricultural policy to impact calorie intake has diminished. Nutrition Reviews® Vol. 72(9):591–604 600 In non-OECD countries, agricultural support has traditionally been much lower (see, for example, Orden 72). Indeed, the implicit taxation of producers to keep consumer staple prices low is a prominent feature of agricultural policy in India, and average implicit taxation of producers in 11 agriculture-based countries in sub- Saharan Africa declined from 28% in 1980–1984 to 10% in 2000–2004. 7The fact that developing countries have had much lower support levels than developed countries implies that policies have had much less impact on diets. 70 On the other hand, levels of both processing and value addition are also lower in developing countries, and thus a farmgate commodity price eﬀect is likely to translate more strongly into a consumer food price eﬀect.

On the whole, it seems that domestic agricultural policy is only of a second order of importance in terms of inﬂuencing diets.

Eﬀects of food policies targeted at consumers Various policies aﬀect diets by targeting consumers directly. Consumption choices may be aﬀected through three routes: 1) by providing direct access to free food, 2) by supporting access to food through income subsidies, and 3) by altering the absolute and relative price levels of foods and of foods relative to nonfoods. The range of policy actions that inﬂuence diets through income and price measures and fall under the second and third routes mentionedisverybroad,andthefocushereislimitedto those measures whose ultimate goal is to change diets and nutrition outcomes.

Food aid Food aid has the potential to alter diets, though “abuse” has been limited by the URAA, and by the 1999 Food Aid Convention. The former ruled out the direct or indirect tying of food aid to commercial exports and also stipu- lated that food aid should be based on free provision to the maximum extent possible or on highly concessional terms. 73The latter coordinates multilateral food aid inter- ventions among donor countries, with a stated aim of decoupling food aid from export promotion mea- sures, and places a growing focus on nutrition and food fortiﬁcation. 74 Trends over the last 20 years show a substantial reduction in global food aid shipments, down from 12.3 million metric tons in 1991 to 5.4 million metric tons in 2010, 75and while there are still reports of distortions, e.g., shipments of maize to pastoral areas in the Horn of Africa in the 1990s and 2000s, causing protein-heavy pastoral diets traditionally based on animal products to shift toward carbohydrate-rich diets based on grain, 76there isnot much evidence to indicate substantial widespread eﬀects.

Additionally, although emergency food aid programs have been found to improve nutritional outcomes by buf- feting short-run shocks, as described by Quisumbing, 77 there is evidence that food aid is too unreliable and too poorly targeted for even the most vulnerable households to be able to depend on it for any length of time (see, for example, Little 78). A recent review 79explores a range of failures and successes and cites food-for-work interven- tions as the more likely way to generate positive nutri- tional outcomes for people at risk of hunger, especially children.

Domestic food-assistance programs, price subsidies, and taxes In developed countries, domestic food- and nutrition- assistance programs have grown in relevance and have improved their targeting of at-risk groups in the popula- tion. The United States is at the forefront: in 2010, there were 15 programs with a total federal expenditure of $68.2 billion, while about 14.5% of US households were food insecure at least some time during the same year. 80 The main “food stamp” program (the Supplemental Nutrition Assistance Program) covers about 40 million people every month. Eligible recipients are provided with electronic debit cards that can be used in approved retail stores to purchase food. Eligibility is based on household ﬁnancial resources, and able-bodied adults are also required to accept employment or training programs referred by the Supplemental Nutrition Assistance Program oﬃce. Some have argued that participation in food stamp programs increases the likelihood of becom- ing obese, especially for women, 81 but this evidence becomes weak once counterfactual trends are taken into account; moreover, rates of weight growth were faster among nonparticipants than among participants. 82–84 In contrast to food stamps, the Women, Infants and Children program in the United States and the Healthy Start program in the United Kingdom are targeted at infants and pregnant and lactating women in low-income groups. In these schemes, the use of food vouchers is restricted to purchases of “healthy” foods such as fruit and vegetables and milk. 85This type of program has been relatively successful in achieving the prescribed nutrient goals without increasing calorie availability 86and, accord- ing to the US Department of Agriculture, is one of the most successful and cost-eﬀective nutrition intervention programs: participant children have higher mean intakes of iron and vitamins without increases intakes of food energy, fat, or cholesterol. Improved growth rates and reduced rates of fetal death and infant mortality have also been shown. 87 Nutrition Reviews® Vol. 72(9):591–604601 In many developing countries (including India, Ethiopia, and Bangladesh), there are domestic food-for- work programs based on the principle that able-bodied vulnerable recipients are paid with food in exchange for public unskilled work. When they are well-timed and well-targeted, these programs are generally found to be eﬀective. 88Other types of domestic food-assistance pro- grams use price subsidies as an instrument to address food insecurity and maintain price stability. For example, the Indian Public Distribution System, a large-scale program oﬀering subsidies for wheat, rice, edible oils, and sugar to poor households, was found to have a signiﬁcant (albeit relatively small) eﬀect on calorie intakes. 89 On the other hand, there is some evidence that price subsidies contribute to rising obesity rates in some devel- oping countries 90; even when subsidies are calibrated to promote healthier eating in the target population, their eﬀectiveness may be reduced by the income eﬀect, mani- fest by recipients who spend their eﬀective increase in real income on nonsubsidized (energy-dense and cheap) foods. 91 CONCLUSION Over most of the past 20 years, stable or falling food prices combined with rising incomes have stimulated increases in calorie intake and promoted the dietary tran- sition away from starchy staples and toward consumption of livestock products and processed foods, although, in the developed world and among the middle classes in developing countries, these same factors have hastened the obesity epidemic. The main forces behind these changes have been technological changes in agriculture, food processing, food distribution, and international trade, along with economic growth (aided by interna- tional trade and liberalization of investment).

In the many regions in which dietary change has been observed, the balance of evidence indicates that income growth and modernization of food systems have been the dominant forces of change, and these changes are closely linked (through cause and eﬀect) to urbaniza- tion and the increased participation of women in the workforce. The liberalization of international investment, when linked to trade reform, has been an important pre- condition for globalization, which, in turn, has been an important force driving changes in food systems. The impact of these changes on preferences and lifestyles is critical, as is their impact on the availability of a range of foodsthatsatisfynewdemands.

Income growth, in tandem with globalization pat- terns, has exerted an important inﬂuence on dietary change since 1992. This includes positive eﬀects in the form of hunger reduction and improvement in dietary quality, as well as negative eﬀects associated with overnu-trition. Although direct evidence remains scarce, the available information suggests that countries experienc- ing increases in income inequality are most vulnerable to overnutrition problems.

The price eﬀects of trade and agricultural policy reforms have not had a major impact on diets. Consumer policy vehicles like food aid and food-assistance pro- grams do not seem to have had major eﬀects on dietary quality,buttheyhavebeeneﬀectiveintheirbasicgoalof assuring minimum calorie requirements are met, particu- larly in times of widespread emergencies.

Acknowledgments This article is derived from the FAO Commodity and Trade Policy Research Working Paper no. 34, Mazzocchi M, Shankar B, and Traill WB. The Development of Global Diets Since ICN 1992: Inﬂuences of Agri-Food Sector Trends and Policies. Rome; 2012. The views, however, do not necessarily reﬂect those of the FAO.

Funding.The authors acknowledge the ﬁnancial support of the United Nations Food and Agriculture Organization (FAO) in the work leading to this manuscript.

Declaration of interest.The authors have no relevant interests to declare.

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