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«Jomo Kwame Sundaram Vikas Rawal Michael T. Clark Tulika Books Published by Food and Agriculture Organization of the United Nations (FAO) Viale delle ...»

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Evidence from many countries has shown that maintenance of home gardens is associated with improved intake of nutrients and improved nutritional outcomes. Berti, Krasevec, and FitzGerald (2004) systematically reviewed evidence on the impact of agricultural interventions in Africa, Asia, and the Americas on nutrition. Of the thirty projects reviewed by them, eighteen were home gardening (vegetable and livestock) projects. In all the home gardening projects, improvements in diet were recorded. Of the six home gardening projects where anthropometric indicators were monitored, three recorded significant improvements. In seven studies where biochemical/clinical indicators were monitored, four recorded improvements in biochemical/clinical indicators for different types of micronutrient deficiencies on account of home gardens. Talukder et al. (2010) evaluated the impact of homestead gardening programmes in Bangladesh, Cambodia, Philippines, and Nepal, and found improved diets among households that participated in these programmes, resulting in faster reduction of anaemia among children from such households compared to children from control households.

28 Ending Malnutrition covering studies from many developed countries. They used energy density (defined as calories available per unit weight of food) as a negative measure of diet quality (that is, the higher the energy density, the poorer the quality of diet). Their review showed that better socio-economic conditions, as reflected in occupational status, level of education and incomes, are associated with greater consumption of foods with low energy density and high vitamin and mineral content, such as whole grains, lean meat, fish, fruits, and vegetables. On the other hand, the diets of persons belonging to the lower socio-economic categories consist of food that is “energydense but nutrient-poor”. Darmon and Drewnowski (2008) point out that other studies using multidimensional indices of diet quality have also found similar relationships between diet quality and economic conditions.

Recent evidence from the United States and the United Kingdom suggests that disparities in quality of diet across socio-economic groups may even have intensified over time. A recent widely cited study of diet quality in the United States shows that persons with relatively high socio-economic status have more diverse and nutritious diets than those with relatively low socio-economic status, and that the diet gap between the rich and the poor has increased between 1999 and 2010 (Wang et al., 2014). The study used a multidimensional Alternate Healthy Eating Index to measure diet quality, and found a positive relationship of diet quality with family income and education levels. Using income and educational levels, it classified the sample into two categories by socio-economic status. The study found that while the diet quality of the group classified as having high socioeconomic status improved significantly between 1999–2000 and 2009–10, no significant trend was seen in the diet quality of the low-socio-economic status group (Wang et al., 2014).

Empirical evidence clearly shows that energy-dense foods such as refined grains, sugars and fats are the cheapest sources of dietary energy, while fruits and vegetables are the most expensive sources of dietary energy (Andrieu, Darmon, and Drewnowski, 2006; Darmon, Briend, and Drewnowski, 2004;

Drewnowski, 2010; Drewnowski and Darmon, 2005). Table 2.4 gives data on the average energy density of different food groups. These data clearly show that energy-dense foods – grain products, fats, and sugars – have the lowest unit cost of calories. Compared to grains, fats and sugars, on average, animalsource foods have lower energy density and higher energy cost. Fruits and vegetables have the lowest energy density and highest energy cost. Data on energy costs from France presented in Table 2.5 also show similar ranking for different food items. While human diets also have social and cultural determinants, the high energy cost of foods with low energy density is the most important reason why the diets of low-income households consist of very low quantities of nutritious food commodities. Evidence on the costs of different types of diets in South Africa is similar (Temple and Steyn, 2009, 2011; Temple et al., 2011). Table 2.6, taken from Jones et al. (2014), shows Transforming Food Systems 29

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Table 2.8 Malaysia: Share of selected commodity groups in total household food expenditure, by monthly household expenditure class, 2009–10 (percent)

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Table 2.9 South Africa: Share of selected commodity groups in total food expenditure, by deciles of monthly per capita expenditure, 2010–11 (percent)

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It is arguable that the lack of a positive relationship between the share of expenditure on fruits and vegetables with economic status in low- and middle-income countries is because the unit cost of calories from fruits and vegetables is considerably higher than the cost of calories from even animalsource foods. As a result, in low- and middle-income countries, although the absolute intake of fruits and vegetables rises with economic conditions, even households with relatively higher economic status cannot afford to adequately substitute the intake of calorie-rich food with greater intake of fruits and vegetables. As a result, the share of food expenditure for fruits and vegetables remains very low for all economic classes.

Other determinants of diet quality Diets and consumption patterns are also affected by non-economic factors, including the social and cultural context, health and dietary awareness among consumers, as well as the influence of advertising. Although there is a positive relationship between economic status and quality of diet, inadequate consumption of nutritious foods like fruits and vegetables and dietary imbalances are found among high-income consumers as well.

Energy-dense foods are rich in fats and sugars, which make the food more palatable, and results in lack of satiation and satiety as their consumption is reduced (Drewnowski, 1998). This in turn results in a considerable degree of resistance to the substitution of energy-dense food despite consumer awareness, and even when more nutritious foods are available and affordable.

Systematic reviews of evidence find that food advertisements primarily focus on energy-dense food high in fat, salt, and sugar, and that such food advertising has a strong influence on diets, particularly of children (Cairns, Angus, and Hastings, 2009; Hastings et al., 2006). It is now widely recognized that improving dietary choices requires combining nutrition education and public information campaigns with regulation of exposure of children to unhealthy food advertisements. In view of the harmful effects of food advertising on the diets of children, the Sixty-third World Health Assembly endorsed a set of recommendations for member-states to regulate marketing of foods and non-alcoholic beverages to children.³ Key messages Improving economic and physical access to nutritious foods that have low energy density and are rich in nutrients is critical for alleviating malnutrition.

³ Set of Recommendations on the marketing of foods and non-alcoholic beverages to children, WHA63.14 Resolution of the Sixty-third World Health Assembly adopted on 21 May 2010, World Health Organization, Geneva; available at whqlibdoc.who.int/publications/2010/9789241500210_eng.pdf?ua=1.

36 Ending Malnutrition This requires that all rural and urban households have sufficient incomes not only to be able to access adequate quantities of foodgrains, but also nutritious diets. Rural households need access to land and other productive resources to support their livelihood, and to produce adequate and nutritious food, not just to feed themselves but other consumers as well.

It is also important that food price volatility is kept under control, and that food prices remain affordable and food production remunerative.

Sustainability of food systems Much food output augmentation in the past has put increasing stress on natural resources – degrading the soil, polluting and exhausting fresh-water supplies, encroaching on forests, depleting wild fish stocks, and reducing biodiversity. More intensive farming systems and continued deforestation for agriculture and other land uses have also become major sources of greenhouse gas emission, particularly in industrialized countries. Harvest and post-harvest food losses, particularly in developing countries, as well as high food wastage at the end of the food chain, particularly in middle- and high-income countries, reduce food availability (FAO, 2011a).

While our approach to food production has become unsustainable, we have the means to transform our production systems and consumption patterns to create better food systems, to ensure healthier people. FAO (2014) provides a conceptual framework for the development of sustainable food systems, based on the following key principles.

1. Improving efficiency in the use of resources is crucial to sustainable agriculture.

2. Sustainability requires direct actions to conserve, protect, and enhance natural resources.

3. Agriculture that fails to protect and improve rural livelihoods, equity, and social well-being is unsustainable.

4. Enhanced resilience of people, communities, and ecosystems is key to sustainable agriculture.

5. Sustainable food and agriculture requires responsible and effective governance mechanisms.

Creating more resilient food systems that take into account the special needs of the more vulnerable is the most practical, cost-efficient, and sustainable way to address all forms of malnutrition. We need to produce nutritious food for all people today, while also protecting the capacity of future generations to feed themselves. Nutrition must become one of Transforming Food Systems 37 the primary objectives of food-system policies and interventions, ensuring access to an adequate, diverse, and balanced combination of dietary energy and nutrients.

At every stage along the way, resources must be used more efficiently and with less adverse impacts. Getting more and better food from water, land, fertilizer, and labour can save resources and make food systems more sustainable. An additional challenge is to manage livestock production (in particular, large, industrial-scale) sustainably, since it contributes more to greenhouse gases, resource consumption, disease transmission, and health problems due to excessive meat consumption.

Consumption of meat, milk, and eggs is growing rapidly in developing countries, providing nutritious diets to previously food-insecure populations. The livestock sector also improves livelihoods and contributes to economic growth and rural incomes. We must manage this sector sustainably, fostering a balanced, participatory, and consultative process among key stakeholders.

Supporting smallholder agriculture to make it more nutrition-sensitive There is increasing recognition that agriculture must be more “nutritionsensitive”, with agricultural policies and practices supporting and facilitating more healthy – nutritionally adequate and diverse – diets.

Improving the productivity of small-scale farms while promoting diversification and more sustainable practices can reduce rural malnutrition by improving the local availability and nutritional quality of food, as well as by raising incomes and access to better food. This typically requires investments in public goods, including physical and social infrastructure, public support for agricultural research and extension, and ensuring that agricultural production, particularly by smallholder producers, remains profitable. Improving access to land, finance, productive assets, technology, input and output markets, as well as other supportive measures generally enhances small producers’ productivity, income, spending, and nutrition.

To make agriculture more nutrition-sensitive, attention must be paid to supporting mixed farming systems, protecting on-farm biodiversity, and promoting production of nutritious but underutilized crops (Mayes et al., 2011). Agricultural research and development must focus more intensely on nutrient-dense foods, such as millets, legumes, fruits, vegetables, and animal-source foods, as well as on local biodiversity and diversified farming systems. Research to develop new varieties and to increase the yields of many of these nutrient-dense crops has not been prioritized historically. It is essential to correct this imbalance in agricultural research.

38 Ending Malnutrition Making agriculture nutrition-sensitive is essential for a sustainable approach to addressing micronutrient deficiencies, and represents both a challenge and an important economic opportunity for agriculture.

Box 2.5 ICN2 Framework for Action: Recommended actions for sustainable food systems promoting healthy diets

• Recommendation 8: Review national policies and investments and integrate nutrition objectives into food and agriculture policy, programme design and implementation, to enhance nutrition sensitive agriculture, ensure food security and enable healthy diets.

• Recommendation 9: Strengthen local food production and processing, especially by smallholdera and family farmers, giving special attention to women’s empowerment, while recognizing that efficient and effective trade is key to achieving nutrition objectives.

• Recommendation 10: Promote the diversification of crops including underutilized traditional crops, more production of fruits and vegetables, and appropriate production of animal-source products as needed, applying sustainable food production and natural resource management practices.

• Recommendation 11: Improve storage, preservation, transport and distribution technologies and infrastructure to reduce seasonal food insecurity, food and nutrient loss and waste.

• Recommendation 12: Establish and strengthen institutions, policies, programmes and services to enhance the resilience of the food supply in crisisprone areas, including areas affected by climate change.

• Recommendation 13: Develop, adopt and adapt, where appropriate, international guidelines on healthy diets.

• Recommendation 14: Encourage gradual reduction of saturated fat, sugars and salt/sodium and trans-fat from foods and beverages to prevent excessive intake by consumers and improve nutrient content of foods, as needed.

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