Agricultural &

Food Policy

Block 4, 2023
Food security and Nutrition

Dagim Belay
Department of Food and Resource Economics

Email: dgb@ifro.ku.dk
Outline

1. Global trends (and definitions)

2. Causes
3. Measurement
4. Policy responses

Learning outcomes
o Familiarize with definitions, burden, key indicators, data,
organizations, and causes of malnutrition
o Is there a case for policy?
o Which interventions are suitable?
Why care about Malnutrition?
Eating too much or too little is a problem
i.e., Double burden of malnutrition

o 1 in 9 (820M) are hungry

o 20M babies born of low birth weight each year
o 2B no regular access to safe, nutritious,
sufficient food

o 40% of adults, 21% of children (5-9)

have unhealthily high body weight

FAO 2019; Global Nutrition Report 2018/20

 Poor nutrition is a universal problem
o Affects all countries, all age groups, rich and poor
people, all sexes
o Inequity (some more affected):
o Young children
o Adolescent girls
o Pregnant/lactating women
o Elderly
o Ill and immuno-compromised
o Indigenous people
o Poor
o People in crisis-affected regions

Global Nutrition Report 2018/20

Good health is not possible without good nutrition

o Poor nutrition & unhealthy body weight associated with

various diseases & premature death
o Poor nutrition in children particularly concerning

Global Nutrition Report 2018/20

Poor nutrition is costly and a public health
concern

o Malnutrition is costly
o For individuals, households, cities,
nations
o Up to US$3.5 trillion

“Nutrition is one of the best drivers of development: it sparks a

virtuous cycle of socioeconomic improvements, such as increasing
access to education and employment.” (Kofi Annan, former UN
Secretary-General)
Global Nutrition Report 2018
 Global Trends (and definitions)

Food security
“Food security exists when all people, at all times, have physical and
economic access to sufficient, safe and nutritious food that meets
their dietary needs and food preferences for an active and healthy life”
(World Food Summit, 1996)
o Dimensions:
o Availability of sufficient food of appropriate quality
o Access to adequate resources for acquiring appropriate
foods for a nutritious diet
o Utilization of food through adequate diet, clean water,
sanitation and health care
o Stability: Access to adequate food at all times

For more information see e.g.,

http://www.fao.org/fileadmin/templates/faoitaly/documents/pdf/pdf_Food_Security_Cocept_Note.pdf
 Key messages

o People might not be “hungry”, suffering physical

discomfort caused by lack of energy intake … but might
still have a poor diet (food insecure)
o Beyond energy (kcal) intake
o Beyond staple food self-sufficiency
o It’s not all about diets…
o Food preparation
o Access to water, sanitation, hygiene; income,
education, health services

Global Nutrition Report 2018

What is malnutrition?
Deficiencies, excesses, or imbalances in the
intake of energy/nutrients

Diet-related NCDs
Micronutrient deficiencies
 Undernutrition

FAO 2020 http://www.fao.org/food-security-and-nutrition-for-all/background/en/

 Underweight in adults
o BMI<18.5: underweight
o BMI<17.0 linked to increases in illness
o BMI<16.0 associated with increased risk for
poor health & physical performance, death
o Prevalence:
o 8.6 % of men (2016)
o 9.4 % of women (2016)

Body mass index (BMI)

o kg/m2
o e.g.: 65/(175*175)=21.2

Global Nutrition Report 2018/20

 Micronutrient deficiencies
o Suboptimal nutritional status due to lack of intake/absorption
of vitamins/minerals
o Micronutrients that remain issues globally:
o Iron, zinc, vitamin A, folate, iodine
o Most difficult to satisfy without diverse diets

Anemia: general indicator of deficiencies

o Caused by multiple deficiencies (especially iron)
o Reduced hemoglobin concentration, affecting capacity to carry
oxygen
o 1/3 (613.2million) of all women of reproductive age have anemia (in
2016)
Global Nutrition Report 2018/20 and WHO
 Stunting in children under 5
o A form of growth failure
o Low height-for-age
o Develops over a long period when growing with limited access to food,
health, care.
o Comparison with reference population
o Can be applied to individuals with different ethnic, socioeconomic backgrounds
o Minor genetic differences
o Large variation due to health/nutrition
o Stunted if height-for-age is >2 standard deviations below the WHO Child
Growth Standards median
o More on calculation:
o Microsoft Word - Mod B 08 clean.doc (who.int)
o Z-score (or SD-score) = (observed value - median value of the reference population) /
standard deviation value of reference population

Global Nutrition Report 2018

 Stunting in children under 5
Global Prevalence and Regional differences

o Global Prevalence: steadily declining

o 165.2 million in 2012 (32.6%) in 2000
o 150.8 million (22.2%) in 2017

Kinyoki et al. 2020, Data 2017

 Stunting in children under 5
Subnational differences

o Substantial regional
differences, even
within countries
o Example: Prevalence of
stunting in India by
district (2015/16)
Global Nutrition Report 2018
Stunting in children under 5
Rural-urban divide

Example Peru: prevalence of

stunting in children under 5:
o 8.2% urban
o 25.5% rural

Global Nutrition Report 2020

 Wasting in children under 5
o Low weight-for-height
o AKA ‘acute malnutrition’
o Cause: acute food shortages or disease
o Rapid deterioration in nutritional status over a short period
o Higher risk of dying
o Definition: Similar to stunting: comparing value to standard
population (how much does the child’s weight differ from children
of the reference population)

o Prevalence: 50.5 million (7.5%) are wasted (from

7.9% in 2012)

Global Nutrition Report 2018; who.net

 Wasting in children under 5
Regional differences

Kinyoki et al. 2020, Data 2017

 Low weight-for-age
o Influenced by both
o Height-for-age
o Weight-for-height
→Makes interpretation complex

who.net
 Overweight and obesity in adults
o Overweight: BMI >25 (BMI: kg/m2)
o Obesity: BMI>30
o Major causes of many NCDs, reducing life expectancy and
quality of life
o Type 2 diabetes (9% of men; 7.8% of women)
o Coronary heart disease, stroke
o Increased the risks for several diseases (e.g., cancers,
musculoskeletal disorders, respiratory symptoms, dementia)
o Associated with social disadvantages (unemployment)
o Health consequences contribute to an estimated 4 million deaths
(7.1% of all deaths)
o 38.9% of adults overweight or obese

Global Nutrition Report 2018

 Overweight and obesity in adults
o What do you think? What proportion of male Danes is
overweight or obese (BMI >=25)
 Overweight and obesity in adults
o What do you think? What proportion of male Danes is
overweight or obese (BMI >=25)
 Prevalence of overweight and obesity (%)
Trends by income group

Overweight 38.9 Obesity 13.2

70
W:39.7 40
W:15.1
M:38.5 M:11.1
60

High- 30 High-
50
income income
40 Upper- Upper-
middle 20 middle
30
Lower- Lower-
20 middle middle
10
10 Low- Low-
income income
0 0
World World
199

200
199

200

200

200

200

201

201

201

201
199

200
199

200

200

200

200

201

201

201

201
6

6
6

6
Y= Prevalence (% of adult population)
Prevalence of overweigt (BMI >=
25) in adults (2016)
Prevalence of obesity (BMI >= 30)
in adults (2016)
 Overweight is affecting all age
groups

FAO 2019
 Overweight (high weight-for-height)
in children
Same as for wasting and stunting:
o Deviation from reference population
o Children with weight-for-height above +2 Z-scores

Global Nutrition Report 2020. Kinyoki et al. 2020, Data 2017

 Double burden: Different form of malnutrition
often found in same country, region, household,
individual

Global Nutrition Report 2020

 Double burden
Overweight and wasting in children

High
Prevalence (children under 5 years of age in
(OVR)

2017)
o Moderate-to-severe overweight (OVR)
Low (MSW) o Wasting (MSW)
o Double burden
Kinyoki et al. 2020
Exercise (5 min.)
o Pick a country (high, low, middle income)
o Look up:
o Prevalence of wasting (children under 5)
o Prevalence of stunting (children under 5)
o Obesity rates (adults)
o Prevalence of anemia in women
o Data sources:
o who.int/data/gho (Global Health Observatory)
o data.worldbank.org (World Bank open data)
o fao.org/faostat/en/ (FAO stat)
o https://globalnutritionreport.org/resources/
o National statistics agencies
o Present your results
The world is eating badly
Global diets are changing
o As incomes rise, households spend ever smaller shares of their incomes on food (Engel’s law)
o Diets become more diverse (Bennett’s law) and include more higher- value products such as
animal based products or fruits and vegetables
Nutrition transition or “Westernization“ of diets
o Increasing intake of
o Animal sourced foods
o Cheap vegetable oil
o Refined carbohydrates
o Added sugars (carbonated drinks, snacks, processed & packaged foods)
“The Sweetening of the World’s Diet”
o 43.7% of school-aged children consume soda every day
o Mexico: Share of calories from processed foods >50% (2012)
o US: about 30% of all calories come from non-processed or mildly-processed foods
o Food consumed away from home
o Snacking, fast-food, food to go
o Low intake of legumes, fruits, vegetables
o About a third (30.3%) of school-aged children do not eat any fruit daily
Popkin et al. 2012; Popkin 2014
Carbonated soft drinks

Global Nutrition Report 2020

FAO 2019
Are processed foods really a
problem?
 Are processed foods a problem?
o Yes and no (see this FAO report for details)
o Ingredients & processes to make products imperishable, palatable,
profitable
o Tends to lead to nutritionally unbalanced products
o Rich in nutritionally undesirable components (total fats, trans
fats, saturated fats, free sugars, salt)
o Poor in desirable components (fiber, micronutrients)
o Problematic when consumed in large quantity
o Studies have linked high consumption of ultra-processed foods to
poor nutritional quality, overweight/obesity, related NCDs, and
overall mortality

(Martínez Steele et al., 2017; Juul et al., 2018; Martínez Steele et al., 2019; Kim et
al., 2019)
Are processed foods a problem?
o Analysis of over 23,000 packaged food products
o 69% are of relatively poor nutrient quality, especially in low
and middle-income countries

Global Nutrition Report 2018

Outline of the lecture
1. Global trends (and definitions)
2. Causes
3. Measurement issues
4. Policy responses
Reasons for poor diets are complex
Economic circumstances
And economic
Biological/genetic development
factors

Psychological
factors

Nutritional
knowledge, Macro-level
Behavior & micro-
level
Crises

Culture, norms,
tradition
Political, institutional,
living environment
 Biological/genetic factors
o Evolution
o Until recently, ability to accumulate body fat and overeat
were advantageous in the face of recurrent periods of
famine/lack of food
o Genetic factors (hormonal differences, genetic
mutations)
o Inheritability of BMI, body weight regulation
o Epigenetics
o E.g., prenatal nutritional insufficiency can increase
susceptibility to obesity (adopting to food-scarce
environment)

Bühler et al. 2019; Popkin et al. 2012

 Psychological factors
o Examples:
o Emotional eating
o Sweets as reward
o Stress
o Sleep deprivation
o Peer-pressure
o Social stigma (e.g., if already obese)

Culture and social factors

o Examples
o Body size preferences/body norms
o Food traditions and values related to food
 Political, Institutional and living Environment

o Economic factors (see next slides)

o Crises (see next slides)
o Institutions and policies
o e.g., heath care system, social safety nets,
sanitation
o Ag. production and trade
o Infrastructure
o Manufacturing, storage, distribution (e.g. cold
chains)
o Possibility to walk and bike

Global Nutrition Report 2020

 Political, Institutional and living Environment

o Food environment
o Availability/affordability of (un)healthy foods
o Location and type of vendors (example: “food
deserts”)
o Product content (e.g., fortification)
o Portion size
o Advertisement/exposure
Income &
Economic development
o Raising incomes
o Smaller share of income is spent on food (Engel’s
law)
o People diversity their diets away from calorie-
dense staple foods towards more nutrient-dense
foods (meat, oil, fruits, vegetables) (Bennett’s
law)
o Higher diversity and quality
o …but also more highly processed foods…
 Income &
Economic development
o Increasing importance of service sector;
decreasing development of sectors that
require energy-expensive labor input
o Sedentary lifestyle
o Sedentary leisure activities
o Technology (e.g., AC, elevator)
o Increasing women labor market
participation
o Less time spent on food preparation;
demand for technology and convenience

Popkin 2001
 Economic development &
Food system changes
o Modern food technology (e.g., production,
transportation, mass distribution, marketing)
o “Supermarket revolution“
o Great benefits:
o food safety and quality, reduction of food
loss, de-seasonalization, availability of
cheap foods; convenience, lower burden on
women
o …but also easy access to empty calories
o Liberalization of trade and foreign direct
investments, saturation of western markets

Popkin et al. 2012

Economic downturn & crises
o Economic shocks, slowdown, downturns affect
multiple households, i.e., systemic shocks, rather
than idiosyncratic shocks that only affect a single
household
o Depreciation of national currencies against the US
dollar (inflation)
o Rising domestic prices
o Loss of gov. revenues (low investments)
o Unemployment and loss of income
o Low purchasing power
o (Individual) coping strategies not effective
o Bad especially for countries with high commodity
dependence and net food importers
 Commodity dependence
o Commodity-export-dependent countries derive the bulk of their
export earnings from primary commodities, such as minerals, ores,
metals, fuels, agriculture raw materials and food.

o Commodity-import-dependent countries or territories have a high

ratio of commodity imports to total import merchandise traded. This
includes essential goods, such as food items and fuel.

o Net food importers are countries or territories where the value of

imports of basic foodstuffs outweighs the value of exports of basic
foodstuffs.
Combinations of commodity
dependence

Commodity-import-dependent
High

Low
Low High
Commodity-export-dependent
 Crisis (conflict & natural disasters)
o Ca. 2B people (large share of poorest, undernourished)
o Loss of livelihoods
o Migration
o Internally displaced: 40M (esp. Syria, Colombia, DRC)
o Refugees bordering countries: 25.4 M (esp. Turkey, Jordan)
o Ca. 201M need humanitarian assistance
o 27 countries protracted crisis response countries (2000-
17)

https://reliefweb.int/sites/reliefweb.int/files/resources/GHA%20report%202019_0.pdf
Conflict, fragility, violence
o Deteriorating governance, prolonged political crisis, failed
states, post-conflict situations

Uppsala Conflict Data Program Department of Peace ACLED Conflict dataset

and Conflict Research https://ucdp.uu.se https://acleddata.com
 Conflict, fragility, violence
o Does conflict cause food insecurity or vise versa?
o Food insecurity fuels protest and violent conflict
o Lack of food can motivate any type of anti-social
behavior
o Food prices and social unrest (protest) (Bellemare
2015)

Global Nutrition Report 2018

Natural disasters
environmental change
o Climatological (drought, extreme heat, fire)
o Hydrological (flood) Data and
information: Centre
o Geophysical (earthquakes, volcano) for Research on the
Epidemiology of
o Meteorological (storm) Disasters
o Biological (pest outbreaks, epidemic) https://www.cre
d.be
o Technological (industrial accidents)
Reasons for poor diets are complex
Economic circumstances
And economic
Biological/genetic development
factors

Psychological
factors

Nutritional
knowledge, Macro-level
Behavior & micro-
level
Crises

Culture, norms,
tradition
Political, institutional,
living environment
Affordability of healthy diets
Relative Caloric Prices (RCPs) of Key Foods

o Headey & Alderman

(2019). Relative Caloric Prices
of Healthy and Unhealthy Foods
Differ Systematically across
Income Levels and Continents |
The Journal of Nutrition | Oxford
Academic (oup.com)
 Relative Caloric Prices (RCPs) of Key Foods
o Data: International comparison program (ICP)
o UN statistical commission
o Used to assess and compare standards of living (GDP,
poverty rates)
o And USDA food composition tables (database)
o Price per calories
o (price of 1 kcal of food x) / (price of 1 kcal of representative
basket of starchy staple foods in each country)
o Represents the cost of diversifying diets away from
cheapest staple food
o Using ratios avoids problems exchange rate

(Headey & Alderman 2019)

 Relative Caloric Prices (RCPs) of Key Foods

o Relative food prices vary across regions

o Non-cereal foods relatively cheap in high-income
countries
o Healthy foods (vit.A rich vegetables, animal-based
foods, fortified infant cereals) relatively expensive
in low-income countries)

o Relative prices correlate with prevalence of

malnutrition, e.g.,:
o Soft-drink prices and overweight
o Milk and fortified infant formula and stunting

(Headey & Alderman 2019)

Home Exercise: What would you eat if you were
really poor? Trade-offs in food consumption choices
1) What would you buy if you were really poor? (Cost of food basket per day)
o Identify about 5-10 items you think might be the lowest cost way to meet a biologically
sustainable diet for a day using online sources (e.g., nemling or coop or rema)
o Compute cost per kg for each item
o How much (kg/day) would you eat of each item and what is the total cost? → cost per
day of food basket
2)What do you get for your money?
o Go to USDA National Nutrient Database https://fdc.nal.usda.gov/index.html
o Compute the nutritional value of what you’ve bought
o Macronutrients: Energy (kcal), Protein (g), Carbohydrates (g)
o Micronutrients: Iron (mg), Vitamin C (mg), Vitamin A (RAE)
3)Have you acquired enough nutritious food to sustain you?
o Go to the U.S. Institute of Medicine’s Dietary Reference Intake at
https://www.nal.usda.gov/fnic/dri-calculator/
o Find out what is required (6 nutrients) to sustain an average person of your age and
sex
o Does your food basked meet recommendations in terms of the 6 aforementioned
macro- and micronutrients
o You have to enter (translate) your weight and height into feet and pound
4) Share your results:
o The cost of your food basked (in DKK)
o Whether or not (yes/no) it is a biologically sustainable diet for (i.e., meeting
recommended intake of energy, protein, carbohydrates, iron, vitamin C, and vitamin A)
Outline of the lecture
1. Global trends (and definitions)
2. Causes
3. Measurement
4. Policy responses
Measurement
o Anthropometrics
o Dietary assessment
o Biochemical parameters
o Clinical examination
Anthropometrics

o BMI (height, weight)

o Kids:
o Stunting
o Height-for-age
o Wasting
o Weight-for-height
o Mid-upper arm circumference (MUAC)
 Dietary assessment
o Nutrient intake and dietary pattern of individual, household members,
population group over time

o Indirect (secondary data) vs. direct methods (primary dietary

data)

o Prospective (when the foods are being consumed) vs.

retrospective methods (recall of food intake)

o Qualitative (types of food consumed) vs. quantitative

(types and quantity of food consumed)

o Selection depends on objectives (food consumption, nutrient

intake, eating habits)

(FAO 2019)
 Food Balance Sheet
o Country-level data on food supply
o Compiled by FAO
o annually
o for ca. 185 countries
o 100 food commodity groups
o Using official primary production & trade data

(FAO 2019)
 Food Balance Sheet

Total Q food National food stock levels

produced & exports
+ - +
Total Q Q used for animal feed,
imported seeds, industrial, other
purposes, losses

Total country’s population

o available amount of food/energy/nutrients

per person per day.
(FAO 2019)
 Food Balance Sheet
o Allow to assess national food availability for consumption
o Food consumption patterns
o Dietary habits
o Adequacy of a country’s supply to meet nutritional requirements

o Global trends
o Trends across regions

(FAO 2019)
 Shortcomings?
o Food availability (not consumption)
o Disaggregation impossible
o Some types of food utilization not captured/difficult to capture
o e.g., food waste
o Seasonal variation
o As good as primary input data
o Wild animals & insects
o Subsistence production
o Time lag from collection to publication

(FAO 2019)
 Household Consumption and
Expenditure Surveys (hh level)
o Food available for consumption in the household
o Typically excludes food eaten away from home
o Unless prepared at home
o All expenses and type of foods consumed during specific period (1-4 weeks)
o Ideally different times in the year
o Routinely undertaken by statistical offices
o Primarily to analyze economic outcomes
o Consumer price indices
o Living conditions, trends in poverty, income inequality
o Can be used to calculate pc food availability (energy, nutrients)
o Examples: Danish GFK dataset, LSMS

(FAO 2019)
 Shortcomings?
o Distribution within households
o Cooking methods
o Food losses
o Measurement issues
o Units often non-standardized
o Food away from home (and processed foods)
o Seasonality

(FAO 2019)
 Direct methods
o Trends in food consumption, food and nutrient intake, eating
patterns, and to evaluate diet–disease associations
Retrospective methods (recall of food intake)
o 24-hour recall
o From first and last food item consumed
o Requires multiple non-consecutive repetitions
o Food frequency questionnaires (FFQ)
o E.g., based on food list
o Dietary history
o In-depth interview to assess eating patterns (6-12
months)

(FAO 2019)
 Direct methods
o Prospective
o When foods are being consumed
o Typically expensive
o Food records (can be supported with technology)
o Duplicate meal method

(FAO 2019)
 Qualitative
Dietary diversity scores (DDS)

o Easy, cheap, quick

o Proxy for micronutrient adequacy

o Various different scores with different food groups

o Count of food groups (and frequency of consumption)
over specified period of time
o Based on recall or list of food items
o At household level or at individual level (women, infants)

(FAO 2019)
Outline
1. Global trends (and definitions)
2. Causes
3. Measurement
4. Policy responses
What do you think?
Is there a case for policy?
o Arguments in favor or against policy interventions?
o Responsibility of individuals?
o Market failures? Negative externalities?
Is there a case for policy?
o Food = private good
o People may make poor, personal decisions (e.g., energy
imbalance leading to obesity)

o Free choice argument (responsibility is placed on individual

rather than companies, policymakers, environment)
o Lobbying by food industry
o Lack of public pressure
o Can explain political inaction
Is there a case for policy?
o Causes negative externalities
o Economic cost for society
o Weight-loss interventions at individual level frequently not
successful
o Changes in diet and activity patterns more likely to
occur as a result of environmental/societal changes
o Forgone contribution to economic development
o Malnourished kids will not grow up to be productive
adults
o Malnutrition liked to poor provision of public services
(government failure)
o Health care, education, information
Is there a case for policy?
o Addictive behavior and exposure
o Unhealthy foods such as sugar have no nutritional value
while increasing risk of disease
o To some extent similar to alcohol, tobacco, drugs
o But consumption levels do matter (more)
International targets
o 2012 & 2013: member states of the WHO adopted a
series of targets to reduce malnutrition by 2025 (2
separate resolutions)
o Comprehensive implementation plan on nutrition
o targets on stunting, wasting, anemia in women, low birth weight,
childhood overweight
o Global Monitoring Framework for the Prevention and Control of NCDs
o Voluntary targets to monitor progress in achieving targets on four NCDs
with diet-related causes

o 2015: SDG target2 : “end malnutrition in all its

forms” by 2030
o 2016: United Nations General Assembly adopted
a resolution proclaiming the UN Decade of Action on
Nutrition from 2016 to 2025
o Goal: eradicate all forms of malnutrition
FAO 2019
Policy options
Group discussion/brainstorming (10 min)
o What are policy options?
 Nutrition-specific investments
o High impact nutrition interventions that address the
immediate determinants of malnutrition
o Micronutrient supplementation / fortification
o Food aid
o Complementary feeding of young children

Global Nutrition Report 2018

 Nutrition-sensitive investments
o Address the underlying causes
o Range of sectors: health, agriculture, water, sanitation and
hygiene promotion (WASH), education, social protection,
transport, urban planning, etc.
o Goals (examples)
o Improve the purchasing power of women
o Improve access to food
o Diversify agriculture
o Advancing biofortification
o Promoting healthy diets
o Supporting breastfeeding
o Improving access to WASH
Global Nutrition Report 2018
Demand and supply-side
interventions
Supply
o Ag production: Decrease cost of producing affordable food
o R&D, subsidies in fruits and vegetable sector
o Distribution (e.g., better infrastructure)
o Processing (food content)
Demand
o Increase people‘s ability and incentives to consume healthy food
and pursue healthy lifestyle
o Incentives and disincentives
 Education

Vouchers/
transfers
Nudging

Sugar tax

School feeding
programs
Labels

Fortification
School feeding programs (SFP)
 School feeding programs (SFP)

o Implemented in many (>70) countries

o Often initiated/promoted by WFP

o Goals
o Improve nutrition and health
o Concentration spans, cognition
o School attendance and educational outcomes
o Nutrition knowledge
o Transfer to families
o Incentives to send kids to school, esp. girls
 School feeding programs (SFP)

o Different forms

o Government provides funds, food, meals

o Rules on content of meals (% staple foods, legumes, vegetables)
o Rules on where to source foods (e.g., local family farms)

o Children get breakfast/lunch vs. food to take home

 Evidence

o Large body of literature

o Jomaa et al. (2011) summarize evidence:
o Positive effects on nutrition, school enrollment and attendance
o Less clear: academic achievement (depends also on other
factors)
 Evidence, examples

o Aurino et al. (2019) find that SFP in crisis affected Mali increases school
enrollment and attendance

o Kikima (2019) SFP in Burkina Faso increases cognitive performance,

reduces absenteeism
o Food rations that can be takenhome
o Poverty levels high, so high incentives
o Shresta et al. (2020) focus on SFP in Nepal
o Meals (13-18 cents) increases meal frequency
o Ghattas et al. (2020) describe SFP in Palestinian Refugee camp in Lebanon

o Subsidized snacks produced by women’s community kitchen program

 Example: Brazil (PNAE)
o One of the largest and oldest SFPs worldwide (50s)
o Launched by federal government
o Reaching 43M children (20% of population)
o Goals: Improve health, nutrition,
education, social protection

o Partnership with local family farms

o 30% of federal funds must be used to purchase
locally
o Criticism: Increasing share of processed food, which is
cheaper

Teo 2017
 Challenges

o Schools need infrastructure, cooks with nutrition knowledge

o Cost vs. nutritional value
o Opportunity cost of labor: incentive has to be sufficiently large
o Distance to school, safety situation

o Program design crucial

o Substitution (kids may eat less at home)
o Targeting (food is shared) especially when snacks/food rations are
provided rather than meals

Goldsmith et al. 2019

Vouchers
 Vouchers
o Distributed to ensure access to food
o In poor countries, especially during crisis
o But also in wealthy countries (SNAP US)

Example Bangladesh: e-vouchers distributed to refugees

o Can only be used in designated outlets in camps
o Access to 20 different food items
o 12 are mandatory
o 8 can be chosen from items in store
o Rational: helps to ensure the quality of the foods while respecting
individual choices
o Combined with nutrition education

FAO 2019
 Example UK

o To support low income families during corona crisis

o 1.3M students are normally entitled to free school lunches
o £15 (17€ or 124 DDK)/week per child
o Vouchers send out by email to the eligible families
o The vouchers can be spent on food at a range of shops

Uk.gov
 Other food/cash transfers

o Food vs. cash

o Unrestricted cash assistance often more
successful (let people decide what they need)
o Conditional vs. unconditional
More
o E.g. Mexico and Brazil
info
o Transfer vs. cash for work programs here
Large-scale food fortification
 Large-scale food fortification
o Adding essential vitamins/minerals to foods that undergo some form of processing

o Proven effective to alleviate deficiencies

o Benefits at low costs
o esp. when there is a convenient food vehicle & centralized processing
o Iron, iodine, and zinc

o Concerns: Potentially higher processing costs, limiting consumer’s choice, and the risks of
micronutrient overdose
o Implemented by regulators for decades
o Iodine fortification of salt in Switzerland (1923) to prevent goiter and cretinism
o >80 countries require grain fortification with iron and/or folic acid
o 29 now have national programs to fortify edible oils with vitamin A
Global Nutrition Report 2018
Related options
o Bioforticiation
o Challenges related to adoption in some cases

o Supplementation
o Challenges: Targeting and scale
Education
 Education

o Generic advertising interventions to increase consumption of fruit &

vegetables implemented in many countries
o e.g. 5 A Day campaign in the U.K.
o Go for 2&5® in Australia
o 5-10 A Day campaign in Canada
o Fruit and Veggies—More Matters in the US

o Evidence of the effects on consumption of healthier foods is mixed

 Education

o More targeted interventions might be modestly more successful

o e.g., maternal educational programs

o Can be costly
o when the target population is large/dispersed
o when they speak different languages

o Information technology
Labels
 Labels
o Front-of-pack nutrition labelling
o Alongside basic nutrient declaration (back-of-the pack
labels)

o Some countries mandate labels warning that foods is high

in sugars, salt, fats and/or calories

Global Nutrition Report 2018

Ecuador France,
Belgium

Australia
Chile/Peru
 Labels

o Nutritional information influences consumer choices

o Cost-effective and trusted method of conveying information

o Yet, impact of food label information on consumer behavior

and outcomes remains controversial

Global Nutrition Report 2018

Nudging
 Nudging
o “Positive reinforcement and indirect suggestions as ways to influence the behavior and
decision making”
o Used to influence consumers in several contexts (Just, 2017)
o Changing shelf space management in supermarkets (Adam et al. 2017)

o Changing the default (that is likely chosen) to a healthy food choice

o Low-fat milk and fruit instead of juices and fried potatoes as side dishes
o Presenting vegetarian option first
o Any additional examples?
Sugar-sweetened beverage (SSB)
taxes
 D S tax
P
S

Burden on consumers

Burden on producers Tax

Q
 Sugar-sweetened beverage
(SSB) taxes

o Different taxes possible

o fat, sugar, salt, “unhealthyfood”

Why sugar?
o Large share of sugar and energy intake from SSBs
o Link between SSBs & caries, body weight, NCDs, substitution of
healthy foods in kids well established

o Recommended by WHO and other UN institutions

o Implemented in over 50 countries and cities

o e.g. Mexico, Saudi Arabia, Ecuador, the Philippines, UK, cities in the U.S.
 SSBs taxes

Bridge et al. 2019

 SSBs taxes

o Opposition from industry; sometimes from public

o Controversies
o What should be included
oe.g., fruit juice, suger-sweetend milk drinks
o Disproportionately affecting poor
o Obesity is a multidimensional problem

o Important to give industry time

o e.g., to reduce sugarcontent

(Bridge et al. 2019; Colchero et al. 2016; Hashem et al. 2020)

 SSBs taxes
o High prevalence of overweight & obesity
o Very high consumption levels
o Sugar intake accounts for 12.5% of total daily dietary energy intake

o 2013/14 government approved SSB tax and a sales tax on certain energy-
dense foods
o 1 Pesos/L (ca 10% tax)
o Tax burden almost entirely passed on to consumers

o Reduction in consumption
o Largest decrease in poor households

(Barquera et al., 2008; Colchero et al., 2016)

 SSBs taxes

o Confirmed by other studies

o e.g., Chile, Berkeley, Philadelphia,UK

o Effectively ↓ sales or consumption

o Findings from UK show manufacturers reformulate products

o Comparison products before and after introduction:
o Sugar & energy content of products ↓ ca. 40%

o Moderate effects (↓) in body weight

 Fat Taxes
o It could be tax on saturated fat and all fats.

o In October 2011, for first time, Denmark introduced taxes on saturated fat.
o a supplement to existing taxation on sugar, chocolate, candy, ice-cream
and soft drinks.

o The fat tax in Denmark distinguishes itself from SSBs taxes.

o It targets a nutrient which occurs naturally in foods, instead of targeting
specific groups of food.

• Jensen and Smed (2013) show that the tax on saturated fat in food products
in Denmark has reduced consumption of fats, such as butter,
blends, margarine and oils – at least in the short run.

• The analysis shows decreases in the consumption of these products in the

range about 10–15%, compared with the intake levels before the
introduction of the tax.
Direct Regulation
o Ban certain unhealthy products

o Ban vending machines in schools/regulate what they

can sell

o Regulate marketing including ban

o Regulate max. content