In 2015, the countries of the United Nations committed to the 2030 Agenda for Sustainable Development. This agenda recognized the importance of looking beyond hunger towards the goals of ensuring access to safe, nutritious and sufficient food for all people all year round, and of eradicating all forms of malnutrition (SDG 2 Targets 2.1 and 2.2). Five years into the 2030 Agenda, it is now time to assess progress and to question whether continuing efforts implemented thus far will allow countries to reach these objectives. For this reason, this year’s report complements the usual assessment of the state of food security and nutrition in the world with projections of what the world may look like in 2030 if trends of the last decade continue. Importantly, as the COVID-19 pandemic continues to evolve, this report attempts to foresee some of the impacts of this global pandemic on food security and nutrition. However, given that the devastation that COVID-19 will cause is still largely unknown, it is important to recognize that any assessment at this stage is subject to a high degree of uncertainty and should be interpreted with caution.

Food security and nutrition are closely interlinked. Food insecurity can lead to different manifestations of malnutrition. One vital element that explains this connection is the food that people eat; specifically, the quality of their diet. Food insecurity can affect diet quality in different ways, potentially leading to undernutrition as well as overweight and obesity. Ensuring access to a healthy diet is a prerequisite for achieving the SDG target of eradicating all forms of malnutrition. For this reason, this report examines several issues related to the quality of diets, including the challenges of assessment and monitoring of food consumption and diet quality at global level.

Section 1.1 presents the latest available evidence on progress towards achieving the hunger and food insecurity targets (SDG 2.1). This assessment is complemented with a first assessment of the potential for achieving these targets by 2030 at the global and regional levels based on the assumption that the trends observed in the last decade will continue.

Section 1.2 presents the latest figures on progress towards achieving global targets for seven nutrition indicators (including three SDG 2.2 indicators), with a spotlight on childhood stunting. The section also provides a glimpse of what the nutrition situation would be like in 2030 if current trends continue.

The analyses presented in Sections 1.1 and 1.2 use input data compiled up to March 2020, but with a reference period that ends in 2019. As such, they should be understood to represent the food security and nutrition situation before the outbreak of COVID-19. At this stage, it is not possible to undertake a complete and well-informed quantification of the impact of the COVID-19 pandemic. Nonetheless, this report provides an assessment of how the pandemic might affect food security and nutrition, within the limitations imposed by the information that is currently available.

Section 1.3 describes the challenges of defining and monitoring diet quality. It also presents evidence on what people are eating around the world including global trends in food availability and assessments of diet quality at the global and national levels. It ends by examining the important link between people’s food insecurity (access) and diet quality. This segues into Part 2 of this report, which scrutinizes in depth the cost and affordability of healthy diets. Section 1.4 summarizes and concludes Part 1.

Ten years remain to eliminate hunger and ensure access to food for all

This edition of the report presents the latest available evidence on progress towards achieving the hunger and food insecurity targets. It also attempts to predict the state of food security in 2030 by assessing the current trajectory of hunger at the global and regional levels.

The assessment benefits from important updates for several populous countries. In particular, newly accessible data for China made it possible to update estimates of inequalities in dietary energy consumption in the country. This has in turn allowed us to revise the entire prevalence of undernourishment (PoU) series for the country back to 2000, and by extension to estimate hunger in the world with greater accuracy (see Box 1).

BOX 1

Updated information for China improves the accuracy of global hunger estimates

Revising parameters to estimate the PoU is standard procedure, conducted annually as more data become available. This makes it impossible to compare PoU estimates across different editions of the report (see Box 2 and Annex 2). Even so, data are not available to update parameters for all countries every year. This year has been rich in updates, including revision of the crucial parameter of inequality in food consumption for 13 countries, among them some of the world’s most populous. As highlighted in previous editions, particularly problematic until this year had been access to more recent data to revise the parameter of inequality in food consumption for China. Given that the country hosts one-fifth of the world’s population, any update of Chinese parameters can be expected to make a significant difference to global estimates.

While still facing food security and nutrition challenges, China has made impressive economic and social development gains since the last update that were not reflected in previous assessments. Our conviction that an update of the PoU for China was needed was reinforced further by a recent assessment on the state of nutrition in China, the Report on Chinese Residents’ Chronic Diseases and Nutrition, published by the Chinese National Health and Family Planning Commission on 30 June 2015. The report showed considerable improvement in the nutritional status of the Chinese population, including a reduction of undernutrition in adults (measured as the percentage of individuals with Body Mass Index below 18.5 kg/m²) from 8.5 percent in 2002 to 6 percent in 2012, and of stunting in children under 6 years from 16.3 percent in 2002 to 8.1 percent in 2013.^11,12* However, the data in the report could not be used for the update, as it does not provide information on inequality of food consumption in the population.

This year FAO obtained data from two surveys in China that could be used to update the PoU estimates. The first is the China Health and Nutrition Survey (CHNS)** conducted from 1990 to 2011, covering 12 provincial-level administrative regions of China. The second is the China Household Finance Survey (CHFS),*** which covers 28 out of 34 provincial-level administrative regions of China, and was conducted every two years from 2011 to 2017. With these data it was possible to update the information on inequality of dietary energy consumption across the Chinese population and, consequently, the estimates of the PoU for China, and to revise the whole series back to 2000 for consistency.

Although based on different sampling frames and designs, CHNS and CHFS provide sufficiently reliable estimates of average food consumption and average food expenditure, respectively, by province and income deciles. This allowed the estimation of a statistical function that links the daily dietary energy consumption of typical households in China to their monthly food expenditure. The estimated model was then used to predict the levels of energy consumption by income decile in each of the provinces and years based on the reported food expenditure data in the CHFS. The results, properly weighted by the current population in each income decile by province, were used to compute estimates of inequality in habitual dietary energy consumption due to income (CV|y) in 2011, 2013, 2015 and 2017. These estimates were then used to update the series of PoU for China.**** With the revision, the estimated PoU for China in 2017 is below 2.5 percent of the population, which is the lowest value that can be reliably reported using the PoU methodology. Without the revision, the 2017 estimate would be close to 10 percent.

The revisions to the China series have resulted in a new series of estimates of PoU and the number of undernourished in the world which, reflecting new information, are now more accurate than in the past. The result was a substantial downward shift of the entire series of global hunger numbers, as depicted in Figure A. Despite this shift in levels, the revision confirms the trend reported in past editions of this report: the number of people affected by hunger in the world has been slowly on the rise since 2014.

A. Number of undernourished in the world, with and without the revision for China

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In addition to the trends on improving nutrition in China from the 2015 report mentioned above, further validation for the revision comes from comparing the revised global estimates of PoU with the recent estimates of the prevalence of severe food insecurity based on the Food Insecurity Experience Scale (FIES). As explained in past editions of the report, the PoU and the prevalence of severe food insecurity based on the FIES are different, independent measures of the extent of serious food deprivation, based on different methods and data sources. However, they are two complementary ways to look at the extent of hunger in the world (see also the section on SDG Indicator 2.1.2 in this report).

The revised PoU estimates, both for the entire world and for the world excluding China (Figure B), display a remarkable convergence with the series of the prevalence of severe food insecurity in 2014–2019. This confirms the validity and urgency of the revision. The greater concurrence of these two indicators – for China and for the world – is a welcome step towards a unified baseline for gauging progress on the road towards the achievement of SDG 2.

B. Prevalence of undernourishment in the world with and without China, compared to the prevalence of severe food insecurity based on the FIES

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The report presents an assessment through 2019 based on the data that was available in March 2020, just before the COVID-19 pandemic began to take hold. The challenge of eradicating hunger and ensuring access to safe and nutritious food for all now appears to be more daunting. The figures and projections reported in this section and in Section 1.2 provide a picture of how food insecurity and malnutrition in the world would have evolved had COVID-19 not appeared. In this sense, it is an important assessment to be used as a baseline against which to evaluate the impact of the pandemic on food security and nutrition.

SDG Indicator 2.1.1 Prevalence of undernourishment (PoU)

The three most recent editions of this report already presented evidence that the decades-long decline in hunger in the world, as measured using the PoU, had unfortunately ended. Additional evidence and several important data updates, including a revision of the entire PoU series for China (see Boxes 1 and 2), show that almost 690 million people in the world (8.9 percent of the world population) are estimated to have been undernourished in 2019 (Figure 1, Tables 1 and 2). Revision in light of the new data, which results in a parallel downward shift of the entire global PoU series, confirms the conclusion of past editions of this report: the number of people affected by hunger in the world continues to increase slowly. This trend started in 2014 and extends to 2019. There are nearly 60 million more undernourished people now than in 2014, when the prevalence was 8.6 percent – up by 10 million people between 2018 and 2019.

Figure 1

The number of undernourished people in the world CONTINUED to increase in 2019. If recent trends are not reversed, the SDG 2.1 Zero Hunger target will not be met

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TABLE 1

Prevalence of undernourishment (PoU) in the world, 2005–2019

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TABLE 2

Number of undernourished people in the world, 2005–2019

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There are a number of reasons why hunger has increased in the last few years. Weak, stagnant or deteriorating economic conditions are underlying causes of increasing poverty and undernourishment. Economic slowdowns and downturns, particularly since the financial crisis of 2008–2009, have had significant impacts on hunger through various channels.¹ Despite significant progress in many of the world’s poorest countries, and extreme poverty rate declining in the last two decades from more than 50 percent to about 30 percent, almost 10 percent of the world population still lives on USD 1.90 per day or less, especially in sub-Saharan Africa and Southern Asia.² Debt has increased significantly in many poor economies during the last decade, with total debt reaching almost 170 percent of GDP in 2018,³ thus contributing to rising global risks and weakening growth prospects in many emerging and developing economies.

A high level of commodity-export and commodity-import dependence is another factor that makes several countries and regions more vulnerable to external shocks. Large inequalities in the distribution of income, assets and resources, together with the absence of effective social protection policies, also undermine food access, particularly for the poor and vulnerable. Economic conditions, structural imbalances and the inclusiveness of the policy framework interact with natural and man-made causes to trigger persisting poverty and hunger.

The increasing frequency of extreme weather events, altered environmental conditions, and the associated spread of pests and diseases over the last 15 years are factors that contribute to vicious circles of poverty and hunger, particularly when exacerbated by fragile institutions, conflicts, violence and the widespread displacement of populations.^4,5,6,7 The number of displaced people in the world in 2018 was about 70 percent higher than in 2010, reaching some 70.8 million, mostly hosted by developing countries.²

Smallholder farmers and communities that rely directly on their ability to produce their own food are affected more by these phenomena. Moreover, the prevalence of hunger is higher in countries with fast population growth and poor access to healthcare and education. This establishes direct links between food security, nutrition and health conditions of the population, which in turn affect the prospects of economic growth and development.

Figure 1 reveals that the world is not on track to achieve the SDG 2.1 Zero Hunger target by 2030. Combined projections of recent trends in the size and composition of population, in the total food availability, and in the degree of inequality in food access point to an increase of the PoU by almost 1 percentage point. As a result, the global number of undernourished people in 2030 would exceed 840 million (see Box 2 and Annex 2 for a description of the projection methodology).

This is the projected situation in 2030 based on trends in recent years, without considering the unknown impact of the COVID-19 pandemic. The pandemic will most likely accelerate the projected increase in the number of hungry people, at least in the immediate future. This reinforces the need for urgent action to get back on track towards achieving the Zero Hunger goal. The possible impact of the COVID-19 pandemic on the food security outlook for the world in 2030 is discussed in Box 3.

BOX 3

How the COVID-19 pandemic may affect hunger in the world

This report presents projections (Figure 1) of what the extent of hunger in the world may be in 2030, if trends of the last decade, observed until late last year, were to continue (see Box 2 and Annexes 1B and 2). At the time of going to press (June 2020), the COVID-19 pandemic was spreading across the globe, clearly posing a serious threat to food security. There is no doubt the pandemic will expose more people to food insecurity and accelerate the projected increase in the number of hungry people, unless immediate actions are taken. As the extent to which the COVID-19 pandemic will persist is not known, both in terms of scope and severity, the projections provided here must be seen as preliminary.

There are multiple ways in which the pandemic may affect food systems and food security.^14,15,16 It is clear that the COVID-19 pandemic is already delivering shocks to both the supply and the demand side of food systems throughout the world. On the supply side, COVID-19 itself may not necessarily create food shortages, as the production of the major food crops (wheat, rice, maize and soybean) is expected to remain above average in 2020.¹⁷ But the pandemic has already created disruptions along the food supply chain. COVID-19 containment measures are already limiting labour mobility in areas dependent on seasonal or migrant labour and making it difficult to access markets and transport food both within and across countries. Further disruptions of logistics could disrupt the new planting seasons.

On the demand side, the massive lockdowns across the world are expected to hamper people’s ability to access food and create serious economic downturns. This will make it difficult to afford food, particularly for the poor and vulnerable groups. Low- and middle-income countries will likely be the most affected, as they do not have the contingency mechanisms and funds to stimulate their economies and protect the most vulnerable. As a consequence, a pandemic-induced global economic crisis is likely to generate new pockets of food insecurity even in countries that did not require interventions previously.

How the COVID-19 pandemic may affect hunger in the world: three scenarios

Estimating COVID-19’s effect on food security comes with a high degree of uncertainty due to lack of data and clarity about what the future of the world economy will look like. Potential scenarios may take different shapes, depending on the kind of policies that will be put in place and the time they will take to start showing their impact. At the time of writing, a so-called “U-shaped” recovery appeared to be more likely, which could mean a recession in 2020 followed by a recovery, whose length is uncertain, but starting in 2021. Such a recovery is conditional on second waves of infections not materializing or being easily contained.

Although it is still too early to quantify the full impact of the pandemic, this box presents the results of a quantitative analysis of the potential consequences in terms of the PoU, as driven by the global economic prospects. The analysis aims to show how the scenario described in Figure 1 might change once some of the potential effects of COVID-19 are factored in.

Because COVID-19 is triggering shocks on both the supply and the demand side of the global economy, the simplest way to gauge its potential effect on the PoU is through its impact on world economic growth. This is done by combining data from the International Monetary Fund’s World Economic Outlook (WEO) released in April and updated in June 2020,¹⁸ with a statistical analysis of the relationship between economic growth and food availability. It follows the methodology and country samples of an earlier exercise conducted by FAO using previously available data.^19,20

Based on time series of total food supplies and GDP growth over 1995–2017 for most countries in the world, the statistical analysis shows that GDP growth reduction significantly affects the net food supply in net food-importing countries, and especially in low-income food-deficit countries (LIFDCs). On average, 1 percentage point of GDP growth reduction is estimated to reduce the food supply in net food-importing countries by 0.06 percent in net food-importing countries that are not low-income, and by 0.306 percent in LIFDCs.

The IMF’s WEO forecasts a contraction of 4.9 percent in the world GDP in 2020, followed by a recovery of 5.4 percent in 2021. It provides country-specific estimates of GDP change in 2020 and 2021. The aforementioned elasticities estimated by FAO were applied using the GDP growth forecasts for 2020 and 2021 to all net food-importing countries (distinguishing between LIFDCs and non-LIFDCs) in order to estimate the likely shift in the series of total Dietary Energy Supply. This is used to compute the PoU, under three scenarios, illustrated by three different lines in the figure presented below. The three simulated scenarios contrast with the projections presented in Figure 1, a world without COVID-19.

The first scenario builds on the WEO, which forecasts world economic growth to be -4.9 percent in 2020 and +5.4 percent in 2021, which closely approximates an earlier forecast by IFPRI.²¹ It is illustrated by the orange line in the figure. Such negative economic performance in 2020 would imply an increase of about 83 million undernourished in 2020 (from 695.7 to 778.3) attributable to the COVID-19 pandemic.

The second, less optimistic scenario (red line) foresees 2.1 percentage points lower GDP growth both in 2020 and 2021 compared with the base one (that is to say, world economic growth would be on average -7 percent and +3.3 percent in 2020 and 2021, respectively). In such case, the increase in the number of undernourished in 2020 would be of 103 million.

The third, more pessimistic scenario (dark red line) implies a reduction of 5.1 percentage points in the GDP growth rates compared to the first scenario, thus assuming a world economic growth of -10 percent and +0.3 percent, in 2020 and 2021 respectively. This scenario would bring the number of undernourished up to almost 828 million in 2020, out of which more than 132 million might be attributable to the impact of COVID-19. The expected recovery in 2021 would bring the number of undernourished down to 766 million, which is 62 million more than the already worrisome projection in the absence of the pandemic (indicated by the yellow line).

In all cases, the world economy would not fully recover in 2021.

The analysis is limited to the potential impact of the pandemic on net food supplies only, as the pre-COVID-19 projections for the population size and compositions and for the food consumption inequality are not altered. As a result, the analysis does not capture the full impact of the economic recession, as it does not consider possible consequences in terms of inequality in food access within countries. Therefore, it may underestimate the total potential impact of COVID-19 on food insecurity should the simulated economic growth scenarios materialize. It is also important to highlight that, as presented in the IMF’s WEO, the analysis assumes that the recovery will happen in two years. Considering the high degree of uncertainty around the duration of the recovery, this represents an important limitation of this assessment.

While it cannot be considered a precise, detailed analysis, it demonstrates that, if no action is taken to prevent foreseeable disruptions in the world food systems, especially in food-deficit countries, COVID-19 will further complicate the already daunting challenge of reaching the SDG target of Zero Hunger.

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The majority of undernourished people in Africa are found in the sub-Saharan subregion, which shows an increase of about 32 million undernourished people since 2015. Hunger has been on the rise throughout sub-Saharan Africa since 2014, though the increase has been especially significant in the Eastern and the Western subregions, as well as in Middle Africa where it has reached 29.8 percent of the total population in 2019 (Figure 2, Tables 1 and 2).

Figure 2

PoU in Africa by SUBREGION, with projections to 2030. The highest levels of undernourishment are found in Middle and Eastern Africa

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Economic slowdowns and downturns help explain much of the observed increase in hunger in several parts of sub-Saharan Africa, especially in the last two to three years. For instance, in Western Africa, recent increases in undernourishment have occurred together with these adverse economic factors, as has been the case in Côte d’Ivoire, Gambia, Guinea-Bissau, Mauritania, Niger and Nigeria.¹

Additionally, a number of conflicts have affected the subregion in recent years, including in Burundi, the Central African Republic, Côte d’Ivoire, Democratic Republic of the Congo, Libya, Mali, northeast Nigeria and South Sudan.^4,8 When such disruptions persist over long periods of time, they impair all dimensions of food security, from the ability to access food, to the availability of supplies and the livelihoods of rural communities, along with the production chains that ensure the distribution of food. Protracted instability can easily destroy the resilience of well-functioning food systems.

The recent rise in undernourishment in Middle Africa and parts of Eastern Africa results from a combination of widespread violence in countries such as Central African Republic and Somalia – where almost half of the population is undernourished – and a drop in crop yields due to climate variability. For instance, in the Great Lakes and the Horn of Africa areas, poor yields of key products, such as maize, sorghum and groundnuts, have fallen further in recent years.⁷ A significant presence of displaced persons from neighbouring countries has added to the challenges already faced by countries like Democratic Republic of the Congo, Ethiopia, Kenya and Sudan.⁴

Furthermore, widespread droughts, generated by El Niño–Southern Oscillation (ENSO), have contributed to the increase in food insecurity seen in recent years in several countries of the Eastern and Southern Africa subregions, including Madagascar, South Africa, Zambia and Zimbabwe.⁷

At the same time, changing environmental conditions and competition for key resources such as land and water, have played a significant role in provoking violence and armed conflicts, exacerbating the vicious circle of hunger and poverty. The conflict in Darfur, for instance, is largely attributed to prolonged drought conditions. Competition between pastoralists and farmers is a source of conflicts in the Horn of Africa, where reduced mobility due to violence has affected grazing patterns and access to land and water. Similar occurrences have fueled conflict in other parts of the Sahel, for instance in the case of Mali, where desertification is reducing available croplands.⁷

In terms of outlook for 2030 (Table 1 and Figure 2), Africa is significantly off track to achieve the Zero Hunger target, even without considering the impact of COVID-19. If recent trends persist, its PoU will increase from 19.1 to 25.7 percent. Undernourishment is expected to worsen, particularly in the sub-Saharan subregion. By 2030, the projected rise in the PoU would bring the number of hungry people in Africa to almost 433 million, 412 million of whom would be in sub-Saharan countries (Table 2).

Asia is home to more than half of the total number of undernourished people in the world – an estimated 381 million people in 2019. Yet, the PoU in the region is 8.3 percent of the total population, below the world average (8.9 percent), and less than half of that of Africa (Tables 1 and 2). In addition, since 2005, the number of hungry people in Asia has gone down by more than 190 million. This outcome reflects progress mostly in the Eastern and Southern subregions. The situation in other subregions is stable since 2015, except for Western Asia (Tables 1, 2 and Figure 3), where it has been worsening due to widespread protracted crises.

Figure 3

PoU in Asia by SUBREGION, with projections to 2030. Western Asia has been off track in the recent past and is the only subregion in the continent where the prevalence of undernourishment is projected to increase

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The two subregions showing reductions in undernourishment – Eastern and Southern Asia – are dominated by the two largest economies of the continent – China and India. Despite very different conditions, histories and rates of progress, the reduction in hunger in both countries stems from long-term economic growth, reduced inequality, and improved access to basic goods and services. Average GDP growth rates were 8.6 percent and 4.5 percent in China and India, respectively, in the last 25 years.¹ In Southern Asia, significant progress was also made in reducing hunger in the last ten years in countries like Nepal, Pakistan and Sri Lanka, owing largely to improved economic conditions.

Conflicts and instability are the primary drivers behind the rise in hunger seen in Western Asia. In particular, conflicts in Syrian Arab Republic and Yemen have increased undernourishment. In Yemen, the economic downturn following the conflict that began in 2015 has resulted in the destruction of social protection networks and basic services, contributing to critical conditions of food security and nutrition. In Syrian Arab Republic, the civil war that started in 2011 has destroyed the economy, infrastructures, agricultural production, food systems and social institutions. All of this is exacerbated by a large presence of internally displaced populations, which is also affecting neighbouring countries.

The projections for Asia in 2030 (Tables 1, 2 and Figure 3) show that significant progress has been made in reducing undernourishment in all subregions, with the exception of Western Asia (see Box 2 for an explanation of how the projections are made), where undernourishment is increasing. Without considering the potential impact of the COVID-19 pandemic, Eastern and Central Asia are on track to meet SDG Target 2.1 by 2030. Southern and South-eastern Asia are making progress, but nevertheless are not on track to achieve the target by 2030. The current increasing trend in Western Asia is the opposite of what is needed to achieve the target by 2030.

In Latin America and the Caribbean, the PoU was 7.4 percent in 2019, below the world prevalence of 8.9 percent, which still translates into almost 48 million undernourished people. The region has seen a rise in hunger in the past few years, with the number of undernourished people increasing by 9 million between 2015 and 2019, but with important differences among the subregions. The Caribbean, the subregion with the highest prevalence, showed some moderate progress in the recent past, while in Central and South America, the situation has worsened (Figure 4).

Figure 4

PoU in Latin America and the Caribbean by subregion, with projections to 2030. Projections point to convergence between central America, where undernourishment is projected to increase, and the Caribbean, where it is projected to decline

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As in other regions, progress and setbacks in reducing hunger are a result of economic conditions, extreme climate events, political instability and conflicts.

In the Caribbean, the most severe conditions are found in Haiti, which has been battered by depletion of natural resources and extreme weather events like droughts, floods, heat waves and earthquakes. They have contributed to dire economic conditions, widespread poverty and high levels of undernourishment. Despite some improvements in the last decade, about half of the population is still estimated to be undernourished.

In South America, the increase in undernourishment observed in recent years is mainly driven by the situation in Venezuela (Bolivarian Republic of) where the PoU has increased from 2.5 percent in 2010–2012 to 31.4 percent in 2017–2019. The persisting political and economic crisis continues to fuel a decline in food security and nutrition levels and quality. Most of the food supply of the country is imported, and the devaluation of the Bolivar currency is making food imports increasingly expensive. As a consequence, these imports fell by 67 percent in 2016–2017, while hyperinflation curbed the purchasing power of households and their ability to access food and other basic goods. The severity of the situation in the country has driven up the number of refugees that flee to neighbouring countries, particularly Colombia and Ecuador.⁹

The Latin America and Caribbean region is not on track to achieve the SDG 2.1 Zero Hunger target by 2030 (Tables 1 and 2). The region is projected to have more than 19 million more hungry people in 2030 compared to 2019, even without considering the likely impact of the COVID-19 pandemic. A 3-percentage point increase in the PoU is projected for Central America. In South America, the PoU is projected to increase to 7.7 percent, equal to almost 36 million people, in 2030. The Caribbean subregion, while making progress, is not on track to achieve the target by 2030.

In summary, despite having achieved the most progress in reducing undernourishment, Asia is currently home to more than 55 percent of the undernourished people in the world. Africa has the highest PoU and the second highest number of undernourished people, accounting for 36.4 percent of the global total. A much smaller share is seen in Latin America and the Caribbean (almost 7 percent), and an even smaller share in Oceania and other regions (Figure 5, left chart).

Figure 5

If recent trends persist, the distribution of hunger in the world will change substantially, making Africa the region with the highest number of undernourished in 2030

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Even without considering the effects of COVID-19, projected trends in undernourishment would change the geographic distribution of world hunger dramatically (Figure 5, right chart). While Asia would still be home to almost 330 million hungry people in 2030, its share of the world’s hunger would shrink substantially, thanks to progress in highly populated countries of Eastern and Southern Asia. Africa would overtake Asia to become the region with the highest number of undernourished people, accounting for 51.5 percent of the total. Similarly, but to a lesser degree, Latin America and the Caribbean would host a slightly larger share of people suffering from hunger in 2030 than today.

The World Bank projections on extreme poverty offer a similar pattern, with sub-Saharan Africa, and particularly the conflict-affected fragile economies of the region, becoming home to a large share of the world’s poor people in 2030.¹⁰

The projections on undernourishment may be substantially altered by differential impacts of the COVID-19 pandemic across the regions. The full extent of the impact of the epidemic is still being assessed. More details, including a preliminary scenario analysis, are reported in Box 3.

SDG Indicator 2.1.2 Prevalence of moderate or severe food insecurity in the population, based on the FIES

Since being introduced by FAO in 2014, the Food Insecurity Experience Scale (FIES) has rapidly become a global reference for measuring food insecurity based on household and/or individual data. Many institutions responsible for food security assessments, including statistical offices and other governmental agencies, have adopted it as a standard tool for food security data collection in population surveys. As a result, many more national data sets are becoming available to complement FAO data collected through the annual Gallup^© World Poll (GWP) to generate estimates of the prevalence of moderate or severe food insecurity (SDG Indicator 2.1.2).

In making the global assessment, preference is given to suitable and reliable FIES data available from large national surveys, whereas FAO data collected in the GWP are used to compile the estimates for countries for which there is no other data and/or to fill gaps in terms of time series. This year, FIES or equivalent food security experience scales data collected by national institutions were used for 30 countries, covering approximately 20 percent of the world population (see Annex 1B). As national data are often available only for one or two years over the monitored period, FAO data are used as a complementary source of information to infer trends and complete the series of annual estimates. In all cases, results are made comparable across all countries and regions regardless of whether the main source is FAO data or official national data, by calibrating the estimated country scales against the standard FIES global reference scale.²²

Compared to SDG Indicator 2.1.1, this indicator focuses specific attention on moderate food insecurity (Figure 6). As noted in the 2019 edition of this report, people who are moderately food insecure do not have regular access to nutritious and sufficient food, even if not necessarily suffering from hunger. This level of food insecurity can have negative effects on diet quality (see Section 1.3) and increase the risk of various forms of malnutrition and poor health. This is a crucial aspect today, when people in many parts of the world are beginning to face the consequences of the COVID-19 pandemic. While FIES data have yet to be collected in the context of the pandemic, it is expected that some people who were previously food secure may face new difficulties in accessing food due to disruptions in food distribution systems, restrictions on movement and loss of income.

Figure 6

EXPLANATION OF FOOD-INSECURITY SEVERITY LEVELS MEASURED BY THE FIES IN SDG INDICATOR 2.1.2

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SDG Indicator 2.1.2 reports on the extent of food insecurity at any level (moderate or severe) so that any reduction can be unambiguously interpreted as an improvement. As in previous editions of the report, it is nevertheless useful to also explore the situation in terms of the prevalence of severe food insecurity only, given its expected relationship to the PoU.

Severe food insecurity

Our latest estimates suggest that 9.7 percent of the world population (slightly less than 750 million people) was exposed to severe levels of food insecurity in 2019 (Tables 3 and 4).

TABLE 3

Prevalence of food insecurity at severe level only, and moderate or severe level, measured with the Food Insecurity Experience Scale, 2014–2019

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TABLE 4

Number of people experiencing food insecurity at severe level only, and moderate or severe level, measured with the Food Insecurity Experience Scale, 2014–2019

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Although obtained using different data and methods, the prevalence of severe food insecurity (FI_sev) is conceptually comparable to the PoU. This is because people experiencing severe food insecurity, as measured by the FIES, are unlikely to be able to acquire enough food to continuously fulfil their dietary energy requirements.

Unsurprisingly, the prevalence of severe food insecurity in Africa (19 percent) is very close to the PoU in the region (19.1 percent, see Table 1), and is the highest among all world regions. In Asia, the prevalence of severe food insecurity (9.2 percent) is lower than in Latin America and the Caribbean (9.6 percent), but not as low as in Northern America and Europe (1.1 percent) (Table 3).

In all regions of the world except Northern America and Europe, the prevalence of severe food insecurity has increased from 2014 to 2019 (Figure 7, darker bars). This is also broadly consistent with recent trends in the PoU in the world and across regions, as noted in the previous section of this report. The only partial exception is Asia, where – contrary to what we noted based on our pre-COVID-19 PoU estimates – severe food insecurity appears to be slightly on the rise in 2018 and 2019 compared to previous years.

Figure 7

Moderate or severe food insecurity affects one quarter of the world population, and it has been increasing over the past six years. Over half of the population in Africa, almost one-third in Latin America and the caribbean and more than one-fifth in Asia are food insecure

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The divergence can be explained by the different timeliness of the data used for the analyses. While FIES data are available almost in real-time, food consumption data are not collected in household surveys on a yearly basis. As PoU estimates rely on data that refers to a few, and sometimes several years back, they may fail to reflect phenomena that affect the actual extent of inequality in food consumption. When recent food consumption data are available, the two series tend to converge more closely.

Moderate or severe food insecurity

While the 746 million people facing severe food insecurity are of utmost concern, an additional 16.3 percent of the world population, or more than 1.25 billion people, have experienced food insecurity at moderate levels. The prevalence of both moderate and severe levels of food insecurity (SDG Indicator 2.1.2) is estimated to be 25.9 percent in 2019 for the world as a whole. This translates into a total of 2 billion people (Tables 3 and 4). Total food insecurity (moderate or severe) has consistently increased at the global level since 2014 (Figure 7), mostly because of the increase in moderate food insecurity.

Figure 7 shows also that the prevalence of food insecurity (moderate or severe) is still on an upward trend in Africa. This is explained by the increase in the sub-Saharan region. Although Africa is where the highest levels of total food insecurity are observed, it is in Latin America and the Caribbean where food insecurity is rising the fastest: from 22.9 percent in 2014 to 31.7 percent in 2019, due to a sharp increase in South America (Table 3). In Asia, the percentage of people exposed to moderate or severe food insecurity remained stable from 2014 to 2016, then started increasing from 2017 on. The increase is concentrated in Southern Asia where the total prevalence of food insecurity increased from less than 30 percent in 2017 to more than 36 percent in 2019.

The global crisis induced by the COVID-19 pandemic will certainly bring these figures to much higher levels, even in regions of the world like Northern America and Europe, which have traditionally been more food secure.

Figure 8 shows that today, out of the 2 billion people suffering from food insecurity, 1.03 billion are in Asia, 675 million in Africa, 205 million in Latin America and the Caribbean, 88 million in Northern America and Europe and 5.9 million in Oceania.

Figure 8

Over half of the people affected by moderate or severe food insecurity in the world live in Asia and more than one-third live in Africa

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Gender differences in food insecurity

The FIES data collected annually by FAO in more than 140 countries at the individual (rather than household) level from 2014 to 2019 provide a unique opportunity to analyse the differences in the prevalence of food insecurity among men and women.

Figure 9 shows the prevalence of food insecurity at different levels of severity among men and women worldwide and in all regions, highlighting the evolution from 2014 to 2019. At the global level, the prevalence of moderate or severe food insecurity is higher among women than men, with significant differences found in almost all years for Africa and Latin America. For Northern America and Europe, the difference is small but statistically significant for most years. For severe food insecurity, the prevalence is also higher among women than men. The differences are statistically significant at the global level in 2019, and for Latin America in all years. At the global level, and more markedly in Africa and Latin America, the gender gap in accessing food increased from 2018 to 2019, particularly at the moderate or severe level of severity.

Figure 9

Globally and in every region, the prevalence of food insecurity is slightly higher in women than in men

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An in-depth analysis conducted by pooling all FIES data collected by FAO from 2014 to 2018 provides more details about the socio-economic characteristics of individuals who lack access to adequate food.²³ In addition to finding that food insecurity is more prevalent among women, regardless of the level of severity, people with higher risk of food insecurity were those in the lowest income quintile, with lower education, unemployed, with health problems, living in rural areas, belonging to the age group between 25 and 49 years old, and separated or divorced (see Annex 2 for a description of the methodology).

After controlling for socio-economic characteristics, women still had about a 13 percent higher chance of experiencing moderate or severe food insecurity than men, and close to 27 percent higher chance of being severely food insecure at the global level.

Globally, the gender gap in food insecurity at both moderate or severe and severe levels only decreased slightly from 2014 to 2018. The gender gap in food insecurity is larger among the poorer and less-educated strata of the population, and for individuals who are out of the workforce, with health problems and who live in suburbs of large cities compared with those who live in rural areas.

These findings point to the need for a deeper understanding of the forms of discrimination that make access to food more difficult for women, even when they have the same income and education levels and live in similar areas as men.

In summary, the continued gradual increase in the number of hungry and food insecure people in most regions of the world is alarming. It may only worsen in the face of the COVID-19 pandemic, emphasizing the need to redouble efforts to achieve the SDG targets in the ten years remaining until 2030. The food insecurity trends described in this section can have nutritional consequences, potentially leading to different manifestations of malnutrition. The next section presents the latest figures on progress towards ending all forms of malnutrition, with projections for 2030. The section includes a special focus on childhood stunting.

This section presents the latest assessment of the progress towards the global nutrition targets, specifically Target 2.2 of the SDGs and those endorsed by the World Health Assembly (WHA) in 2012 to be achieved by 2025.²⁴ To align with the 2030 SDG agenda, the WHA targets were extended to 2030 (see Table 5).²⁵ In addition, the WHA adopted a Global Monitoring Framework for the Prevention and Control of non-communicable diseases (NCDs) in 2013. This framework includes a target to halt the rise in adult obesity, a nutritional risk factor for NCDs, by 2025.²⁶

TABLE 5

The global nutrition targets endorsed by the World Health Assembly and their extension to 2030

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In April 2016, the United Nations Decade of Action on Nutrition (2016–2025)²⁷ was proclaimed to provide all stakeholders with a unique opportunity to strengthen joint efforts to end all forms of malnutrition by 2025.

The assessment examines progress made since the baseline (2012) and projected trajectories towards 2025 and 2030 targets (more details are presented in Annex 2), looking at subregional, regional and global levels. It is based on data available prior to the COVID-19 pandemic, which is likely to affect progress in the coming months, if not years. This edition includes a spotlight on stunting, highlighting other key factors related to the promotion of optimal growth.

Global trends

This year’s report includes updated estimates for four of the seven global nutrition indicators: child stunting, wasting, overweight and exclusive breastfeeding. Globally, progress is being made towards stunting and exclusive breastfeeding targets, but the pace must be increased to achieve them by 2025 and 2030. Currently the prevalence of child wasting is above the 5 percent target for 2025, putting the lives of tens of millions of children at risk in the immediate term. The increasing trend in childhood overweight is of great concern and must be urgently addressed.

Anaemia in women of reproductive age (15–49 years) remains the most challenging nutrition target to monitor. There are various research initiatives to improve the evidence base for the indicator used to assess this target. In 2016, 32.8 percent (or 613 million) of women of reproductive age (15–49 years) globally were affected by anaemia, practically unchanged since 2012.^28,42 An update of the global estimates for anaemia is expected in 2021. Hence, progress for this target is not assessed in this report.

Figure 10 summarizes progress made towards the nutrition targets at the global level. Worldwide, 21.3 percent of children under 5 years of age were stunted in 2019, or 144 million.²⁹ Although there has been some progress, rates of stunting reduction are far below what is needed, at 2.3 percent per year in recent years (defined as the period from 2008 to 2019). A rate of 3.9 percent per year is required to reach the targets of 40 percent reduction for 2025 and 50 percent reduction for 2030, starting from the baseline year (2012).³⁰ If recent trends continue, these targets will only be achieved in 2035 and 2043, respectively.

Figure 10

Despite some progress for most indicators, only the 2025 target for exclusive breastfeeding is on track to be achieved. childhood overweight and adult obesity trends need to be reversed

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The global prevalence of overweight among children under 5 years of age has not improved, increasing slightly from 5.3 percent in 2012 to 5.6 percent, or 38.3 million children, in 2019.²⁹ Urgent efforts are needed to reverse this trend in order to halt the rise in childhood overweight by 2025 and achieve the target of no more than 3 percent by 2030.

Wasting is an acute condition that can change frequently and rapidly over the course of a calendar year. This makes it difficult to generate reliable trends over time with the input data available. As such, only the most recent global and regional estimates are reported. Globally, 6.9 percent of children under 5 (47 million) were affected by wasting in 2019²⁹ – significantly above both the 2025 target (5 percent) and the 2030 target (3 percent).

Worldwide, 14.6 percent of infants were born with low birthweight (less than 2 500 g) in 2015.³¹ The Average Annual Rate of Reduction (AARR) for this indicator of 1 percent per year shows that some progress has been made in recent years, but not enough to achieve the target of a 30 percent reduction in low birthweight by 2025 (the 2030 target is the same). If progress continues at the current rate, the target will be achieved only in 2046.

As of 2019, it was estimated that 44 percent of infants aged less than six months globally were exclusively breastfed.³² The world is currently on track to achieve the 2025 target of at least 50 percent for this indicator. If additional efforts are not made, however, the global target for 2030 of at least 70 percent will not be achieved before 2038.

Adult obesity continues to rise, from 11.8 percent in 2012 to 13.1 percent in 2016³³ and is not on track to reach the global target to halt the rise in adult obesity by 2025. If the prevalence continues to increase by 2.6 percent per year, adult obesity will increase by 40 percent by 2025, compared to the 2012 level.

The projections for 2025 and 2030 described in this section do not take into consideration the likely impact of COVID-19 on the different forms of malnutrition. It is still very early to know the magnitude and duration of the pandemic and to predict its impact on the projected progress to the global targets. Box 4 presents some of the ways COVID-19 might impact malnutrition.

Regional and subregional trends

Global estimates of various nutrition indicators do not reveal the wide variations that exist between regions. Table 6 summarizes the progress made since baseline (2012) and the projected trajectories towards 2025 and 2030 targets based on current trends, by region and subregion.

TABLE 6

Most regions are making some progress, but not enough to achieve global targets; no subregion is on track for the low birthweight target, and adult obesity is worsening in all subregions

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In 2019, more than nine out of ten stunted children lived in Africa or Asia, representing 40 percent and 54 percent of all stunted children in the world, respectively. Most regions have made some progress in reducing stunting between 2012 and 2019 but not at the rate needed to achieve the 2025 and 2030 targets. The prevalence of stunting in sub-Saharan Africa is decreasing, but only at half the rate needed, and is still very high (31.1 percent in 2019). Moreover, the subregion has actually seen an increase in the number of stunted children from 51.2 million in 2012 to 52.4 million in 2019. The Central Asia, Eastern Asia and Caribbean subregions are on track to achieve the 2025 and 2030 targets (Table 6). If current progress continues, Asia and Latin America and the Caribbean regions will be very close to achieving the targets for 2025 and 2030 (missing by only one year), while Africa will need to triple its progress rate if population growth continues to increase as projected (Figure 11).

Figure 11

Most regions are not on track to achieve the targets for child overweight, and adult obesity is on the rise in all regions

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Out of the 38.3 million children who were overweight in 2019, 24 percent lived in Africa and 45 percent in Asia, despite these being the regions with the lowest prevalence of children who are overweight (4.7 percent in Africa and 4.8 percent in Asia). Australia and New Zealand is the only subregion with a very high prevalence (20.7 percent). Southern Africa (12.7 percent) and Northern Africa (11.3 percent) have prevalences considered high,⁴¹ followed closely by Oceania (9.4 percent) and Western Asia (8.4 percent). Australia and New Zealand has also experienced the largest increase in childhood overweight, followed by Oceania (excluding Australia and New Zealand); these subregions require concerted efforts to reverse their rapidly rising upward trends. There has been little or no progress to stem the rate of overweight for most of the subregions between 2012 and 2019 (Table 6). Africa as a whole has halted the increase in childhood overweight so far, but increased efforts are needed to achieve the target of 3 percent by 2030. All other regions also require urgent action to reverse their upward trends (Figure 11).

The most recent estimates (2012–2015) indicate that none of the regions are on track to achieve the target of 30 percent relative reduction in the proportion of babies born with low birthweight, even by 2030. Notably, the Southern Asia subregion had the highest prevalence estimate (26.4 percent in 2015). Rates of reduction for this indicator are very low for all subregions, with a maximum AARR of 1.2 percent per year in Southern Asia. Moreover, recent trends indicate no reduction in South America and a slight increase in Australia and New Zealand (Table 6).

Most subregions are making at least some progress towards the 2025 and 2030 targets for exclusive breastfeeding, except Eastern Asia and the Caribbean, the only subregions experiencing a decline in prevalence. Central America is nearly on track to reach both the 2025 and the 2030 targets for exclusive breastfeeding, missing both targets by only one year if current trends continue. If the Eastern Africa, Central Asia and Southern Asia subregions maintain their current rates of progress, they will reach the targets set for both 2025 and 2030. The African and Asian regions present a sustained increasing trend in exclusive breastfeeding and are on track to achieve the target of at least 50 percent by 2025, but not the 2030 target of at least 70 percent (Figure 11).

All subregions show increasing trends in the prevalence of adult obesity between 2012 and 2016. Thus, they are off track for the target of halting the rise in obesity by 2025. Northern America, Western Asia and Australia and New Zealand had the highest levels, 35.5 percent, 29.8 percent and 29.3 percent, respectively, in 2016. Latin America and the Caribbean as a whole and Oceania excluding Australia and New Zealand also had levels above 20 percent in 2016.

The assessment of child wasting is made based on the latest estimates (2019) through a straight comparison to the target levels of 5 percent and 3 percent for 2025 and 2030, respectively. The prevalence of wasting for the African region is 6.4 percent, with only the Southern Africa subregion having a prevalence below 5 percent. Oceania excluding Australia and New Zealand has the highest prevalence of wasting of all regions (9.5 percent), followed by Asia (9.1 percent). Southern Asia, which is home to more than half of the world’s wasted children under 5 years of age, is the only subregion having a high prevalence of 14.3 percent (25 million) in 2019. By contrast, Latin America and the Caribbean is the only region with a prevalence of wasting (1.3 percent) already below the 2025 and 2030 targets (Figure 11).

Spotlight on stunting

Stunting, or being too short for one’s age, is defined as length/height for age that is more than two standard deviations below the World Health Organization (WHO) Child Growth Standards median.⁴³ This indicator is a well-established risk marker of poor child development. Before the age of two years, it predicts poorer cognitive and educational outcomes later in childhood and adolescence,⁴⁴ and higher susceptibility to NCDs in adulthood.⁴⁵ Stunting is also associated with impaired education and economic development at the individual, household and community levels.⁴⁶ According to World Bank estimates, a 1 percent loss in adult height due to childhood stunting is associated with a 1.4 percent loss in economic productivity.⁴⁷ It is estimated that stunted children earn 20 percent less as adults compared to children who were not stunted.⁴⁸ Stunted and wasted children also have a higher mortality risk, which is further increased when the two conditions coexist.⁴⁹

Stunting and other forms of undernutrition early in life may predispose children to overweight and NCDs later in life. In some settings, early stunting might predispose an individual to a more central distribution of adiposity at later ages, which could translate to overweight or obesity. The extent to which maternal obesity adversely affects early growth and development of offspring might be exacerbated if the mother was undernourished in early life, reinforcing the intergenerational cycle of malnutrition in its different forms.⁵⁵

In 2019, 144 million children under 5 were affected by stunting worldwide, a 12 percent reduction relative to the baseline reference year for the global nutrition targets in 2012 (164 million). Current progress is insufficient for the world to achieve the target of 40 percent reduction in the number of stunted children by 2025 (98.6 million) as well as the 2030 target of 50 percent reduction (82.2 million). Across subregions, progress in reducing stunting between the baseline (2012) and latest (2019) years show the disparities in terms of acceleration required to achieve the 2025 and 2030 targets (Figure 12).

Figure 12

Sub-Saharan Africa is the only subregion with a rising number of stunted children

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The biggest challenge remains in the sub-Saharan Africa subregion, where projected rapid under-5 population growth would offset the projected progress in terms of prevalence, hampering efforts to bring down the number of children affected. In contrast, the projected decrease in population in Asia and in Latin America and the Caribbean, together with the projected decrease in prevalence, have contributed to progress towards the target.

The prevalence of stunting is unequally distributed across the globe, and even within regions and subregions, with contrasting severity levels (Figure 13).

Figure 13

Globally, 21.3 percent of children under 5 are stunted, and 7 subregions out of 17 have high or very high stunting prevalences in 2019

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Globally, stunting estimates vary by wealth, residence, age and gender (Figure 14).⁵⁶ Among available groupings, the largest disparity in stunting prevalence is seen between the poorest and richest wealth quintiles. Children from the poorest wealth quintile had a stunting prevalence of 43 percent, more than double that of children from the richest quintile. The prevalence of stunting among children residing in rural areas was 34 percent, 1.7 times higher than children in urban areas. Between boys and girls, the difference in stunting prevalence is small at the global level. A large proportion of childhood stunting that makes up the under-5 stunting burden is accumulated in the first 1 000 days. These findings are aligned with previous studies⁵³ and reiterate the need to target stunting prevention interventions during this critical window of opportunity.

Figure 14

The prevalence of stunting is higher in rural areas and in poorest households

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Disparities in the prevalence of child stunting between the richest and poorest households are observed in all regions and subregions with available estimates (Figure 15). The differences at the regional level in Africa and Asia mask large variances seen at the subregional level. For example, children from the poorest households in Central Asia have significantly lower stunting prevalence than those from the richest households in Southern Asia. Southern Asia is also the only subregion where more than half of the children from the poorest wealth quintile are stunted. The poorest in Northern Africa have a prevalence which is only 1.4 times higher than the richest, the smallest relative difference of all subregions in the world. Western Africa, on the other hand, is the only subregion where the gap in prevalence of stunting between the poorest and richest surpasses 30 percentage points. While the absolute difference between richest and poorest in Latin America and the Caribbean is the smallest of all regions, the relative difference is the largest, with children from the richest households classified as having a low stunting prevalence and those in the poorest households as having a high stunting prevalence in terms of severity level. This suggests the need for intensified efforts to address inequities even in this region where stunting reduction as a whole may no longer be considered a pressing issue.

Figure 15

In Latin America and the Caribbean, stunting prevalence of children living in the poorest households is about three times higher compared to those living in the richest households

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Framework for action on stunting

Following the set of recommendations in the Framework of Action of the Second International Conference on Nutrition (ICN2), the UN Decade of Action on Nutrition and its Work Programme, countries are encouraged to address the persistent problem of childhood stunting.^25,27,57 According to the Stunting Conceptual Framework developed by WHO,⁵⁸ a range of actions is needed, targeting the individual, household, community, national and global levels.

Tackling child stunting requires the involvement of different sectors, including health, agriculture, social protection and education, and different levels of involvement, from planning and implementation to monitoring and evaluation.

Some key evidence-based actions include:

1. Adolescent and maternal nutrition: Consistent access to affordable foods that support healthy diets, including food sources of vitamins and minerals, are vital to ensure that adolescents and women have the ability to maintain an adequate diet throughout pregnancy and lactation. Globally, approximately 11 percent of births occur among girls between the ages of 15 and 19 years. Adequate nutrition before and during pregnancy is essential for meeting maternal and foetal growth needs, optimal birth outcomes and reducing the risk of later NCDs. When a growing adolescent becomes pregnant, there is competition for nutrients between the mother and the foetus. This can result in cessation of the prospective mother’s linear growth and increase her risk of stunting, and can also lead to foetal growth restriction and low birthweight.⁴⁶ However, many adolescents and women cannot access healthy diets needed to meet the demands of pregnancy, especially in low- and middle-income countries where numerous micronutrient deficiencies coexist. Balanced energy and protein supplementation are an important intervention for the prevention of adverse perinatal outcomes in undernourished women. It increases birthweight by 41g and reduces the risk of stillbirths by 40 percent and small-for-gestational-age births by 21 percent.⁵⁹ Thus, increasing daily energy and protein intake for pregnant women in undernourished populations is recommended to reduce the risk of low-birthweight neonates, especially in highly food-insecure areas or in populations with little access to a variety of foods. Social protection programmes also increase food security and reduce women’s risk of becoming undernourished due to periods of pregnancy and lactation.⁶⁰

2. Optimal breastfeeding practices: Early initiation and exclusive breastfeeding for the first six months provides protection against gastrointestinal infections, which can lead to severe nutrient depletion and therefore stunting.⁶¹ Breastmilk is also a key source of nutrients during infection. Studies in resource-poor settings have associated non-exclusive breastfeeding with poorer growth outcomes, because breastmilk is replaced by less nutritious foods or water that often also expose infants to diarrheal infections. Similarly, continued breastfeeding in the second year contributes significantly to intake of key nutrients that are lacking in low-quality complementary diets in resource-poor settings.

3. Child dietary diversification: One of the most effective interventions for preventing stunting during the complementary feeding period is improving the quality of children’s diets. For example, the consumption of animal source foods has been associated with improved linear growth.^62,63 Vitamins and minerals in the diet are also vital as they boost immunity and healthy development.⁶⁴ Assessments of nutrition-sensitive agriculture interventions identify dietary diversification and income generating activities through family farming as likely pathways through which agriculture and food systems could improve nutrition and reduce stunting. Recent analyses suggest that households that can afford diversified diets, including fortified complementary foods, experience improved nutrient intakes and reduced stunting.⁴⁶ However, the paradox remains that the price and accessibility of these nutritious foods which are necessary for healthy development are often much higher than their less nutritious counterparts. These price patterns are an element of the shift of dietary patterns observed in the “nutrition transition”.⁶⁵ Thus, improving the availability and the affordability of nutritious foods that contribute to healthy diets can ensure healthy feeding and eating habits and reduce the risk of child stunting (see Part 2).

4. Water, sanitation and hygiene: Infectious diseases caused by a lack of hygienic conditions and clean water are important determinants of child stunting. Clean and sufficient drinking water, proper sanitation, drains for wastewater and proper management of solid waste are key interventions in deprived areas.

5. Social protection/cash transfer programmes: Social protection schemes can improve access to food products that are rich in protein, vitamins and minerals that would otherwise not be accessible to poor households. These programmes targeted to low-income households are more effective when coupled with additional interventions or conditions such as attending health and nutrition services and good sanitation practices.

6. Monitoring health inequalities: Monitoring stunting at national and subnational levels is needed to identify geographic areas and subpopulations where prevalence is highest. The most affected areas and population groups should be prioritized for interventions. The most disadvantaged and vulnerable groups are often adolescents, women and children living in poorest households in rural areas but also urban areas. Addressing these inequalities might help to prevent stunting.

Recognizing that both the drivers and solutions to the multiple facets of malnutrition are intricately linked, ten “double-duty actions” have been identified to address the problems of undernutrition (including stunting) and obesity simultaneously.^66,67 These actions include interventions, programmes and policies to be implemented at all levels of the population – country, city, community, household and individual. Several of the above recommendations are also considered double-duty actions to address malnutrition in all its forms. Other double-duty actions include school food programmes and policies to promote food environments able to provide healthy diets.⁶⁷

In summary, although countries are making some progress,⁶⁸ they are encouraged under the UN Decade of Action on Nutrition to scale up and strengthen many of the above actions to prevent stunting.⁶⁹ Many of the above interventions aim to prevent stunting by implementing strategies designed to achieve SDG Target 2.2 to end all forms of malnutrition. In the section that follows, the focus will be on how healthy diets can contribute to achieve this and other targets of the SDG agenda.

Since 2017, The State of Food Security and Nutrition in the World has reported on progress made towards eliminating hunger and food insecurity (SDG Target 2.1), and malnutrition in all its forms (SDG Target 2.2), presenting evidence of the link between these two SDG targets. As highlighted in previous editions of this report, food insecurity can increase the risk of various forms of malnutrition.^1,7,4 One vital element that helps explain this is the food that people eat: specifically, the quality of diets. Food insecurity can affect diet quality in different ways, potentially leading to undernutrition, including micronutrient deficiencies, as well as overweight and obesity.

Healthy diets are a prerequisite to achieving many SDGs and global nutrition targets.⁷⁰ However, global monitoring of diet quality poses multiple challenges. While there are evidence-based guiding principles for healthy diets, it has been difficult to develop valid food- or diet-related metrics of diet quality for global monitoring because of the rich variety of foods consumed and dietary patterns observed worldwide. Existing metrics are relatively new and have not yet been applied widely enough to provide global data or are specific only to a single population group. The scarcity of data on what people are eating – especially data that are comparable across countries – adds to the challenge of monitoring trends in diet quality worldwide.

After describing some of these challenges in monitoring diet quality globally, this section presents evidence on global trends in availability of food for human consumption and assessments of diet quality at the global and national levels. The important link between food insecurity and diet quality is also examined.

The evolving view of diet in the food security and nutrition debate

In the mid-twentieth century, food security interventions focused on agricultural production strategies to increase food supplies and meet dietary energy needs. Production of staple foods was emphasized, typically with less attention given to the nutritional diet quality.

In the decades that followed, awareness grew that this focus was largely misguided. The real problem was that many people did not have year-round access to safe, affordable healthy diets in sufficient quantity necessary to support health and well-being.⁷¹ The nutrient adequacy of diets became a central element of food security and nutrition programmes.

As the century drew to a close, it became increasingly evident that food insecurity was associated not only with undernutrition, but often with overweight and obesity, as well, particularly in upper middle- and high-income countries. This put a spotlight on additional aspects of diet quality in the food security and nutrition policy debate. Consequently, interventions and policies have shifted from closing the dietary energy gap to making healthy diets more widely available and affordable, while simultaneously addressing multiple forms of malnutrition through the adoption of double-duty actions (see Section 1.2).⁶⁶ Actions and policies aimed at ensuring food security must also focus on increasing access to nutritious foods that contribute to healthy diets in order to combat all forms of malnutrition.

A healthy diet is guided by basic principles that can be put into practice in multiple ways

Diet quality comprises four key aspects: variety/diversity (within and across food groups), adequacy (sufficiency of nutrients or food groups compared with requirements), moderation (foods and nutrients that should be consumed with restraint) and overall balance (composition of macronutrient intake).⁷² Exposure to food safety hazards is another important quality aspect. According to WHO, a healthy diet protects against malnutrition in all its forms, as well as non-communicable diseases (NCDs) such as diabetes, heart disease, stroke and cancer.⁷³ It contains a balanced, diverse and appropriate selection of foods eaten over a period of time. A healthy diet ensures that a person’s needs for macronutrients (proteins, fats and carbohydrates including dietary fibres) and essential micronutrients (vitamins and minerals) are met, specific to their gender, age, physical activity level and physiological state. Healthy diets include less than 30 percent of total energy intake from fats, with a shift in fat consumption away from saturated fats to unsaturated fats and the elimination of industrial trans fats; less than 10 percent of total energy intake from free sugars (preferably less than 5 percent); consumption of at least 400 g of fruits and vegetables per day; and not more than 5 g per day of salt (to be iodized).⁷³ While the exact make-up of a healthy diet varies depending on these individual characteristics, as well as cultural context, locally available foods and dietary customs, these basic principles of what constitutes a healthy diet are the same (Box 5).

The changes needed across food systems and beyond to promote healthy diets vary considerably depending on the context. Populations have different health and nutritional profiles, as well as food habits and customs, livelihoods, ecosystems and food supply chains. While science provides quantified nutrient intake requirements for different population groups, there are myriad ways in which individual foods from various food groups can be combined within diets to meet these requirements. For these reasons, while the basic principles for healthy diets in Box 5 apply to all countries, it is not feasible to define a single healthy diet for all countries to follow, in terms of specific foods and quantities. Rather, each country must translate the basic principles for healthy diets into specific guidelines for their populations to follow. Accordingly, a growing number of countries have established national food-based dietary guidelines (FBDGs), with dietary recommendations that are appropriate for their unique contexts. Some countries also address food combinations (meals), eating modalities, food safety considerations, lifestyle and sustainability aspects in their FBDGs.

Figure 16

Different ways of applying the principles for healthy diets: examples from three countries

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When national FBDGs include quantitative recommendations, they can also be used as a tool to assess adherence to the guidelines in a given population (see Box 6). Quantitative recommendations facilitate the use of FBDGs for other research purposes, as well: the analysis of the cost and affordability of diets presented in Section 2.1 is an example (see Box 11 and Annex 4). At this time, however, only about a third of countries with FBDGs specify quantities, which presents challenges for assessing adherence to the guidelines and for research aimed at global and regional analyses.

BOX 6

How do current consumption patterns compare with national food-based dietary guidelines recommendations? Case study from Belgium

To help guide daily food choices, some FBDGs include recommended dietary intake patterns expressed as servings (often in grams) to be consumed from each food group per day by age and sex group. In such cases, if individual food consumption data are available for a given country, the adherence to FBDGs can be evaluated for specific population groups.

The image on the left side of the figure below shows the pyramid graphic chosen by Belgium to communicate the recommendations in its national FBDGs. The image on the right compares the mean habitual food consumption of 14–17 year-olds in Belgium taken from the 2014–2015 National Food Consumption Survey with the FBDGs recommendations for this age group.⁷⁸

Looking at the graphic, it is evident that adolescents in Belgium are eating much less than the recommended amount for most food groups. This pattern is similar to that found in other European countries. A study covering ten cities in nine countries found that adolescents ate half of the recommended amount of fruits and vegetables and less than two-thirds of the recommended amount of milk (and dairy products), but consumed much more meat (and meat products), fats and foods and drinks containing high amounts of sugars than recommended. Nonetheless, median total daily energy intake was estimated to be nearly in line with the recommendations.⁷⁹

Some countries have developed a Healthy Eating Index (HEI) based on their FBDGs, by converting their FBDGs messages into a score which is used to monitor diet quality over time. However, since an HEI needs to be developed, validated and updated whenever the FBDGs are revised, these indices are not very common, and currently not available for any lower-middle-income countries. In their absence, a “snapshot” comparing the current diet and FBDGs, as presented here for Belgium, can be very useful.

Compliance of mean habitual food consumption with the food-based dietary guidelines in adolescents (14–17 years)

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While each country must define the best way to translate the basic principles for healthy diets into FBDGs appropriate for its own context, there have been efforts in recent years to define theoretical global healthy diet patterns (see Section 2.2). This is for the purpose of researching global dietary intake patterns and their relationship to health and environmental outcomes, and of enabling cross-country comparisons.

As the concept of healthy diets evolved with growing knowledge about the impacts of diets on health outcomes, the impacts of diets on the environment have come under increasing scrutiny. A growing body of scientific evidence reveals how the way we produce and consume food is taking a toll on the natural resource base and contributing to greenhouse gas emissions (see Section 2.2).^81,74,82 The environmental and health impacts will increase if trends in diet and population growth continue.⁸³ As populations become more affluent and urbanized, they demand more food, particularly more meat, fish, dairy, eggs, sugar, fats and oils,⁸⁴ which can contribute to higher risk of diet-related diseases as well as greater environmental impacts, for example those associated with consumption of animal source foods. In addition, projected population growth of 2 billion people by 2050, most of which is likely to occur in currently low- and middle-income countries, will further increase diet-related environmental pressure. In light of these trends, it is therefore crucial to promote healthy diets in ways that are environmentally sustainable.

Trends in food available for human consumption and aspects of diet quality in the world: a look at the evidence through different lenses

Global assessment of food consumption and diet quality poses many challenges. To date there is no single, validated composite index to measure the multiple dimensions of diet quality mentioned above across all countries: variety/diversity; adequacy; moderation; and overall balance. Alternative approaches used to assess the diet quality of populations include use of measures that capture a single facet of diet quality such as dietary diversity,⁷² or consumption of food groups, single foods or food components whose intake should be increased or limited to protect health.^72,85 An additional challenge is the lack of robust, cross-country comparable data on individual dietary intake worldwide.⁸⁶ In its absence, different sources of data may be used for global assessment of food and nutrient intake and diet quality, each with certain strengths and limitations (see Annex 2).

An added issue which hampers comparability of dietary estimates and recommendations from different studies and countries is the use of different food group classifications and the total number of food groups used. Classification of foods into food groups can be done based on different aspects, such as the nutritional profiles of foods (e.g. protein-rich), purpose of the analysis (e.g. identify vitamin A and iron-rich foods), and botanical definition and their common use (e.g. tomatoes and eggplants are consumed as vegetables, but botanically they are fruits). Furthermore, imposing a classification on already existing data is circumscribed by the granularity of the data. For example, it is not possible to identify highly processed foods high in fats, sugars and/or salt using Food Balance Sheets or Supply and Utilization Accounts data. The remainder of this section and Part 2 present various analyses which rely on slightly different food groupings. Nevertheless, each analysis is based on a relevant food group classification according to the study purpose and the type of data used.

Trends in global and regional food availability

Data on food availability from FAO Food Balance Sheets (FBS) have been widely used by economists, researchers and policymakers as a proxy of national average food consumption. They are used to identify very broad aspects of dietary patterns across the world. In fact, for some countries, particularly low-income nations, FBS may be the only data source available for this purpose.

FAO has put together FBS annually for most countries and territories since 1961. The balance sheets^87,88 are compiled from Supply and Utilization Accounts (SUA), which are detailed lists of over 400 food and agricultural items. The availability estimates are produced by balancing the data on a country’s food supply (production, imports and opening stocks) against its food utilization (exports, availability for consumption, seeds, feed, post-harvest losses, other utilizations and closing stocks). The FBS provide information on quantities expressed in terms of primary equivalents for crops, livestock products and fish commodities. SUA provide more granular information of official or assessed quantities of commercialized food products. However, both FBS and SUA data provide information on food availability only at the national, aggregate level. They do not provide information on actual individual food or nutrient intake, or the distribution of access to the food available by the different population groups. In some cases, national SUA, as well as FBS, might not reflect production from some small farms or private households. Therefore, these caveats should be carefully considered when using and interpreting FBS and SUA data.

Low-income and lower-middle-income countries rely heavily on staple foods like cereals, roots, tubers and plantains. The availability of staple foods for the world has changed little between 2000 and 2017 (Figure 17). There were modest fluctuations in the availability of cereals across regions and country income groups. In 2017, cereal availability was highest in lower-middle-income countries (391 g/capita/day), and lowest in high-income countries (259 g/capita/day). Availability of roots, tubers and plantains increased in lower-middle-income countries, driven by a rise in Africa. It decreased in high-income countries, due primarily to reductions in Northern America and Europe. The global availability of pulses, seeds and nuts increased 24 percent from 2000 to 2017, with the largest increases in low- and lower-middle-income countries (Figure 18).

Figure 17

From 2000 to 2017, the global availability of fruits and vegetables and dairy products increased, while availability of staple foods remained stable

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Figure 18

From 2000 to 2017, the global availability of pulses and nuts, and poultry and fish increased, while availability of red meat increased largely in upper-middle-income countries

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Only upper-middle-income countries and Asia have enough fruits and vegetables available to meet the FAO/WHO recommendation of consuming a minimum of 400 g per day.^91,92 In 2000, in all regions, availability of fruits and vegetables for human consumption was below 400 g/capita/day. Out of all country income groups, only upper-middle-income countries surpassed that mark. Between the years 2000 and 2017, the world average availability of fruits and vegetables increased from 306 to 390 g/capita/day (Figure 17). Upper-middle-income countries showed the highest percentage change increase (50 percent) in total fruits and vegetables available. These countries had a notably higher total combined availability of fruits and vegetables (645 g/capita/day) than the other country income groups. For high-income countries, availability of fruits and vegetables has declined slightly over time.

From 2000 to 2017, the availability of fruits and vegetables in Africa increased from 167 to 191 g/capita/day. In low-income countries it grew from 121 to 142 g/capita/day. However, the total amounts available in Africa and low-income countries fall far short of the 400 g/capita/day consumption target. In 2017, Asia was the only region with enough fruits and vegetables available to meet the recommended amount (470 g/capita/day). However, even if the per capita availability appears to cover the recommended consumption at the population level, there is no assurance that consumption is distributed in a manner that satisfies the needs of all individuals.

The results from this analysis are generally in agreement with the findings of two other studies based on individual-level data, which found that in most regions of the world, consumption of fruits and vegetables (among adults) is largely inadequate.^93,94

Availability of animal source foods overall is highest in high-income countries, but it is fast growing in upper-middle-income countries. Global trends in the availability of animal source foods showed an increase for eggs, fish, poultry, processed meat and dairy products between 2000 and 2017 (Figures 17, 18 and 19).

Figure 19

From 2000 to 2017, the global availability of processed meat, eggs and fats increased, while availability of sugar decreased

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Most of the global increases in animal source foods were observed in lower- and upper-middle-income countries. Asia showed the largest increase in the total amount of animal source foods available, driven mostly by increases in dairy products in Central and Southern Asia (not shown).

In high-income countries during the period 2000–2017, availability of meat and dairy products was double the amount available in other country income groups. In 2017, red meat availability for these countries was 97 g/capita/day, which translates into 35.4 kg/capita/year. Availability of processed meat increased in all regions and country income groups between 2000 and 2017, particularly in upper-middle-income countries, Asia and Latin America and the Caribbean. Dairy availability in high-income countries declined since 2000, particularly in Oceania and Northern America and Europe. Low-income countries had the lowest availability of meat, eggs and fish with minor variations. Large increases in availability of eggs and fish between 2000 and 2017 are noted in lower-middle- and upper-middle-income countries.

Increased availability of meat, which likely reflects increasing demand, may have positive or negative implications for health depending on the context. For poor and vulnerable people in most low-income countries, and for population groups with higher nutrient requirements, such as infants and women of reproductive age, a small increase in meat and other animal source foods can greatly improve the nutritional adequacy of their diets, because they are good sources of quality protein and important micronutrients.⁹⁵ However, a high consumption of red and processed meat can contribute to high saturated fat and/or salt intakes, and is associated with higher risk of certain types of cancer and other diet-related NCDs.^93,96 Furthermore, diets high in animal source foods, particularly beef, lamb, milk and other dairy products have a higher environmental impact than plant-based diets (see Section 2.2).

The availability of sugars and fats is highest in high-income countries, but the largest increases were seen in upper-middle-income countries. Availability of fats and oils increased steadily for all regions and country income groups from 2000 to 2017 (see Figure 19). The highest increases were observed in upper-middle-income countries. High-income countries had the highest availability over time, but the smallest increase in percentage change. Looking at sugars and sweeteners, the availability in high-income countries (109 g/capita/day or 39.8 kg/capita/year) was double that of upper- and lower-middle-income countries in 2017, and four times the amount available in low-income countries.

The findings presented in Figures 17, 18 and 19 are in line with other empirical evidence that shows that in recent decades, diets, particularly from upper-middle-income countries, have shifted away from staples towards more animal source foods, sugars, fats and oils.^84,97

Food groups available for consumption differ across country income groups. At the global level, in 2017, cereals, roots, tubers and plantains represent the highest contribution to the total food available for human consumption, both in terms of edible quantities (34 percent) and dietary energy (51 percent) (Figure 20). Globally, and in all country income groups dietary energy availability has increased since 2000, with high-income countries showing the smallest increase (not shown). Fruits and vegetables represent the second-most available food group (in percentage of weight), whereas their contribution to total dietary energy availability is small (6 percent globally), which is to be expected as they tend to be low in dietary energy. Conversely, sugars and fats are the second-highest group in terms of total dietary energy contribution, but they represent a relatively small fraction in terms of quantity available.

Figure 20

The proportionS of different food groups available for human consumption differ across country income groups: a snapshot of 2017

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In low-income countries, cereals, roots, tubers and plantains represent nearly 60 percent of all food available (by weight) in 2017. This percentage decreases gradually with country income groups, down to 22 percent in high-income countries. Likewise, the contribution from animal source foods (fish, meat, eggs and dairy), in percentage of weight, varies with the country income group. It is higher in high-income countries (29 percent) compared to upper-middle- and lower-middle-income countries (20 percent), and lowest in low-income countries (11 percent).

The SUA data that informs the above analyses reflect food availability for human consumption up to 2017. As such, this analysis does not factor in the effects of the COVID-19 pandemic on food availability. Box 7 summarizes some of the potential ways in which the COVID-19 pandemic is likely to impact the availability of nutritious foods and, consequently, diet quality of the population.

These analyses of national level food availability provide indirect information on trends in diet quality over time and across regions and country income groups. But it is information derived from actual food consumption and nutrient intake data – when available – that allows detailed assessments of diet quality in different populations. Indicators of dietary diversity like those used in the following section, compiled from such data, are an increasingly valuable component of the evidence base.

Dietary diversity of young children and women

A key element of diet quality is dietary diversity, or the variety of foods from different food groups that make up the diet. Eating a larger variety of foods tends to increase the chances that a person will consume adequate amounts of different nutrients necessary for their overall health and well-being. Several tools for measuring dietary diversity have been developed for specific populations, including the Minimum Dietary Diversity for Women (MDD-W) indicator (Box 8) and the Minimum Dietary Diversity (MDD) indicator for infants and young children. The latter is used for the global assessment below. The data that inform such indicators are generally collected using individual-level, non-quantitative food consumption modules, providing a much more direct assessment of what people are actually eating than the SUA data.

BOX 8

Minimum dietary diversity for women: evidence from three countries

The Minimum Dietary Diversity for Women (MDD-W) indicator is a proxy that reflects dietary diversity and micronutrient adequacy for women of reproductive age.¹⁰⁹ It is calculated by counting how many out of ten defined food groups* have been consumed over the previous 24 hours. If foods from five or more of these food groups have been consumed, minimum dietary diversity – which is associated with a greater chance of adequate intake of 11 micronutrients – is considered to be achieved.¹¹⁰ Since the launch of the MDD-W in 2015, ten countries have collected nationally representative MDD-W data and many others have used it for research or impact evaluation at subnational level. The MDD-W indicator is one of the World Food Programme’s (WFP) corporate indicators for stunting prevention and nutrition-sensitive programming in specific contexts. In 2018, there were data available for programmes in 29 countries.** In 2019, it was decided that the MDD-W would be included as a core indicator in the Demographic and Health Survey (DHS) Programme, which currently covers 90 countries.

Before this decision was taken, however, a few countries had already included the MDD-W in their national DHS. Nepal (2016), Tajikistan (2017) and Nigeria (2018) have reported the most recent available results.^111,112,113 The table in this box shows the percentage of women aged 15–49 years meeting MDD-W (≥5 food groups) in these three countries according to area of residence (urban/rural) and wealth quintile. Overall, 50 percent of women in Nepal achieved minimum dietary diversity; the figures for Nigeria and Tajikistan were 56 percent and 80 percent, respectively. A higher percentage of urban residents achieved minimum dietary diversity than their rural counterparts.

Foods from the “grains, white roots and tubers, and plantains” group were consumed most. Over 98 percent of the women in all three countries reported eating them. At least 70 percent of women in Nigeria and Tajikistan reported consuming food from the “meat, poultry and fish” group, compared with only 35 percent in Nepal. The percentage of women reporting consumption of “dark green leafy vegetables” was highest in Nigeria (72.7 percent) and lowest in Tajikistan (18.7 percent). For “other vitamin A-rich fruits and vegetables” the percentage was highest in Tajikistan (59.9 percent). For “other fruits”, the percentage was lowest in Nigeria (35.7 percent).

Percentage of women aged 15–49 years MEETING MDD-W (≥ 5 food groups) in the 24 hours preceding the interview, according to urban/rural residence and wealth quintile

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The first two years of life are marked by rapid physical growth and brain development. Children 6–23 months of age are especially vulnerable to growth faltering and nutrient deficiencies. To meet the energy and nutrient needs of infants and young children, a variety of foods and a minimum number of feedings a day are recommended.^105,106 UNICEF and WHO recommend a set of three indicators (minimum dietary diversity, minimum meal frequency and minimum acceptable diet) to assess the diet quality of young children through household surveys.¹⁰⁷ These indicators consider the number of different food groups consumed and the number of times a child was fed in the 24 hours prior to the survey.

Globally, less than one in three children 6–23 months of age (29 percent) met the minimum dietary diversity, i.e. ate foods from at least five out of eight food groups on the day prior to the interview, although there is wide variation across the world (Figure 21).¹⁰⁸ Dietary diversity was low in the majority of the regions, with less than 40 percent of children meeting minimum dietary diversity in seven out of the eleven subregions (Figure 22). Nearly three in five children 6–23 months of age met the minimum dietary diversity in Central America compared with only one in five in Southern Asia and Middle Africa. Overall, there are no notable differences in dietary diversity between boys and girls, but there are stark disparities in the prevalence of minimum dietary diversity by the place of residence (urban/rural) and wealth status. The prevalence of children eating foods from at least five out of eight food groups is on average 1.7 times higher among children living in urban areas than in rural, and those living in the richest households compared to the poorest (Figure 21).

Figure 21

Children living in urban households and those from richer families have better dietary diversity

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Figure 22

Percentage of children 6–23 months of age eating foods from minimum number of food groups. The vast majority of children 6–23 months of age are not meeting the minimum dietary diversity

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Looking at consumption patterns by food group, three in four children consume grains/starchy foods and breastmilk. The Pan American Health Organization (PAHO) and WHO guiding principles for feeding breastfed and non-breastfed children indicate that flesh foods and eggs should be consumed daily (or as often as possible) because they are rich sources of many key micronutrients like iron and zinc.^105,106 However, less than one in three children consumed flesh foods such as meat, poultry and fish, and only one in five children consumed eggs in the previous day (Figure 23).¹⁰⁸

Figure 23

The majority of children in the world consume grains, roots and tubers. few children are being fed flesh foods or eggs

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How does food insecurity affect what people eat?

Households and individuals that experience food insecurity face uncertainties about their ability to obtain enough safe and nutritious foods for an active and healthy life, due to lack of money or other resources. As a consequence, they may have poorer diets than those that are food secure or only mildly food insecure.

Much of the existing evidence highlighting the association between household food insecurity levels and dietary outcomes comes from Northern and Latin America and is based on data collected using experience-based food insecurity measures similar to the FIES. Studies from different countries have shown that both dietary diversity and consumption of nutritious foods, such as fruits, vegetables, dairy and meat, tend to worsen as food insecurity becomes more severe.^{115,116,117,118,119} Preliminary analysis of FIES data, combined with data collected using new cross-country comparable metrics of diet quality, point to a similar association (Box 9). The body of evidence that is comparable across countries is growing as more countries include the FIES, or compatible scales, in national population-based surveys that also collect food consumption data.

Overall, the analysis reveals that people who experience moderate or severe food insecurity consume less meat and dairy products (in all four countries) and less fruits and vegetables (Kenya and Sudan) than those who are food secure or mildly food insecure (from here on, referred to as “food secure”) (Figure 24). Consumption of cereals, roots, tubers and plantains, and pulses, seeds and nuts either decreases slightly, remains similar, or increases, resulting in a higher proportional contribution of these food groups to the total diet. The more food insecure people are, the larger the share of staples in their diet. This holds true even if food insecure people in Kenya and Sudan reduce their consumption of staples, because they reduce consumption of other food groups even more.

Figure 24

As food insecurity becomes more severe, food consumption and dietary energy intake decrease and staples make up a larger share of the diet

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In Kenya and Sudan, those who experience moderate food insecurity consume lower quantities of all food groups than those who are food secure – with the exception of cereals in both countries and fish in Kenya – and have a lower dietary energy intake. People experiencing severe food insecurity consume lower quantities of roots, tubers and plantains, dairy, vegetables, fats and oils, sweets and sugars (Kenya and Sudan), cereals, fruits, eggs and fish (Kenya) than those who are moderately food insecure. In Kenya, food insecure people consume a slightly higher amount of fish, compared with those who are food secure. This could be explained by the fact that subsistence fishing is practiced by some of the poorest and most food insecure communities in the country.¹²⁴

In Mexico and Samoa, notable variations in the diet are also observed between the food secure and the food insecure groups, but they follow a different pattern than Kenya and Sudan. As food insecurity becomes more severe, dietary energy intake remains relatively stable in Samoa and declines less markedly in Mexico compared to Kenya and Sudan. There is a reduction in the consumption of some animal source foods (such as dairy and meat), but minimal change (or even an increase) in the consumption of some plant-based foods (such as cereals, roots, tubers and plantains, pulses, seeds and nuts, and vegetables) and sweets and sugars. In Mexico, fruit consumption decreases with food insecurity, whereas in Samoa it increases. Conversely, consumption of eggs in Mexico is higher for those who are food insecure.

The finding that diet quality worsens with increasing severity of food insecurity is consistent with the theoretical construct of food insecurity on which the FIES is based: people experiencing moderate food insecurity face uncertainties about their ability to obtain food and have been forced to compromise on the nutritional quality and/or quantity of the food they consume. On the other hand, people experiencing severe food insecurity have typically run out of food and, at worst, gone one or more days without eating.¹²⁵

The ways in which moderately food insecure people modify their diets vary according to the income level of the country. In the two lower-middle-income countries studied (Kenya and Sudan), there is a marked decrease in consumption of most food groups, and an increase in the share of staples in the diet. In the two upper-middle-income countries examined (Mexico and Samoa), people who are moderately food insecure consume more foods that are typically cheaper on a per-calorie basis (cereals, roots, tubers and plantains), and consume lesser amounts of expensive foods (meat and dairy), compared with those who are food secure. Mexico in particular shows a decrease in fruit and dairy consumption as the severity of food insecurity increases. This is in line with studies that show that the purchase of fruits and milk is sensitive to changes in income and prices.¹²⁶ The increase in fruit consumption with worsening food insecurity in Samoa may be explained by the fact that those who are food insecure consume more fruits from their own-production instead of purchasing it.¹²⁷

There are several plausible reasons why food insecurity, as measured by experience-based scales like the FIES, may contribute to different dietary outcomes in lower-middle- and upper-middle-income countries, to the extent that these countries may be exemplary of other countries in the same income-level groups. First, healthy diets may generally be less affordable in lower-middle-income countries than in upper-middle-income countries. As discussed in Section 2.1 of this report, healthy diets are unaffordable to many people, especially the poor, in every region of the world. Second, social protection programmes may receive less funding in lower-middle-income countries.¹²⁸ Lastly, vulnerable people’s access to food, especially perishable nutritious foods, may be more compromised in lower-middle-income countries than in upper-middle-income countries, due to lack of physical infrastructure and food processing and storage technology, as well as food safety issues.¹²⁹ Problems like these associated with the food supply chain tend to drive up the cost of nutritious foods, as discussed in Section 2.3 of this report.

One possible reason the difference in dietary energy intake between food secure and moderately food insecure people is smaller in Mexico and Samoa than in Kenya and Sudan is that Mexico and Samoa are well into the nutrition transition, which is characterized by a rapid shift in diet composition towards a higher intake of highly processed, energy-dense foods that have minimal nutritional value and are cheap and widely available.⁹⁷

As more countries collect good quality household- or individual-level food security and food consumption data, this analysis can be expanded to shed more light on the links between food insecurity and diet quality around the world. Combined with ongoing efforts to develop national FBDGs and address the challenges of global monitoring of diet quality, more and better evidence will soon be available to guide actions aimed at guaranteeing universal access to enough nutritious foods for healthy diets.

With ten years to go until 2030, the world is off track to achieve the SDG targets for hunger and malnutrition. After decades of long decline, the number of people suffering from hunger has been slowly increasing since 2014. The trends shown by the prevalence of undernourishment and the prevalence of severe food insecurity based on the FIES both point to failed progress. Beyond hunger, a growing number of people have been forced to compromise on the quality and/or quantity of the food they consume, as reflected in the increase in moderate or severe food insecurity since 2014. Projections for 2030, even without considering the potential impact of COVID-19, serve as a warning that the current level of effort is not enough to reach Zero Hunger ten years from now.

As for nutrition, progress is being made on decreasing child stunting and low birthweight and increasing exclusive breastfeeding for the first six months of life. However, prevalence of wasting is notably above the targets and the prevalence of both child overweight and adult obesity is increasing in almost all regions, a worrisome trend that will add to the global burden of disease and increase public health service and health care costs. These trends in hunger, food insecurity and malnutrition must be reversed. COVID-19 is expected to exacerbate these trends, rendering vulnerable people even more vulnerable. Urgent action is needed in order to meet the 2030 targets, even as the world braces for the impact of the pandemic.

Increasing availability of and access to nutritious foods that make up healthy diets must be a key component of stronger efforts to achieve the 2030 targets. The availability of dietary energy per person has increased globally over the past two decades. However, this has not translated into an increase in the availability of nutritious foods that contribute to healthy diets. There are large discrepancies in the per capita availability of foods from different food groups across countries of different income levels. Low-income countries rely more on staple foods and less on fruits and vegetables and animal source foods than high-income countries. An increase in per capita availability of fruits and vegetables has been observed since 2000. And yet, according to the analysis presented, only upper-middle-income countries and Asia have a daily per capita availability above the recommended level of consumption. Worldwide, less than a third of young children are eating foods from the minimum number of five food groups needed to meet their energy and nutrient needs.

The quality of people’s diets worsens with increasing constraints on their access to food, putting them at higher risk of undernutrition as well as overweight and obesity. Among other factors, cost is a key determinant of access to food. Part 2 of this report sheds light on how food prices and affordability of diets contribute to food insecurity and inequalities in diet quality. It also maps out actions needed to reshape food systems in ways that guarantee universal access to enough nutritious foods that contribute to healthy diets. The remaining years of the UN Decade of Action on Nutrition 2016–2025 present an opportunity for policymakers, civil society and the private sector to work together and accelerate efforts. There is still time to get back on track towards achieving Zero Hunger and ending all forms of malnutrition by 2030.

Policies that aimed to increase food availability and energy intake with less focus on improving the quality of the food have long been a key element of the efforts to end hunger. But this paradigm is changing. The prevailing strategy to end hunger and eliminate malnutrition must address other multifaceted challenges: i) there are multiple burdens of malnutrition; ii) food policies have overemphasized calories and protein quantity, neglecting a wider range of dietary quality required for people’s health and development; and iii) any approach to addressing hunger and all forms of malnutrition must also consider the sustainability of food systems.

As shown in Part 1 of this report, most countries are not on track to meet the SDG 2 targets to end hunger and food insecurity (SDG Target 2.1) and all forms of malnutrition (SDG Target 2.2) by 2030. The COVID-19 pandemic will make it more difficult to get back on track. Part 1 shows that undernourishment and food insecurity are not the only challenges, but also overweight and obesity and other forms of malnutrition. In this respect, food and diet quality is a critical link between food security and nutrition outcomes, in all its forms, particularly overweight and obesity. No doubt, the link should be strengthened to achieve SDG 2.

The health impacts associated with poor quality diets are significant. Unhealthy diets are a leading cause of non-communicable diseases (NCDs), mainly cardiovascular diseases, cancers and diabetes, that result in death.¹ Both overweight and obesity are significant risk factors for NCDs, and increasing healthcare costs linked to rising obesity rates are a trend across the world. Out of 56.9 million deaths globally in 2016, 40.5 million deaths, or 71 percent, were attributable to NCDs.²

A healthy diet ensures adequate calories and nutrients. It includes a balanced, diverse intake of foods from several different food groups. It is intended to meet all requirements of nutrient adequacy and help prevent malnutrition in all its forms, as well as NCDs. Diet quality is an important link between food security and nutrition outcomes and is a crucial part of all efforts to achieve the hunger, food security and nutrition targets of SDG 2. Meeting these targets will only be possible if people have enough food to eat and what they are eating is nutritious.

One of the biggest challenges of achieving this, is the cost and affordability of healthy diets. New evidence presented in this part of the report shows that healthy diets are unaffordable for many people in every region of the world, especially for the poor and those facing economic challenges. Evidence presented in this part of the report also demonstrates that the higher cost and unaffordability of healthy diets is associated with increased food insecurity and different forms of malnutrition, including stunting and adult obesity. Shocks, like the COVID-19 pandemic, exacerbate this because they negatively affect poor people’s quality of diet and make healthy diets less accessible in many parts of the world.

The story does not end there. There are also hidden costs and externalities associated with current food consumption patterns, notably those related to the health and environmental consequences of our dietary choices. They increase the costs of dealing with health problems and adverse effects of climate variability, among other environmental challenges. However, these costs are not reflected in the price of foods and diet.

These issues must be considered within the context of a world where hunger continues to increase, 2 billion people experience food insecurity, and the burden of malnutrition in all its forms remains a challenge. With just a decade away from the endpoint of the 2030 Agenda for Sustainable Development (2015–2030) and with only five years remaining in the UN Decade of Action on Nutrition (2016–2025), hard questions remain. How can the world end hunger and all forms of malnutrition, while transforming food systems to provide affordable healthy diets for all? How can the remaining years of the Decade of Action on Nutrition be leveraged to accelerate action? What are the costs and trade-offs of actions? This part of the report provides new evidence that addresses these important questions and identifies the main drivers that make access to affordable healthy diets challenging. Further, this part of the report also identifies the main drivers behind the high cost of nutritious foods and provides guidance on policy and investments for countries to transform their food systems to provide access to affordable healthy diets for everyone, while tackling trade-offs and making the most of synergies for environmental sustainability.

Cost and affordability of healthy diets are critical for food security and nutrition

The world faces immediate challenges in making healthy diets accessible for everyone, an essential requirement in meeting the hunger and nutrition targets of SDG 2. The COVID-19 pandemic has made the situation even more difficult. One of the biggest challenges is the current cost and unaffordability of healthy diets.

What does the evidence tell us?

These results not only apply to high-income countries but also to lower-middle and low-income countries, where overweight and obesity are a pervasive and growing problem. Income growth of countries is associated with lower levels of stunting, as well as with increases in overweight and obesity.¹¹ The relative inexpensiveness of energy-dense foods high in fat, sugar and salt is implicated in high rates of obesity. This is seen in high-income countries¹² as well as in transitional economies, such as China, India and urban Africa. New research also shows that overweight increases in lower-middle-income countries are mainly due to very rapid changes in food systems, particularly the availability of cheap, highly processed food and sugar-sweetened beverages.¹³

Recent evidence shows that reductions in child stunting, which also reduces the risk of overweight and obesity, are associated with lower relative prices of fresh cow’s milk, eggs, meat, fish and fortified infant foods.^7,14 However, evidence is not conclusive and additional studies are needed, including the potential nutritional impacts of eggs and cow’s milk in key target groups.^{15,16,17,18,19}

BOX 10

Description of the three diets used in the cost and affordability analysis

For the purpose of this analysis, three reference diets are analysed for cost and affordability to simulate incremental levels of diet quality, starting from a basic energy sufficient diet to a nutrient adequate diet and then to a healthy diet.

“ENERGY SUFFICIENT DIET”

This diet provides adequate calories for energy balance for work each day. This is achieved using only the basic starchy staple for a given country (e.g. maize, wheat or rice only).

“NUTRIENT ADEQUATE DIET”

This diet not only provides adequate calories (per the energy sufficient diet above), but also relevant nutrient intake values of 23 macro- and micronutrients through a balanced mix of carbohydrates, protein, fat, essential vitamins and minerals within the upper and lower bounds needed to prevent deficiencies and avoid toxicity. Macronutrient intakes are within the Acceptable Macronutrient Distribution Range (AMDR) set by the Institute of Medicine (2006).⁴⁵

“HEALTHY DIET”

This diet provides adequate calories and nutrients (per the energy sufficient and nutrient adequate diets above), but also includes a more diverse intake of foods from several different food groups. As described in the last section of Part 1 of this report, this diet is intended to meet all nutrient intake requirements and to help prevent malnutrition in all its forms, including diet-related non-communicable diseases (see Part 1, Box 5).

The healthy diet is based on global guidelines^46,47,48 that are nationally adapted to a country’s individual characteristics, cultural context, locally available foods and dietary customs through national food-based dietary guidelines (FBDGs). At this time, however, there are relatively few countries that have quantified national FBDGs. Therefore, for analysis purposes, the healthy diet in this section is guided by the quantified recommendations from ten national FBDGs, which represent a range of dietary recommendations articulated by countries. These are then locally adapted to each country through the assignment of least-cost food items available by food group in each country (see Box 11 and Annex 4, Table A4.1 for the description of the ten FBDGs). Although the healthy diet is not selected on the basis of nutrients but is determined by FBDGs, this diet meets on average 95 percent of nutrient needs, and it can be therefore almost always considered as nutrient adequate.⁴⁹

THE AIM OF THE COST AND AFFORDABILITY ANALYSIS

The ultimate aim of the analysis presented in this section is to measure whether food systems bring these three levels of diet quality within reach of the poorest, using those foods that meet each standard at the lowest possible cost. In this case, the least cost of the three diets are theoretical and do not necessarily represent diets currently consumed.

See Boxes 11 and 12 for a brief description of the methodology for estimating the cost and affordability of the three diets and its caveats. For a full description of the definition, methodology and data sources of the three diets, see Annex 3.

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Figure 25

The unaffordability of a healthy diet is strongly associated with food insecurity and different forms of malnutrition, including child stunting and adult obesity

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The association between adult obesity and affordability of a healthy diet is the inverse of the other associations. High-income countries have the highest affordability figures of the healthy diets and, at the same time, the highest rates of adult obesity. Likewise, Latin America and the Caribbean have also among the highest adult obesity rates, although with slightly higher unaffordability (Figure 25E-F), as the cost of the healthy diet in this area is higher than the average in high-income countries (USD 3.98 vs. USD 3.43). In fact, results in these regions align with recent research on the different stages of the so-called “obesity transition”, in which as countries develop and GDP per capita grows, the prevalence of overweight and obesity increases substantially. However, this picture hides demographic and socio-economic differences within countries and, over time, different groups are affected. Where cheap energy-dense foods of minimal nutritional value are available, the poor will buy these foods, as healthy diets are still too expensive for them.^20,21 Many high-income countries, notably the United States of America and Europe, have for some time been in that stage of the “obesity-transition” where the prevalence of obesity among those with lower socio-economic status surpasses that of those with higher socio-economic status. However, it should be noted that, although this is not the only variable that influences weight gain, the focus of this report remains on the cost and affordability.

How do costs and affordability of diets constrain access to food?

Cost and affordability measure one aspect of food systems, namely the degree to which food choices are constrained by food prices and household (or per capita) income. Of all the barriers to food access, cost and affordability are among the most important, particularly in the case of nutritious food.^22,23 According to FAO and WHO (2019),²⁴ “Sociocultural aspects of food choice notwithstanding, people generally eat what they can afford.”

Access to food is generally determined by physical access (e.g. own production, distance to markets, availability in markets, natural resources and biodiversity that provide wild foods) and economic or financial access (e.g. purchasing power, access to credit). In some circumstances social access (e.g. ability to secure food through social networks, based on extended family, ethnicity, religion or political affiliation) may substitute for financial and physical access.

Globally, enough food is being produced or in stock to meet dietary energy needs. Nonetheless, both food availability and food access vary across regions and country income groups, especially with regards to foods that contribute to a healthy diet. Although food systems facilitate food availability in markets at all levels, there are still physical, economic and social barriers that prevent many people from having sustainable access to food for an active and healthy life. Physical barriers may include poor road infrastructure, or simply the absence of transport and the long distances required to reach marketplaces.

During the COVID-19 outbreak, for example, food has been by and large available. However, it remains to be seen to what extent, over time, food supply chains remain undisrupted and prices generally unaffected; countries can continue to import food; and food consumption of vulnerable populations is not compromised due to income losses and the containment measures enacted by governments around the world. All of this could potentially translate into problems of food availability and access, but information is too scarce at the time of writing to draw conclusions. The next editions of this report will monitor and analyse the future implications.

To reiterate, what people eat depends on what is available and what they can afford – a function of the cost of food and incomes.²⁵ Once food is available, food choices are the result of the interaction between incomes, prices and preferences, whereby higher incomes and lower prices provide for more choices, allowing people to consume more and diverse foods. Affordability is also a relative concept that encompasses the market price of a food in relation to other household expenses and household income.

How do food prices and income affect the choice and consumption of foods?

To understand the effect of prices and income on the consumption of healthy diets, it is important to consider the extent to which the quantity of food consumed shifts in response to price and income changes. This extent of response, or elasticity, describes the percentage change in the demand of a given food item after a percentage change in its price or a person’s income. Generally, there is a negative association between food prices and the quantity of food demanded, while the association is positive between income and the quantity of food demanded.

The own-price and cross-price elasticities and income elasticities of demand for any particular set of foods reflect a combination of substitution effects (e.g. substituting potatoes for rice when the price of rice increases) and income effects (e.g. consuming more of other foods when the price of all starchy staples decreases). For example, if the price of basic staples declines, the reduction in the cost of a basic diet comprising those staples frees up money to buy more expensive foods. It translates into a higher real income level, all other things remaining constant. These concepts are critical to understanding how the cost and affordability of foods affect people’s diets.

The price and income elasticities of demand for staple foods are known to be very small and not significantly different from zero at least in the short term.²⁷ Even large swings in prices or incomes are not associated with significant changes in total calories of staple foods consumed. However, the short-term response of dietary intake to changes in price and income does affect diet composition, as people will substitute among foods to meet their daily energy needs.

Price elasticities for nutritious foods are larger than for basic staples.^28,29 This is due to both substitution and income effects. A meta-analysis shows that a 10 percent increase in the price of fruits and vegetables is associated with an average reduction in their consumption by 6.1 percent, while a 10 percent increase in the price of cereals is associated with an average decrease in cereal consumption of 5.2 percent.³⁰ Furthermore, it is shown that price elasticities estimated at the product level (e.g. apples) tend to be higher in absolute terms than those estimated for broader product categories (e.g. fruits). This might be due to substitution possibilities between products in the same food category, which reduce the average own price response of the product category (Annex 5, Table A5.1).^30,31

Food consumption is generally inelastic with regard to income, although large differences exist as income elasticities of demand tend to be higher in countries where income per capita is relatively lower (Figure 26). Within countries, it is possible to see high income elasticities of demand in poorer segments of the population, even in high-income countries. There are also considerable differences in income responsiveness across food items. Demand for food staples, such as grains, is generally less elastic than demand for fruits and vegetables or meat and dairy products.

Figure 26

Income elasticities OF DEMAND FOR FOOD PRODUCTS tend to be higher in countries where income per capita is lower

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Price elasticities tend to increase for countries with lower economic development, meaning that increases in the price of all foods result in greater reductions in food consumption in poor countries (Annex 5, Table A5.2).²⁸ Studies for high-income countries and emerging economies show that people living on low incomes are most likely to respond to changing prices.⁸ Changes in food prices had the largest own-price effects in low-income countries. Cross-price effects were more varied and were found to reinforce, undermine or alleviate the own-price effects, depending on country income group.^29,32,33,34

Looking at income elasticities, a rise in income leads to a rise in consumption of nutritious foods, such as fruits and vegetables.³⁵ Income elasticities for animal source foods, as well as fruits and vegetables, are positive and virtually always greater than for grains and tubers. Nutritious foods, such as horticultural products, meat and dairy, have a high income elasticity of demand in poor countries, such as those in sub-Saharan Africa. In general terms, these food items are less affordable than staple foods. In fact, staple foods, such as cereals, have smaller demand responses to income changes than high-valued food items, such as meat, fish and dairy.^3,28,36

In low- and middle-income countries, high socio-economic status or living in urban areas is associated with some elements of healthy dietary patterns, including higher intakes of fruits and vegetables, better diet quality, increased dietary diversity and higher vitamin and mineral intakes. However, high socio-economic status or living in urban areas was also found to be related to higher energy, cholesterol and saturated fat intakes due to concurrent consumption of highly processed foods.³⁷

In summary, lowering food prices – which can potentially result from changes triggered by both supply³⁸ and demand – is not likely to affect demand for calories, but which food prices are lowered will have a large impact on consumption choices. That is, the cost of nutritious foods specifically is important in understanding economic access to healthy diets. This cost is proving too high for many people to afford, as shall be seen next.

Healthy diets are unaffordable for many people in all regions of the world, especially the poor

Evidence of cost comparisons of individual food items and/or food groups from existing studies indicates that the cost of nutritious foods, such as fruits, vegetables and animal source foods, is typically higher than the cost of more energy-dense foods high in fat, sugar and/or salt, and higher than the cost of starchy staples, oils and sugars. However, these costs vary across the world and by a country’s gross national income per capita.^4,39,40

The relative prices of nutritious foods and energy-dense foods with minimal nutritional value have also been shown to differ systematically across income levels and regions.^7,14 Most noncereal foods are relatively cheap in high-income countries, including sugar- and fat-rich foods. In lower-income countries, nutrient-rich or fortified foods are generally expensive, especially most animal source foods and fortified infant foods. Prices for vegetables and animal source foods are shown to be systematically higher than prices of starchy staples around the world.^7,14

Studies have also shown that the relative caloric unit costs of most nutritious foods are substantially higher in poorer countries, although there are some exceptions.^7,41 Moreover, the cost of nutritious foods tends to vary more across geographic locations. Nutritious foods are often highly perishable and less tradable. As such, their prices are largely determined by local productivity and value chain efficiency, including transport and cold chains.^7,42

There is some evidence that the cost difference between nutritious foods and energy-dense foods is increasing over time in some parts of the world.⁴ For example, a study from the United States of America found that the price disparity between nutritious foods and highly energy-dense foods with minimal nutritional value has grown between 2004 and 2008 in parts of the country.⁴² Results from South-eastern Asia show similar patterns.⁴³

This report bridges some of these knowledge gaps. It offers new analysis on the cost and affordability of diets of increasing diet quality around the world, by region and different development contexts. Three diets are simulated in order to determine the affordability of three levels of increasing diet quality, starting from a basic energy sufficient diet meeting calorie needs to a nutrient adequate diet, and then to a healthy diet, including an estimation of recommended intake of more diversified and desirable food groups. A full description of the three diets is provided in Box 10.

The cost and affordability analysis of the three diets aims to answer three questions: i) what is the cost and affordability of the three different levels of diet quality? ii) what is the relative difference in cost and affordability moving from a diet that is energy sufficient to one that is nutrient adequate and then to one that is healthy? iii) how many people are unable to afford each type of diet and where are they in the world? The analysis explores these questions from a global, regional and development context perspective.

When actual dietary patterns are compared, the world’s poorest people consume something close to a basic energy sufficient diet. Any additional income above subsistence is typically spent to improve the starchy staple-based diet, with small amounts of a second and third food group that is more expensive per calorie but provides at least some variety and adds nutritional value.

Further income increases are typically associated with acquisition of more diverse foods, often achieving higher levels of most nutrients but using more expensive ingredients than the least-cost nutrient adequate diet in an effort to achieve higher levels of palatability, convenience and other attributes beyond essential nutrients. In the case of high-income countries, where a reverse wealth gradient of obesity exists, lower income correlates with obesity, according to the “obesity-transition” as explained above, due to the “nutrition transition”.

Between the energy sufficient diet and nutrient adequate diet, there are other diets that contain more than just staple food for basic energy needs but are still low in essential nutrients. These diets may be deemed as unhealthy as they may be abundant in unhealthy fats and sugars and/or salt, or may simply lack enough nutrient rich-foods to meet nutrient requirements (e.g. due to poverty or subsistence farms with limited access to markets).

For people who cannot afford a healthy diet due to relatively high costs of nutritious foods, unhealthy options such as sugary drinks and snacks high in sugars or saturated fat or salt are more affordable, and can be attractive because they are convenient, ready-to-eat or highly marketed. People for whom healthy choices are still largely unaffordable may also face other pressures related to income earning and time constraints to prepare balanced meals. These unhealthy diets, however, are not analysed in this report as the purpose of the affordability analysis is to determine the lowest possible cost to meet certain nutritional targets.

A brief summary of the methods used to compute the cost of the three diets that have been simulated for the analysis is provided in Box 11, and the methods to compute the affordability of the diets is provided in Box 12. A full description of the methodology and data sources, as well as limitations of the analysis are found in Annex 3.

Analysis of cost and affordability of three diets

Lowest cost of the three diets around the world

TABLE 7

The cost of a healthy diet is 60 percent higher than the cost of the nutrient adequate diet, and almost 5 times the cost of the energy sufficient diet in 2017

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As expected, the cost of the diet increases incrementally as the diet quality increases. The cost of a healthy diet is 60 percent higher than the cost of the nutrient adequate diet, and almost 5 times the cost of the energy sufficient diet. This pattern holds across all regions and country income groups (Table 7). At the global level, a nutrient adequate diet was USD 2.33 per person per day in 2017, whereas the healthy diet was USD 3.75 per person per day.

The average cost of a diet varies by region and country income group. However, there is a wide and overlapping cost range among countries across these regions and country income groups of the world (see Annex 3, Table A3.2 for cost of the three diets by country, income level and population). For example, the healthy diet in this analysis was on average more costly per person per day in lower-middle-income countries, estimated at USD 3.98, but the cost across these countries ranged from USD 2.85 to USD 5.00. The next most costly healthy diet was in upper-middle-income countries (USD 3.95, range USD 2.80–5.60) and low-income countries (USD 3.82, range USD 2.77–5.72). Healthy diets were cheapest in high-income countries (USD 3.43, range USD 1.88–5.50).

Geographically, the cost of a healthy diet was highest in Latin America and the Caribbean (USD 3.98, range USD 2.80–5.60) and in Asia (USD 3.97, range USD 2.81–5.50), especially in Eastern Asian countries (Table 7), with ranges showing cross-country variations within regions. The cost of a healthy diet was lowest in Oceania (USD 3.06, range USD 2.37–4.06), Northern America and Europe (USD 3.21, range USD 1.88–4.42), and Africa (USD 3.87, range USD 2.77–5.72).

Calculating ratios between the cost of diets across regions and country income groups brings to light an important finding: significant premiums (i.e. additional costs) must be paid in order to afford a higher diet quality across regions and development contexts. Worldwide, the cost of a nutrient adequate diet is on average 3.4 times (range 1–9) more expensive than an energy sufficient diet. A healthy diet is 1.7 times (range 1–2.8) more expensive than a nutrient adequate diet and 5.4 times (range 2–11) more expensive than an energy sufficient diet.

In general, low-income countries followed by lower-middle-income countries face relatively higher premiums to move from a nutrient adequate diet to a healthy diet than other countries. Geographically, Africa and Asia stand out as having the highest premiums to reach a healthy diet from a nutrient adequate diet. This is a significant challenge, considering that most of the food insecure and malnourished populations in lower-middle-income countries and low-income countries are consuming diets near to the energy sufficient diet. For example, it would cost a person living in a low-income country around 6 times more to move from an energy sufficient to a healthy diet.

The results are more striking for high-income countries as 75 percent of them pay as much as 7.4 times more for a healthy diet than they would for an energy sufficient diet. This stems from the fact that the cost of an energy sufficient diet in high-income countries (USD 0.71 per person per day) is much cheaper compared with the world average value (USD 0.79 per person per day). While rich countries have managed to make calories cheap, they have neglected to also make nutritious foods cheap. A person in a high-income country, on average, would have to pay 6 times more to move from an energy sufficient to a healthy diet.

Dairy, fruits, vegetables and protein-rich foods (plant and animal-sourced) are the highest-cost food groups globally, in terms of quantity recommended for consumption per day for a healthy diet (Figure 27A). There are regional differences, with fruits and vegetables being notably more expensive in Eastern Asia, and dairy being more expensive in sub-Saharan Africa, Eastern and South-eastern Asia but cheaper in Western and Northern Europe, Australia and New Zealand. Starchy staples and oils account for only 16 percent of the cost of a healthy diet. Fruits and vegetables account for a little less than 40 percent of its cost, and dairy and protein-rich foods combined account for a little more than 44 percent (Figure 27B).

Figure 27

Dairy, fruits, vegetables and protein-rich foods are the highest-cost food groups for a healthy diet globally IN 2017

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These proportions vary somewhat by country income group, with dairy being notably more expensive in low-income countries (see Annex 5, Figures A5.1 and A5.2). These findings imply that the cost of nutritious foods that contribute to a healthy diet, particularly dairy, vegetables, fruits and protein-rich foods, needs to decrease in order for their consumption to increase.

Affordability of the three diets around the world

After analysing the cost of this report’s three reference diets, the next important step is to examine their affordability. In this analysis, affordability is measured comparing the estimated cost of the least-cost diet per person per day for each of the three reference diets described for these analyses with: i) the international poverty line; ii) typical food expenditures in each country; and iii) estimated income distribution in each country. The methodology is described in Box 12.

Affordability comparing cost of the diets to the international poverty lines

Findings show that while most of the poor around the world can afford an energy sufficient diet, as defined here, they cannot afford either a nutrient adequate or a healthy diet (Figure 28). A healthy diet is far more expensive than the full value of the international poverty line of USD 1.90 PPP per day, let alone the upper bound portion of the poverty line that can credibly be reserved for food (63 percent) of USD 1.20 PPP per day (Figure 28). It is assumed that a minimum of 37 percent of expenditures must be reserved for non-food expenditures, such as housing, transport, education and health, and farm inputs.^51,52,53,54 On average, the cost of a nutrient adequate diet and a healthy diet are respectively 2 and 3 times greater than the poverty threshold of USD 1.20 per person per day. This is true by any of the definitions of healthy diets (based on national food-based dietary guidelines) used in these analyses (see Annex 4, Figure A4.1).

Figure 28

A healthy diet is unaffordable for the poor in every region of the world in 2017

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A nutrient adequate diet and a healthy diet are unaffordable for those living below the poverty line. They are also unaffordable for even the populations who are vulnerable to become poor because their incomes are just above the poverty line, and the cost of these diets well exceeds the poverty line of USD 1.90 per person per day.

This holds true across regions as well. Both the nutrient adequate and the healthy diets exceed USD 1.20 (63 percent of the poverty line) in sub-Saharan Africa, as they are 1.7 and 3.2 times higher than the poverty line, respectively. In Latin America and the Caribbean, they are 2.3 and 3.3 times higher, respectively, and in Asia, they are 1.8 and 3.3 times higher, respectively. In Northern America and Europe, both the nutrient adequate and heathy diets are unaffordable for the poor, as they are 1.9 and 2.6 times higher than the poverty line, respectively.

While a healthy diet costs more than USD 1.20 in every country, the least-cost nutrient adequate diet falls below this threshold only in Qatar, and falls between USD 1.20 and USD 1.90 for seventeen African, eleven Asian, six European, one Latin American and one Oceanian country. In comparison, the least-cost energy sufficient diet is affordable (still using the USD 1.20 threshold) for the poor around the world, except in Bolivia (Plurinational State of) (USD 1.42), British Virgin Islands (USD 1.56), Dominica (USD 1.22), Ecuador (USD 1.31), El Salvador (USD 1.46), Grenada (USD 1.33), Japan (USD 3.03), Nicaragua (USD 1.44), Saint Vincent and the Grenadines (USD 1.32), Sint Maarten (USD 1.72), South Africa (USD 1.26), Taiwan (USD 1.46) and Togo (USD 1.94).

These results imply that the international poverty line may need to be adjusted to avoid misguidance, as it is the basis for programme targets and social safety net programmes, but currently does not support the ability of people to access even the least-cost versions of a healthy diet. Specifically, poverty lines are not high enough to reflect incomes/consumption needed to support food security and nutrition needs. Poverty lines are determined by applying typical food consumption patterns expressed by food expenditure shares, using what is called a “basic needs approach”. This approach uses food prices to determine the cost of calorie needs weighted by food expenditure shares. The cost analysis of a healthy diet above shows that the poverty line, which includes provision for basic food needs, does not provide for having either a nutrient adequate or a healthy diet in most countries. Hence there is a need for new food price metrics, based around global nutritional and dietary goals, to estimate food poverty lines that are nutrition-sensitive. This issue is flagged as an area for further research in the last section of this report (see Box 29).

Affordability comparing cost of the diets to average daily food expenditures in each country

Looking now at diet costs compared with average national food expenditures per person per day, this report finds that the energy sufficient diet is affordable for most countries in the world (Figure 29A). On average, this diet represents 19 percent of the average food expenditure in the world, indicating affordability. However, the degree of this affordability varies across country and development contexts.

Figure 29

In most countries in the global south, the cost of a healthy diet exceeds average national food expenditures per capita in 2017

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As expected, an energy sufficient diet is most affordable in high-income countries (costing 10.5 percent of average food expenditure), with the degree of affordability decreasing as income level of the country declines. It is the least affordable in low-income countries (40 percent), followed by lower-middle-income countries (23 percent) and upper-middle-income countries (16 percent). The energy sufficient diet is least affordable in Western African low-income countries (50 percent). Moreover, this is the only region with two countries where the energy sufficient diet is not affordable, costing more than the average food expenditure. Specifically, the cost of an energy sufficient diet is 1.3 times higher than per capita food expenditures in Liberia, and 1.4 times higher in Togo (Figure 29A).

There are many more countries in the world where a nutrient adequate diet is not affordable (Figure 29B). For low-income countries as a whole, this diet is unaffordable as it represents 113 percent of the average food expenditure, meaning that it costs, on average, 1.13 times more than the average food expenditure. A nutrient adequate diet is affordable in high-income countries (costing 34 percent of average food expenditure), in upper-middle-income countries (46 percent) and also in lower-middle-income countries but to a lesser extent (62 percent).

A nutrient adequate diet is overall affordable in sub-Saharan Africa (91 percent). However, in this region affordability varies across its subregions and countries (Figure 29B). In fact, the nutrient adequate diet is not affordable in Western Africa as it represents 109 percent of average food expenditures, with countries such as Niger and Liberia where this diet costs, respectively, two and almost four times more than the average national food expenditure. Although this diet is on average affordable in Latin America and the Caribbean (57 percent) and in Asia (43 percent), it is less affordable for several countries in these regions (Figure 29B).

Of all the regions in the world, the affordability of a healthy diet poses the greatest challenge in Africa. In this continent, the average cost of a healthy diet exceeds the average food expenditure (USD 3.87 vs. USD 3.57), and it is 2.2 times higher in Western Africa (USD 4.03 vs. USD 2.66) (Figure 29C). Some countries show a much more disproportionate cost of this diet compared with their average food expenditures. In Burundi, Liberia, Niger and Togo, in particular, the cost of healthy diets is between 4 and 7 times higher than average food expenditures, with Liberia reporting the highest unaffordability.

While a healthy diet is on average affordable in North Africa (71 percent of average food expenditures), it is not affordable in three subregions of sub-Saharan Africa (Eastern, Middle and Western Africa). In Western Africa, it is 2.2 times more expensive than the average food expenditure, followed by Eastern Africa and Middle Africa, where the diet is 1.8, and 1.4 times higher than average food expenditures, respectively. It is affordable in Southern Africa where the healthy diet represents 92 percent of average food expenditures. Overall, a healthy diet is not affordable for more than 70 percent of the countries in Africa (35 out of 50).

In Asia, a healthy diet is on average affordable (78 percent of average food expenditures), owing to the affordability seen in Western Asia (56 percent), Eastern Asia (81 percent), Central Asia (85 percent), and South-eastern Asia (88 percent). However, it is not affordable in Southern Asia (102 percent). For 10 countries in Asia, out of 40 countries analysed, the cost of a healthy diet exceeds the average food expenditure.

Countries in food crisis face even greater challenges in accessing a healthy diet, especially countries with a protracted crisis situation which are characterized by complex, multidimensional conflicts and extreme fragility. In these contexts, the cost of a healthy diet is similar to the global average (USD 3.80 and USD 3.75 per person, respectively); however, the proportion of the people who cannot afford this diet is significantly higher compared with the world average. Most or 86 percent of the population in countries with a protracted crisis situation cannot afford a healthy diet. This is double the world average figure (38 percent) and is 57 percent higher than what is estimated for the Global South (Box 13).

BOX 13

Countries with a protracted crisis situation face immense challenges in ensuring the affordability of healthy diets

Countries in food crisis face even greater challenges in ensuring the availability of nutritious foods and the affordability of a healthy diet. This is especially the case for countries with a protracted crisis situation,* which are generally characterized by complex, multidimensional and prolonged conflicts and extreme fragility.

Countries with a protracted crisis situations present specific challenges related to the cost and affordability of healthy diets.⁵⁹ Almost all these countries have experienced some form of violent conflict over prolonged periods. Their populations face frequent food price fluctuations and spikes, disruptions in food supply and access to functioning markets, and greater uncertainties, risks and inefficiencies in food systems. Most of these countries are also characterized by very weak governance, breakdown of local institutions, poor health of the affected populations, higher risk of climate variability and climate change impacts and high prevalence of natural disasters. Moreover, a significant proportion of the population in these contexts are acutely vulnerable to hunger, malnutrition, disease and disruptions to livelihoods over prolonged periods.

FAO currently identifies 22 countries with a protracted crisis situation, but information on cost and affordability is not available for seven of them: Afghanistan, Democratic People’s Republic of Korea, Eritrea, Somalia, South Sudan, Syrian Arab Republic and Yemen (see Annex 6). The table below presents the analysis of the costs and affordability of the three reference diets (i.e. energy sufficient, nutrient adequate and healthy) for the 15 countries with a protracted crisis situation for which price data are available.

The cost and affordability analysis highlights the immense challenge in ensuring affordable healthy diets in these contexts. The findings show that while the cost of a healthy diet in these contexts is comparable to the global average, the proportion of the population who cannot afford a healthy diet is significantly higher. Specifically, the cost of a healthy diet is on average slightly higher than the global average (USD 3.80 and USD 3.75 per person, respectively). However, this is unaffordable for most (86 percent) of the population in countries with a protracted crisis situation – a figure that is double the world average (38 percent), and is 57 percent higher than what is estimated for the Global South.

Within-country analysis of variations in cost and affordability is available for a number of the most affected countries with a protracted crisis situation.** The results show that compared with countries with a stable context, the cost of an energy sufficient diet is usually only slightly higher. However, the cost of a nutrient adequate diet is significantly higher due to inefficiencies in supply and lower availability of nutritious foods.

For example, in North Burundi, Tanganyika region in the Democratic Republic of the Congo, Maradi and Zinder in Niger and the plateau Dogon in Mali, a nutrient adequate diet would be unaffordable for nearly everyone (above 90 percent).⁶⁰ In the Democratic Republic of the Congo and in Somalia, rural markets tend to offer significantly less variety of foods than urban markets in the same regions, especially animal source foods.*** When comparing the cost of a nutrient adequate diet to an energy sufficient diet, the nutrient diet in these regions was found to be 4–7 times higher, as opposed to 2–4 times higher in stable country settings.

Given the extreme severity and persistence of food insecurity and malnutrition they suffer, countries with a protracted crisis situation require special attention and approaches to transforming food systems in order to ensure affordable healthy diets for all.^59,61,62

While the cost of a healthy diet is comparable to theWhile the cost of a healthy diet is comparable to the global average, the proportion of people who cannot afford this diet is significantly greater in countries with a protracted crisis situation

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More than 3 billion people in the world cannot afford a healthy diet

Affordability comparing cost of the diets to estimated income distribution in each country

The above analysis has shown clearly that a nutrient adequate and a healthy diet are significantly less affordable than an energy sufficient diet. In many countries, the poor would have to use most or all of their total income in order to acquire adequate quantities of essential nutrients and a diversity of nutritious food groups; and for a number of countries, even this amount would not be enough. In such situations, affordability imposes an insurmountable obstacle, so price and income constraints need to be addressed within supportive food environments for nutrition knowledge and behaviour change to be effective in influencing choices.

Ultimately, the aim of the cost and affordability analysis presented so far is to quantify the number of people for whom even a lowest-cost healthy diet is out of reach. Table 8 presents estimates of the prevalence and the total number of people for whom each of the three levels of diet quality is not affordable, based on estimated income distribution. These estimates assume that people spend on average 63 percent of their income on food, where this chosen percentage represents the food share expenditure of the poorest segment of the population in low-income countries, according to the World Bank (see Box 12 and Annex 3). To give a range of confidence to these estimates, the prevalence and number of people who cannot afford the three diets are also computed using lower-bound and upper-bound estimates that are shown in Annex 3 (Table A3.3).

TABLE 8

More than 3 billion people in the world cannot afford a healthy diet in 2017

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Based on this analysis, it is estimated that more than 3 billion people in the world could not afford a healthy diet in 2017. Most of these people live in Asia (1.9 billion) and Africa (965 million), although there are millions that live in Latin America and the Caribbean (104.2 million), and in Northern America and Europe (18 million). The highest proportion of the population that could not afford a healthy diet is seen in Western Africa (82 percent), Middle Africa (78 percent), Eastern Africa (75 percent), Southern Africa (64 percent), followed by Southern Asia (58 percent), South-eastern Asia (46 percent), the Caribbean (37 percent), Central Asia (33 percent) and Central America (28 percent). Looking at country income groups, the highest proportion is seen in low-income countries (86 percent) and lower-middle-income countries (59 percent), whose populations face the greatest challenges in affording healthy diets.

In summary, 77 percent or more of the population throughout sub-Saharan Africa and 58 percent in Southern Asia cannot afford healthy diets. Furthermore, high proportions of people throughout other parts of Asia (30 percent) and Latin America and the Caribbean (26 percent) cannot afford healthy diets either (see Annex 5, Figure A5.3).

These findings imply that: i) the cost of nutritious foods that constitute healthy diets needs to decrease, including dairy, fruits, vegetables and protein-rich foods; and ii) poverty lines may need to rise, as they are the basis for programme targets and social safety net programmes, and currently do not provide a good gauge of people’s ability to access even the least-cost versions of a healthy diet. That is, they do not support food security and nutrition.

National FBDGs reflect the translation of global guiding principles of a healthy diet that takes into account a country’s nutrition situation, food availability, culinary cultures and eating habits (see Section 1.3 in Part 1 of this report). FBDGs are intended to establish a basis for food and nutrition, public health, education, social protection and agricultural as well as other sectoral policies and programmes, and also for food and nutrition education programmes to foster healthy eating habits. The findings indicate that as part of comprehensive strategies in order to shift population consumption towards recommended diets by enabling all people to access healthy diets, prices of those diets need to decline.

Costs and affordability within countries

The cost and affordability of diets varies around the world, across regions and in different development contexts. They may also vary within countries due to temporal and geographical factors, as well as variations in the nutritional needs of individuals across the life cycle. These within-country variations in cost are not captured in the above global and regional analysis.

Within-country variation driven by temporal and geographical factors

The affordability of a healthy diet can vary widely within a country, driven by variation among regions with regard to higher prices of nutritious food, lower economic status of a population, limited availability and diversity of nutritious foods or a combination of these factors. There are significant temporal and geographical patterns in the cost variations. For example, in a study of Southern Asia, for some countries, the price of a nutrient adequate food basket varied more by season and has been increasing at a faster rate than the price of a typical food basket. This phenomenon was largely due to the variable cost of vegetables.⁶⁶

Figure 30

Affordability of a nutrient adequate diet varies widely within many countries due to temporal and geographical variations in prices and differences in incomes

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Varying food prices, which directly impact the cost of a nutrient adequate diet, often mirror urban-rural divides. In the urban south of Mozambique, the prices of eggs and tomatoes, which are imported from South Africa, were 4–5 times higher than in the rural central region, where they were mainly produced by local households. However, a nutrient adequate diet was more affordable in the urban south, even if it was more expensive, because incomes were higher. This is a typical observation in many countries. Rural areas were also impacted more strongly by seasonality, with food prices in rural areas rising higher in the lean season compared with those in urban contexts.

In all contexts, food prices varied by ecological system and livelihood. In rural Myanmar, the “breadbasket” region of Ayeyarwady, where most of the rice and other crops are produced and sold on rural markets, the cost of a nutrient adequate diet was 10 to 25 percent lower than in remote regions of the country where transport, storage and retail are required to get the foods there. In the pastoralist belt of north Burkina Faso, 82 percent of households were unable to afford a nutrient adequate diet. In contrast, the agricultural southern regions showed variation in unaffordability of a nutrient adequate diet from 35 to 43 percent.

Furthermore, higher food prices and the higher cost of a nutrient adequate diet were also seen in remote mountainous communities of Lesotho and El Salvador due to the challenges of food supply and the difficulties in meeting nutrient requirements from the foods that are locally available. In El Salvador, the number of nutritious foods available on the market decreased with altitude, increasing the cost of meeting nutrient requirements. Unaffordability of a nutrient adequate diet varied from 23 percent in the plains to 44 percent in the high-altitude Morazan region.

Within-household variation driven by life-cycle needs

Nutritional needs vary across the life cycle, and hence dietary intake requirements differ both in terms of quantity and diversity. This has implications for cost and affordability, and risk of micronutrient deficiencies.⁶⁷ Within the same household, the cost of a nutrient adequate diet is not the same for everyone, as members are generally at different stages of life. This is mainly due to the increased need for some nutrients during phases which should be met with foods of higher nutritional value, such as pregnancy or adolescence, which tend to be more expensive.⁴⁹

For example, in Malawi, pregnant and lactating women and adolescent boys faced the highest cost for a nutrient adequate diet. The average cost of a nutrient adequate diet of these groups was more than USD 1.50 per day, which was much higher than the 70 percent of international poverty line and the food expenditure per capita per day in Malawi.⁴⁹ In terms of the cost per 1 000 kcal, females in general faced a higher cost compared with males, as they require more nutritious foods. This trend is the same at the global level, showing adolescent girls and older females facing particular challenges in terms of the need for highly nutritious foods.⁴⁹

A recent study that modelled the cost of a nutrient adequate diet based on locally available foods in four countries (El Salvador, Ghana, Lao People’s Democratic Republic and Madagascar) found that in a five-person household, meeting the needs of an adolescent girl would cost the most, exceeding not only the diet cost of an adult man but also of a lactating woman.^64,68,69,70 The higher cost of a nutrient adequate diet was mainly driven by the elevated need for calcium, iron and vitamin A to fuel growth and compensate nutrients lost through menstruation. In the countries studied, these nutrients would be met most cost-efficiently through foods like meat and dairy, which cost more than less nutritious foods such as starchy staples.

In Ghana, a nutrient adequate diet for an adolescent girl would cost 3 times more than a nutrient adequate diet for a boy of the same age and twice as much as a nutrient adequate diet for an adult man. The girl’s nutrient needs, and therefore diet cost, are elevated further if she happens to be pregnant or breastfeeding due to the increased nutrient intake requirements. Analyses for El Salvador and Lao People’s Democratic Republic found that pregnancy on average increased the cost of a nutrient adequate diet for an adolescent girl by 12 percent and by 18 percent if she is breastfeeding.^68,69,70

Figure 31

Pregnant and lactating women and adolescent girls have higher dietary energy and iron needs, which increases the cost of a nutrient adequate diet: Burundi and Uganda case studies

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Another stage of life that requires foods of high nutritional value is the period between 6 and 23 months. At this age, children have high nutrient needs for growth but can only eat small quantities of food because of their small stomachs; therefore, they require breastfeeding and nutrient-dense complementary foods. Although the cost of complementary feeding for a child of 6–23 months of age is the lowest in the household, the number and quality of foods selected for that child is higher than for an adult man, because of the nutrient density required. For example, per 100 kcal of food, a breastfed infant of 6–8 months of age needs 9 times as much iron and 4 times as much zinc as an adult man.⁷¹

Conclusion

In summary, the analysis of the costs and affordability of the three reference levels of diet quality presented in this section helps determine where, geographically, attention needs to be paid if a healthy diet is to become affordable for all, across and within countries, by regions and country income groups. The evidence presented serves to highlight where the cost of a healthy diet must fall to be an affordable level for all, as well as where the need is most pressing, so that people can then have more choice options. It shows that healthy diets are unaffordable to many people, especially the poor, in every region of the world. In fact, for more than 3 billion people, even the lowest-cost healthy diet is unaffordable. In many countries of the world, the cost of a healthy diet is much higher than both the international poverty line, established at USD 1.90 PPP per day, and average food expenditures. More than 77 percent of the population cannot afford these diets throughout sub-Saharan Africa, and 57 percent cannot afford it in Southern Asia, and the challenges are even greater for countries with a protracted crisis situation. More than 1.5 billion people in the world cannot even afford a diet that only meets required levels of essential nutrients.

Aside from recognizing the prohibitive costs of healthy diets for many of the world’s populations, it is also important to understand what is making these diets costly. Evidence points to a number of different factors driving up the price of nutritious foods throughout food systems. The following sections further explore this in order to identify the key areas of policy intervention and food systems transformations.

Current food systems have been successful at producing low-cost calories that have fuelled a fast-growing and more urbanized population, and economic development more broadly. However, these productivity gains and cheap calories have not improved access to healthy diets, which remain costly and unaffordable for billions of people in the world. But the issue of cost of diets is problematic in another sense as well, one that should not be overlooked.

The health impacts associated with poor quality diets are significant for many people in the world. In addition to the health and social costs associated with undernutrition, unhealthy diets are a leading risk factor for deaths and disability associated with from non-communicable diseases (NCDs). Increasing healthcare costs linked to rising obesity rates are a trend across the world, and both overweight and obesity are significant risk factors for NCDs. Out of 56.9 million global deaths in 2016, 40.5 million, or 71 percent, were due to NCDs.² The four main NCDs are cardiovascular diseases, cancers, diabetes and chronic lung diseases.

Current global methods of food production also result in negative environmental impacts,⁷² with repercussion for society as a whole. This is seen for example in countries where energy intake and consumption of animal source foods is too high, a rebalancing of the diets to a higher content of plant-based foods may be needed to reduce negative environmental impacts, including on land use, freshwater extraction and biogeochemical flows.⁷³

The health and environmental consequences of unhealthy diets translate into actual costs for many people in the world and for society as a whole, such as increased medical costs and the costs of climate change, respectively. These costs incurred in the production and consumption of food are currently not reflected in the price of food, even though they are a result of the production and consumption of this food. They are what economists call negative externalities, and they can lead to market failures, overconsumption, and production of energy-dense foods and diets that are harmful to environmental sustainability. According to economic theory, correcting such market failures requires integrating the previously unaccounted costs in the price of those foods, so that consumers and producers can make their decisions based on full costs.

Properly valuating these hidden costs or externalities of food systems would significantly modify the assessment of what is “affordable”. To show the significance of this, this section presents new estimates of an economic valuation of the health and climate change consequences associated with dietary choices, but not currently reflected in their costs.

Considering total global consumption, a rebalancing of consumption towards healthy diets that takes into account environmental sustainability would significantly reduce negative externalities, creating synergies for other SDGs. However, this global pattern does not need to result in a decrease in each country. At the national level, the impact of this rebalancing depends on a country’s existing food security and nutrition situation, the speed at which it has been able to make progress, and the magnitude of health and environmental externalities. For some countries, a shift may imply trade-offs, and the downsides may last for some time. For example, the current diet of a young child in a low-income country may have a low environmental footprint, but its nutritional content may be inadequate. In this case, the environmental impact may have to increase to meet the desired nutritional targets first. Another example is the diversification of production that is needed for healthy food items. To minimize unfavourable trade-offs, the livelihoods of family farmers and smallholder producers for whom transition to diversification is not immediately feasible should be prioritized, particularly in countries where food systems not only provide food but also drive the rural economy. Hence, this section offers ideas for prioritizing and making the most of synergies while avoiding unfavourable trade-offs along the transformation of food systems.

A valuation of hidden costs of dietary patterns

This report’s valuation of hidden costs of dietary patterns includes separate valuations of health and climate-change costs, but does not consider many other potential environmental costs. Nonetheless, health and climate-change costs are critical to consider in any transformation of food systems aimed at delivering affordable, healthy diets that include sustainability considerations. While these two costs are different in nature – one directly affecting only some people (health), the other affecting the world as a whole – here they are also evaluated together to understand their full impact on current and future food production systems.

Underlying the valuation of the health and climate-change cost analysis are estimates of current and future food consumption and the four alternative consumption scenarios that have been devised as being healthy and include sustainability considerations. Current food demand, referred to as the “benchmark diet” in the analysis presented below, is estimated based on a harmonized data set of food availability estimates by FAO. Future food demand is estimated considering expected changes in income, population and dietary preferences.⁷⁴ The food demand projections are comparable with other estimates.⁷⁵

Four alternative healthy diet patterns are analysed: a predominantly plant-based flexitarian diet which contains small to moderate amounts of animal source foods; a pescatarian diet that is based on sustainable aquaculture and which contains moderate amounts of fish but no other meat; a vegetarian diet that includes moderate amounts of dairy and eggs, but no fish or other meat; and a completely plant-based, vegan diet that is based on a variety of fruits and vegetables, whole grains and plant-based protein sources, such as legumes and nuts. These diets conform to the general recommendations of the EAT-Lancet Commission on Healthy Diets from Sustainable Food Systems and take into account regional preferences for specific staple crops, fruits, vegetables and other food categories, as well as population-specific energy requirements (Box 14).

Hidden health costs

As highlighted in Section 1.3 of this report, a healthy diet ensures adequate calories and nutrients, and includes a balanced, diverse intake of foods from several different food groups eaten over a period of time. It is intended to meet all requirements of nutrient adequacy and to help prevent malnutrition in all its forms, as well as NCDs. Diets of poor quality are a principal contributor to the multiple burdens of malnutrition, like stunting, wasting, micronutrient deficiencies, overweight and obesity. Both undernutrition early in life and overweight and obesity are significant risk factors for NCDs.⁹⁵

Even considering only obesity, estimated economic costs from existing studies vary considerably due to the different methodologies used to estimate indirect and direct costs.^95,99 For example, estimates from the United States of America range from USD 89 billion to USD 212 billion in total costs per year; those from China are estimated at 3.6 and 8.7 percent of gross national product (GNP) in 2020 and 2025, respectively; and for Brazil, it is projected that there could be a doubling of the obesity-related healthcare costs from USD 5.8 billion in 2010 to USD 10.1 billion in 2050.

There are also data limitations on the healthcare costs and the effect of obesity and overweight on productivity and disabilities, as these have rarely been studied in low- and middle-income countries, despite the fact that more than 70 percent of all obese or overweight people in the world live in these contexts. The most widely quoted, for 2014, reports that obesity is projected to cost USD 2 trillion annually by 2050, largely driven by the value placed on lost economic productivity plus direct healthcare costs.¹⁰⁰

In valuing the economic impacts of poor quality diets, it is not only linked to mortality and the direct medical and healthcare costs associated with treating a specific disease, but also involves indirect costs. The indirect costs can be significant, accounting for up to 60 percent of the total costs of being overweight or obese.¹⁰¹ They include, for example, reduced educational attainment, lower lifetime earnings, costs of informal care, loss of productivity, increased disabilities and loss of working days.

Despite these challenges, valuating the health impacts of diet-related diseases, specifically NCDs, provides a useful indication of the level of impacts. This report provides a comparative analysis of the health benefits of global dietary changes for all major regions in the world and by country income group. The analysis of hidden costs or externalities related to the health impact of diets combines two parameters: the estimated number of deaths due to four specific NCDs (coronary heart disease, stroke, cancer, type 2 diabetes mellitus), and the estimated health costs associated with those NCDs. Due to data limitations, the indirect costs included in the analysis presented in this report only relate to the loss of productivity/working days, and the costs of informal care.

As mentioned above, ideally cost estimates should include the costs related to the health impact of undernutrition, both in terms of deaths and lost productivity due to diets that are not sufficiently nutritious. However, data for these estimations do not exist. The health costs presented here, therefore, are likely to be underestimated. Despite these data limitations, the current analysis provides important insights on the costs and health benefits of consuming healthy diets.

Results

Shifting to healthy diets, including not only cutting out energy-dense foods of minimal nutritional value, but also increasing the diversity of nutritious foods, is associated with significant reductions in mortality. This finding is seen across all four healthy diet scenarios, looking at average estimates of avoided deaths in 2030 compared with the benchmark scenario of national average current food consumption patterns (Figure 32). At the global level, for example, the adoption of the flexitarian diet would result on average in 12.7 million avoided deaths, ranging between a minimum of 7 and a maximum of 18.3 million avoided deaths. For the other three diet patterns, avoided deaths are projected to be even higher: an average of 13.2 million (7.5–18.9) for the pescatarian, 12.9 million (7.3–18.6) for the vegetarian and 13.7 million (7.9–19.4) for the vegan diet (Figure 32).

Figure 32

Compared WITH current consumption patterns, adopting any of the four alternative HEALTHY DIET patterns is projected to lead to significant reductions in mortality by 2030

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Moving away from the global averages, important differences in health benefits emerge across regions and country income groups. Middle-income countries, which represent 69 percent of the world population in 2030, have the most to gain in terms of reduced mortality by switching to any of the four alternative diet scenarios. Between 73 and 75 percent of avoided deaths in the world, across the four diets, occur in middle-income countries. Specifically, the highest percentage of deaths avoided (range 54–56 percent) would be seen in lower-middle-income countries, followed by upper-middle-income countries (range 19–20 percent), high-income countries (17–19 percent) and low-income countries (8 percent), whose reduced mortality is the same across the four diets. The low percentages in low-income countries are explained by the fact that mortality is only measured in terms of NCDs, which are major causes of mortality in higher-income countries. In low-income countries, major causes of mortality are more related to the multiple forms of communicable, maternal, neonatal conditions and undernutrition. Of the low- and middle-income countries, the largest proportion of health benefits in terms of avoided deaths from adopting any of the four diet scenarios, 22–23 percent, is found in South-eastern Asian countries.

On a per capita basis, taking account of the total population in each country income group, 36 percent of per capita avoided deaths are projected to occur in upper-middle-income countries. This is followed by 30 percent in high-income countries, 23 percent in lower-middle-income countries and 11 percent in low-income countries.

Further insight is gained by examining the contribution of the weight-related risk factors (obesity, overweight and underweight) and diet-related risk factors (by food group) to the total avoided death. This shows that for the four diet scenarios, the majority of avoidable deaths (on average 68 percent) are due to imbalances in dietary composition. The remaining 32 percent of the avoided deaths are due to imbalanced weight levels (see Annex 8, Table A8.1).

Assuming that current food consumption patterns accommodate expected changes in income and population, as per in the benchmark scenario (BMK), health costs are projected to amount to an average of USD 1.3 trillion in 2030 (Figure 33). More than half (57 percent) of these are direct healthcare costs as they are associated with expenses related to treating the different diet-related diseases. The other part (43 percent) accounts for indirect costs, including losses in labour productivity (11 percent) and informal care (32 percent).

Figure 33

Under current food consumption patterns, diet-related health costs are projected to reach USD 1.3 trillion per year in 2030

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Across country income groups (Annex 8, Figure A8.1), the level of total costs is influenced by the general level of healthcare spending (healthcare costs are highest in high-income countries) and by population numbers (middle-income countries have the largest share of world population, estimated at 76 percent). Hence, the greatest costs are seen in high-income countries (USD 637 billion), followed by lower-middle-income countries (USD 415 billion), upper-middle-income countries (USD 252 billion) and low-income countries (USD 17 billion).

If, instead, any of the four alternative diet patterns used for the analyses are adopted (FLX, PSC, VEG, VGN), diet-related health costs dramatically decrease by USD 1.2–1.3 trillion, representing an average reduction of 95 percent of the diet-related health expenditures worldwide compared to the benchmark scenario in 2030 (Figure 34).

Figure 34

Adoption of any of the four alternative healthy diet patterns would dramatically decrease diet-related health costs by 2030

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Although most avoidable deaths would be found in middle-income countries (more than twice as many as in high-income countries), on average, 49 percent of all cost savings would occur in high-income countries due to their higher health expenditure.

Lower-middle-income countries not only stand to benefit from the highest number of avoided deaths, but their cost saving is also significant, second only to high-income countries. More important, this cost saving in lower-middle-income countries derives mostly from savings on indirect costs, which include avoided productivity losses and days not worked, potentially leading to positive second-round effects for livelihoods and growth in the economy overall.

Hidden climate-change costs

What people eat, and how that food is produced, not only affects their health, but also has major ramifications for the state of the environment and for climate change. Most global and cross-country valuations of environmental impacts focus on GHG emissions, because data limitations hamper global cross-country comparisons of other important environmental impacts related to land use, energy and water use.

Increases in GHG emissions and other environmental impacts are set to continue to rise under current food consumption patterns and food systems. FAO estimates that the world will need to produce about 50 percent more food by 2050 to feed the growing world population, assuming no changes occur in food loss and waste.¹⁰³ If current dietary patterns and food systems remain, this would engender significant increases in GHG emissions and other environmental impacts, including loss of biodiversity, soil degradation, pollution and water use.

Many studies indicate that dietary shifts can significantly reduce GHG emissions. Setting dietary and nutritional goals with no consideration for the environment could in some cases increase GHG emissions.¹³⁶ For instance, several studies highlight that if current dietary trends are maintained, this could lead to a significant climate-change emissions from agriculture of approximately 20 GtCO₂-eq per year by 2050.^{73,84,104,105,106,107,108} A few studies show contrasting results, but they focus on one or more dietary components of self-selected healthy diets (diets freely chosen by consumers). One study found that the lowest emission diets analysed were lower in meat but higher in oil, refined grains and added sugar.¹⁰⁹

Recent analyses have highlighted that reductions in consumption of meat and dairy in many diets would not only have health benefits in many countries but would have significant environmental benefits. The analyses have shown that reductions in global meat consumption and other dietary changes, for instance, would ease pressure on land use^84,86,110 and reduce GHG emissions.^{86,106,110,111} Other studies have found that rebalancing consumption towards healthy diets could help significantly cut emissions from the food systems¹¹¹ and may be essential to avoid negative environmental impacts, such as major agricultural expansion¹⁰⁵ and global warming of more than 2 degrees,¹⁰⁶ while ensuring access to safe and affordable food for an increasing global population.¹¹²

The latest Intergovernmental Panel on Climate Change (IPCC) Special report on Climate Change provides an in-depth examination of GHG emissions in relation to climate mitigation and food security and concludes there are significant opportunities to achieve both objectives simultaneously¹⁰² by adopting diets in line with health-based dietary recommendations. National food-based dietary guidelines (FBDGs) for healthy eating are based on global guidelines⁴⁶ and are broadly similar across most countries. They are typically capped by number of calories and higher in plant-based foods, such as vegetables, fruits, whole grains, legumes, nuts and seeds, and lower in trans and saturated fats, free of sugars and salt. Such diets have the potential to be both healthy and include sustainability considerations, but this requires both climate change and health being considered together.

Healthy diets present important opportunities for reducing GHG emissions in some contexts, because they are rich in plant-based foods that emit lower GHG levels compared with diets that are heavy in red meat consumption. However, this may not be the best option in order to pursue a reduction in GHG emissions, especially in contexts where consumption of red meat and dairy can provide valuable sources of essential nutrients to vulnerable populations, particularly to prevent undernutrition. There is no exact make-up of a healthy diet that includes sustainability considerations, but the guiding principles for a healthy diet are the same (see Section 1.3, Box 5). One of these guiding principles is that a healthy diet can contain animal source foods in moderate to small amounts. Specifically, a healthy diet can include moderate amounts of eggs, dairy, poultry, fish and small amounts of red meat. This principle based on health considerations, also presents an opportunity for countries to make the shift to healthy diets and simultaneously contribute to reductions in GHG emissions.

Not all healthy diets include aspects of sustainability because there is no “unique” healthy diet. For example, most of the national FBDGs that define a national healthy diet are highly variable in their recommendations and generally do not include aspects of sustainability. While some FBDGs are associated with reductions in GHG emissions, these reductions are generally estimated to be moderate. Most FBDGs are not compatible with a set of global environmental targets related to climate change and environmental resources. The policy measures that shift production and consumption to healthy diets are not explicitly designed to address the climate change problems of the world. But healthy diets that include aspects of sustainability present important opportunities for synergies for reducing GHG emissions. The four diet scenarios analysed are only four out of many possible diet scenarios that could be simulated to achieve results in terms of GHG emissions reductions.

Simply put, not all healthy diets are sustainable and not all diets designed for sustainability are always healthy or adequate for all population groups. This important nuance is not well understood and is often missing from ongoing discussions and debates on the potential contribution of healthy diets to environmental sustainability.

Dietary shifts that include sustainability considerations can play an important role as part of a broader strategy, for increasing the environmental sustainability of food systems. These include limiting the impacts of diets on the environment through technological and productivity advancements, sustainable and integrated land and natural resource use, and enhanced efficiencies and innovations along the food supply chain, including those aimed at reducing food loss and waste. Limiting the impacts of diets on the environment in this way may help create a virtuous circle, or a recurring cycle of events, each having a beneficial effect on the next, as all the enhancements contribute to reducing the environmental cost of producing nutritious food. This is further explained in the next section.

Though beyond the scope of this report, there is an abundance of technological knowledge and practices that can inform a combination of approaches for increasing the environmental sustainability of food systems.¹¹³ One example is sustainable land management practices which do not require land use change and do not create demand for more land conversion, including sustainable management of cropland and grazing lands, livestock, forest, fisheries and aquaculture production.¹⁰² Another example is integrated agricultural production systems that use efficient climate-smart agricultural practices, such as integrated rice and fish farming and integrated crop-livestock systems.¹¹⁴ Addressing the contribution of livestock production to GHG emissions is critical, but there are numerous sustainable efficiency enhancements that can be adapted and applied across the diverse livestock production systems (e.g. promoting the use of by-products and waste as livestock feed and recycling manure for energy and nutrients).^{115,116,117,118} Land-use regulation, combating desertification and halting biodiversity loss are also important.¹⁰² These approaches can also contribute to reducing the cost of healthy diets.

As stated previously, data limitations hamper global cross-country comparisons of other important environmental impacts related to land, energy and water use. This has of course limited this report’s own global analysis, which looks at the hidden climate-change costs by focusing exclusively on GHG emissions and their climate impacts. Nonetheless, Table 9 summarizes additional evidence from the literature on the impact of current dietary patterns on these other environmental impacts, and the estimations of potential impacts from shifting to healthy diet patterns that include sustainability considerations. Another environmental impact to consider is food biodiversity, which is essential for guaranteeing diverse diets around the world.¹¹⁹ One of the main factors influencing biodiversity loss is land-use change and diets. Animal source foods, in particular, have been one of the main contributors to biodiversity loss.¹²⁰

TABLE 9

Shifting to healthy diets that include sustainability considerations can contribute to reductions in environmental impacts on land, energy and water use

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Results

Due to data availability constraints to conduct a global and regional analysis, this report presents estimates on the environmental costs of diets focusing only on GHG emissions. For this reason, this report makes more reference to climate-change costs rather than all environmental costs. A two-step approach is adopted. In the first step, GHG emissions associated with food consumption are calculated. In the second step, these emissions are paired with cost estimates of climate damages to gauge the climate-change costs of each dietary pattern (see Annex 7 for the methodology and data sources and Annex 8 for additional figures and tables). Both steps present important results with policy implications.

GHG emissions associated with different dietary patterns

Figure 35

Adoption of any of the four alternative healthy diet patterns could significantly reduce projected diet-related GHG emissions in 2030

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More than half of all emissions under current food consumption patterns (4.2 GtCO₂-eq or 52 percent) are associated with food demand from lower-middle-income countries (Annex 8, Table A8.2). Looking at per capita emissions, however, these are largest in upper-middle-income countries (1.6 MtCO₂-eq), followed by high-income countries (1.0 MtCO₂-eq). The lowest emissions were associated with low-income countries (0.7 MtCO₂-eq).

The global and country income group aggregates hide important variations across subregions and countries. These, in turn, indicate that there are potential trade-offs that need to be managed as countries transform food systems towards healthy diets that include sustainability considerations. For example, countries with high burdens of undernourishment and multiple forms of malnutrition might see their consumption-related emissions rise as growing shares of their population consume healthy and nutrient adequate diets. In these cases, fighting hunger and malnutrition by increasing the diversity of nutritious foods available for infants and young children outweighs the negative effects deriving from higher national GHG emissions.

Figure 36

Increases in GHG emissions will be necessary for some countries to meet dietary energy and protein needs

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Climate-change costs associated with different dietary patterns

Regional distribution of the social cost of GHG emissions shows that, in the group of lower-middle-income countries, South-eastern Asia and the Western Pacific regions would have the highest social cost of GHG emissions in 2030, amounting to an average of USD 339 billion, while lower-middle-income countries in Europe would have the lowest social cost of GHG emission (USD 75 billion). In line with the regional distribution of emissions estimated, lower-middle-income countries would account for half of the social costs (52 percent), upper-middle-income countries for a fifth (21 percent) and high- and low-income countries for 15 to 12 percent each, respectively.

Figure 37

Adoption of plant-based dietary patterns would reduce the social cost of GHG emissions by 41–74 percent in 2030

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About 75 percent of the social cost of GHG emissions from current food consumption patterns come from meat and dairy products. The largest share is from beef (36 percent), followed by milk (25 percent). Cereals account for 11 percent of the total cost. The adoption of any one of four alternative heathy dietary patterns could potentially lead to significant reductions in social cost of GHG emissions, even by means of the flexitarian diet that includes moderate amounts of animal source foods and small amounts of red meat (Annex 8, Figure A8.4).

Health and climate-change costs: putting them into context

To put the health and climate-change costs into context, it is useful to compare the hidden costs with the wholesale costs of the diets, estimated at the consumption level and valuated based on estimates of commodity prices by region. On the aggregate level, the wholesale costs of diets mirror those assessed at the consumption level, and hidden costs are not included (see Annex 7 for the methodology for estimating the wholesale costs of the diets).

Combining the total cost of diets measured at current wholesale prices and estimates of the hidden health and climate-change costs allows a more complete estimate of the full cost of these diets. These full cost estimates can help inform food policy to incentivize shifts towards healthy diets that include sustainability considerations (see Section 1.3).

Figure 38

The adoption of any of the four alternative healthy diet patterns could potentially lead to 22–29 percent reduction in the full cost of diets on average by 2030

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If the diet-related health and climate-change costs were added to the total wholesale cost of the benchmark diet representing the current consumption pattern, then the full cost of this benchmark diet would increase by 50 percent globally, from USD 6.0 to USD 8.9 trillion by 2030. This increase ranges from 35 percent in lower-middle-income countries to 87 percent in high-income countries.

On the other hand, if the diet-related health and climate-change costs were added to the total wholesale cost of the four alternative diet patterns (FLX, PSC, VEG and VGN), then the full cost of these diets globally would only increase between 8 and 19 percent. Overall, this translates into a significant cost savings, compared with the benchmark diet. Considering the full costs (wholesale cost and diet-related health and climate-change costs), the adoption of any of the four alternative dietary patterns would lead to reductions in the full cost of diets between 22 and 29 percent globally, ranging from 11–21 percent in low-income countries to 52–58 percent in high-income countries (Figure 38).

Recognizing the externalities that result from current food consumption patterns is therefore important. The analysis shows that for every USD 1 spent on food, health and climate change externalities create an additional cost of USD 0.5. Put differently, considering all the costs (monetary and external), the external cost of food makes up one-third of the total cost. However, there is some variation across regions. In sub-Saharan African countries, for instance, for every USD 1 spent on food, health and environmental externalities represent a cost of USD 0.35, or 26 percent of the total cost.

Under the benchmark diet, the highest cost of health and climate change externalities are found in high- and upper-middle-income countries: for USD 1 spent on food, these external costs amount to an additional USD 0.87 and USD 0.79, respectively. This represents 47 and 44 percent of the full cost (wholesale value, plus hidden cost) for high- and upper-middle-income countries, respectively. On the contrary, the cost of health and climate-change externalities are much lower for low-income and lower-middle-income countries, amounting to only USD 0.37 and USD 0.35, respectively.

Of course, the estimated hidden costs or externalities would be much higher than USD 0.5 for every USD 1 spent on food, if data were available to factor in the full range of health impacts of malnutrition in all its forms, including undernutrition, as well as all of the current dietary patterns’ environmental impacts related to land use, energy and water use.

Ignoring the hidden costs of current dietary patterns would result in a serious underestimation of the true cost of achieving food security and nutrition and environmental sustainability. Bringing to light the previously unaccounted for health and climate-change costs can help inform concrete policies that target such externalities, including fiscal policies that incentivize a shift towards healthy diets. As shown above, a shift to healthy diets would bring about significant reductions in both individual health costs and global carbon footprint by 2030, compared with current dietary patterns. However, given that not all healthy diets are sustainable and not all diets designed for sustainability are always healthy for everyone, the nature of this shift needs to be decided carefully, as we explore further below.

Managing trade-offs and exploiting synergies in the transition towards healthy diets that include sustainability considerations

A shift towards healthy diets that also include sustainability considerations is essential, if we are to end hunger and all forms of malnutrition, and ensure the sustainability of agriculture and food production systems – in short, achieve SDG 2. The challenge is huge, as most countries do not meet or are unlikely to meet dietary recommendations for healthy diets by 2030 based on current trends.

This dietary shift will require large transformative changes in food systems at all levels. Given the large diversity of current food systems and wide discrepancies in food security and nutrition status across and within countries, there is no one-size-fits-all solution for countries to shift towards healthy diets and create synergies to reduce their environmental footprints.^44,73,80,84 Raising awareness and influencing policy concerning healthy diets is complicated because of persistently high levels of hunger and undernutrition in many countries, and low levels of understanding about the multiple burdens of malnutrition and how they are interconnected.

As noted previously, to address hunger and malnutrition in all its forms, many countries may need to increase their carbon footprint in order to ensure that certain food items are available to their population, particularly to the most vulnerable groups. This is illustrated well in a country analysis covering Indonesia (Box 15). Most Indonesians’ diets do not meet minimum dietary recommendations, but exceed recommended levels of dietary energy intake due to high consumption of rice, sugar and fats. To increase dietary diversity, some increases in food consumption-related GHG emissions would therefore be necessary. To lower the excess energy intake levels, a substantial reduction in rice consumption would also be needed, even though rice has been at the forefront of the country’s food security policy. This would require major changes in current dietary practices and food production, whose impacts would reverberate across the entire food supply chain, with impacts on domestic and international trade as well. The analysis also shows that affordability of healthy diets is a major barrier for the majority of Indonesians, as the cost of healthy diets is higher than the current average food expenditure in the country. Similar conclusions could be drawn for countries where large parts of the population do not meet minimum dietary recommendations.

BOX 15

Moving from current dietary patterns to healthy diets that include sustainability considerations: balancing goals and trade-offs in Indonesia

Indonesia is an emerging lower-middle-income country that has made enormous gains in poverty reduction and whose prevalence of undernourishment (PoU), currently at around 8 percent, is well below the average for lower-middle-income countries. Nevertheless, the country faces a triple burden of malnutrition: more than one-third of children under 5 years of age are stunted, indicating a large undernutrition problem; a quarter of all adults are overweight or obese; micronutrient deficiencies are widespread.

The current diets are dominated by staple foods, mainly rice, which provides 70 percent of dietary energy needs (see “baseline” diet, Figure A). Energy intake is higher while protein intake is lower than recommended by the Indonesian FBDGs. Low dietary diversity in the country leads to an inadequate intake of essential micronutrients, which affects people’s short- and long-term health and development; moreover, the current intake of nutritious foods is too low to prevent NCDs. Furthermore, the disproportionately high level of energy intake from rice and foods high in fat and sugar increases the prevalence of overweight and obesity, while micronutrient deficiencies persist.

According to a recent analysis^44,126 comparing current consumption with a number of different healthy diets that include sustainability considerations (i.e. diets that help reduce climate-change costs), some increases in food consumption-related GHG emissions would be necessary for Indonesia to achieve global dietary recommendations^{44,127,128,129,130,131,132,133} (Figure B). The results show that current food consumption patterns (“baseline”)¹²⁷ provide 2 607 kcal and 56 g of protein per capita per day. Reducing energy to an amount that is more in line with estimated needs for a healthy diet (i.e. 2 300 kcal/capita/day, and ensuring that 12 percent of energy comes from protein (69 g/capita/day), while maintaining relative contributions of current dietary protein sources) would result in a 15 percent increase in Indonesia’s GHG emissions (“baseline adjusted”, see Figure B).

Dietary patterns in Indonesia, current and modelled

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The recommended reduction in rice consumption is substantial and would require major changes in dietary practices and food production patterns. Compared with current food consumption patterns, the “no red meat”, “pescatarian”, “low food chain” and “vegan” diets have lower GHG emissions (Figure B). But only the latter two have GHG emissions below the target for sustainable food systems.^44,126 In terms of nutrient adequacy, the optimized diet has the best score, but that diet also has the highest GHG emissions.

In summary, Indonesians need to consume more diversified diets in order to meet nutrient needs, prevent undernutrition and its consequences for human capital development, prevent the risks of NCDs later in life, and promote healthy lives in general. The challenge is that a more diversified diet with less rice costs more and has higher GHG emissions than diets consumed today, even when limiting the increase of animal source foods consumption and focusing on non-ruminants and seafood as animal sources of proteins and micronutrients. Two exceptions to this are the low food chain and vegan diets, but these do not meet nutrient needs.

Policies to improve access to and affordability of more diversified, healthy diets that meet nutrient needs while possibly contributing to reductions of GHG emissions would need to focus on reducing the cost of nutritious foods, adding nutritional value and promoting the use of sustainable agricultural practices. This could be done through food production, food value chain optimization, food fortification and creation of healthy food environments. This would also require policies to provide better access to nutritious foods to lower-income consumers through social protection instruments, including school feeding programmes and healthy public procurement policies. More policy recommendations along these lines are presented later.

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Clearly, the process of food systems transformation will not be easy, and therefore countries must carefully assess their own context-specific barriers and manage the potential trade-offs and synergies. For example, where the food system not only provides food, but also drives the rural economy, a shift towards healthy diets could mean the loss of livelihoods or incomes for small farmers and the rural poor as well. In these cases, care must be taken to mitigate the negative impact on incomes and livelihoods as food systems transform to deliver affordable healthy diets. Many lower-income countries whose populations suffer nutrient deficiencies may also need to increase their national GHG emissions in order to first meet nutrition targets. Conversely, in upper-middle-income countries and high-income countries, where diet patterns exceed optimal energy requirements and people consume more animal source foods than required, major changes in dietary practices and system-wide changes in food production patterns will be needed to reduce their environmental impact.

Conclusion

Section 2.1 of this report highlighted that the cost of a healthy diet must fall to an affordable level for all, to enable people to consume a healthy diet. But the matter of cost has another, broader dimension to consider. Section 2.2 has further shown that diets have hidden costs, whose consideration is not only critical for meeting the SDG 2 targets to end hunger and food insecurity and all forms of malnutrition by 2030, but also other SDGs. Specifically, this section has brought to light the health (SDG 3) and climate-related (SDG 13) consequences of our dietary patterns and food systems that support these.

Using different variants of healthy diets as a reference, this section has shown that a shift towards healthy diets can result in savings projected to exceed USD 1.3 trillion per year by 2030 as direct and indirect health costs associated with diet-related non-communicable diseases are avoided. Furthermore, dietary shifts to healthy diets can play an important role in increasing the environmental sustainability of food systems. For example, the diet-related social cost of GHG emissions associated with current dietary patterns is estimated to be more than USD 1.7 trillion per year by 2030, which could be reduced significantly through a shift towards healthy diets.

However, there is no one healthy diet, let alone one that includes sustainability considerations for every context. Furthermore, there could be other technological and productivity advancements that may be more cost effective in addressing sustainability concerns and mitigating climate change. Every country will have to consider the potential trade-offs and synergies arising from the transformations needed in its transition towards healthy diets that include sustainability considerations.

As seen from the full cost analysis in this section, high- and upper-middle-income countries stand to benefit the most from shifts to healthy diets, as in those countries the two hidden costs considered constitute almost half of the full cost of their current food consumption patterns (i.e. 47 to 44 percent of the full cost, respectively). Indeed, looking at per capita emissions under current food consumption patterns, these are projected to be the largest in upper-middle- and high-income countries. Therefore, importantly, the bigger change towards healthy diets that include sustainability considerations will have to happen in upper-income and high-income countries.

On the other hand, an seen from the above regional and country-income distribution of the social cost of GHG emissions, a real difference can be made in lower-middle-income countries given that by 2030 they would account for more than half or 52 percent of the social cost of GHG emissions under current food consumption patterns, because they house the majority of the world’s population. Small changes in these countries can make a significant difference, and the change that they need to make in terms of change of diet is much smaller than the changes needed in upper-middle-income and high-income countries.

The shift towards healthy diets that help mitigate the effects from climate change, no doubt, can also create a virtuous circle. This can happen, for example, by limiting the impacts of diets on the environment through technological and productivity advancements, and through sustainable and integrated land and natural resource use. Enhanced efficiencies and innovations along the food supply chain, including those aimed at reducing food loss and waste and accompanied with concrete policy measures such as fiscal policies are other examples. Moving towards healthy diets through these enhancements will contribute to reducing the cost of producing and consuming nutritious food because, as shall be seen in the next section, it simultaneously addresses some of the factors driving the cost of food. The remaining years of the UN Decade of Action on Nutrition, for which creation of sustainable, resilient food systems for healthy diets is a priority, present an opportunity to accelerate country level action in this area.

As shown in the cost and affordability analysis, even the most conservative cost estimate of a healthy diet is unaffordable for more than 3 billion people in the world. To understand what is driving the high cost of healthy diets relative to people’s incomes, we need to look at their most costly food groups. As was shown previously, the highest-cost food groups in a healthy diet are those that are more nutritious: dairy, fruits, vegetables, protein-rich foods (plant-based and animal source), with some variations by region (Figure 27). Therefore, to increase the affordability of healthy diets, the cost of these nutritious foods must come down.

Recently food markets have been confronted with significant uncertainties that affect the price of foods, ranging from a fast-changing trade environment to the rapid spread of African Swine Fever over several continents, Desert Locust outbreaks in Eastern Africa and Southern Asia, and the devastating impacts of the COVID-19 pandemic on economies and markets of so many countries around the world (Box 16). These major events place upward pressure on food prices, thus affecting the cost and affordability of healthy diets. The full impact of COVID-19 on food prices remains to be seen.

Affordability of diets is determined by the cost of food relative to people’s incomes. The 2019 edition of this report addressed the relationship between food security, nutrition and poverty. It showed that poverty and inequality reduction is critical to improving people’s capacity to access sufficient and nutritious food, pointing to concrete policy recommendations, some of which are revisited in the last section of this part of the report. While the broader issue of how to increase people’s incomes is at the core of economic development,¹⁴⁴ this topic is beyond the scope of this year’s report. On the other hand, increasing affordability through food price reductions is not as widely studied, hence the drivers of the cost of foods, rather than the drivers of people’s incomes, are the focus of this section.

Many factors determine the consumer price of nutritious foods, from the point of production throughout the food supply chain and also within the food environment, where consumers engage with the food system to make decisions about acquiring, preparing and consuming foods. As food systems have become more globalized, industrialized and dominated by large actors capable of economies of scale and of maintaining long supply chains,¹⁴⁵ this has had different effects on food prices and the affordability of various diets across countries. Other drivers, including rising incomes, increasing urbanization and changing consumer demands, have led to food markets becoming outlets for mass-produced and highly processed foods, often energy-dense foods of minimal nutritional value that are high in fats, sugars and/or salt.¹⁴⁵ This has resulted in vegetables, fruits and animal source foods often being too expensive or inaccessible to many households, leading to low nutritional quality diets.

Within the broad context of these global trends, the unique structure and performance of a multitude of food systems (and their supply chains) at national, subnational and municipal (or community) levels imply different cost structures for nutritious foods in different locations. Some of the cost drivers, such as food losses and waste, cut across food systems, whereas others vary by food group or are specific to the country context, such as domestic policies aimed at increasing the availability of staple foods. International trade and related government policies and the aspects of the political economy of food also represent major drivers of the cost of nutritious foods. Finally, climatic shocks (as highlighted in the 2018 edition of this report) and other unexpected shocks, including those caused by infestations and diseases at the regional level (e.g. African Swine Fever or Desert Locust outbreaks) or at the global level (COVID-19) are becoming more frequent and severe, often disrupting the world’s food supply chains.

Hence, food systems today are facing huge challenges in adapting to a multitude of developments. They simultaneously face demands to ensure that healthy diets are affordable not only to a growing urbanized world population but especially also to the majority of the poorest living in rural areas. While production and processing advances have made food more convenient, widely available and affordable for large portions of the world,¹⁴⁶ these same food systems are a dominant driver of the increased availability of energy-dense foods of minimal nutritional value that are high in fats, sugars and/or salt. They are also a driver of health threats like NCDs and many environmental threats, including climate change, biodiversity loss, and degradation of land, soil and freshwater.

This section focuses on four main sets of drivers determining the cost of food. The following drivers are specifically covered:

1. Cost drivers that relate to the production of diverse nutritious foods that contribute to healthy diets (insufficient diversification and low productivity; low levels of technology; pre-harvest and post-harvest losses; seasonality and other climate risk factors; insufficient investment in R&D, limited access to knowledge and information).

2. Cost drivers that relate to the food supply chain beyond food production (inadequate food storage, handling and preservation, especially of perishable foods; food losses beyond pre-harvest and post-harvest losses; poor road networks and limited transport capacity).

3. Cost drivers that relate to the food environment as well as consumer demand and behaviour (population growth, urbanization, access to markets; food preferences and culture; consumer knowledge and behaviour).

4. Cost drivers that relate to the political economy of food (including the unique impact of food and agricultural policies on the cost of nutritious foods; trade measures and government policies that favour energy-dense foods of minimal nutritional value over nutritious foods; public expenditure; unfavourable trade mechanisms and the impact of food and agriculture industry lobbying on the cost of nutritious foods).

Cost drivers in the production of diverse nutritious foods

Low levels of technology, innovation and investment in food production

Addressing low productivity in food production can be an effective way of raising the overall supply of food including nutritious foods, reducing food prices and raising incomes, especially for the poorer family farmers and smallholder food producers in low-income and lower-middle-income countries, like farmers, pastoralists and fisherfolk. Sustained productivity growth in food and agriculture, without depleting natural resources, depends on food producers having the capacities to innovate (enabling them to raise yields), manage inputs more efficiently, adopt new crops or breeds and improve quality, while also conserving natural resources.¹⁴⁷

Productivity growth at every stage of the food supply chain requires technological and institutional innovations, which allow food production, handling and processing to remain profitable at a lower per-unit cost for consumers,¹⁰³ while at the same time being sustainable. In recent decades, the expansion of agricultural areas has played only a marginal role in increasing production. Hence, technological innovation in many forms (e.g. mechanization, increased access to irrigation, plant and animal breeding, improved management practices, along with increased access to global and locally specific information) is urgently needed for substantial and sustained growth in yields and productivity in most of the world, especially in sub-Saharan Africa. Furthermore, reducing pre-harvest and post-harvest losses at the production level should be an integral part of efforts to increase productivity.

In addition to low productivity, insufficient diversification towards the production of horticultural products, legumes, small-scale fisheries, aquaculture, livestock and other nutritious food products also limits the supply of diverse and nutritious foods in markets, resulting in higher food prices. Diversified and well-integrated production systems not only increase the availability of nutritious foods, but also help vulnerable populations to increase their resilience to climate and price shocks and reduce seasonal variation in food production.¹⁴⁸ It is also critical to increase the variety of foods produced and move into higher-value products, such as from staple foods to also producing fruits and vegetables and exportable food products.¹⁴⁹

Further efforts to improve diet quality, especially for the growing populations in low-income countries, may require increased consumption of animal source foods (ASFs), including dairy products, as well as fisheries and aquaculture products, to meet protein intake requirements for those populations. Increasing livestock production can lead to lower prices of livestock products and, therefore, increased access to such products by the poor, especially poor urban consumers.¹⁵³ However, the perishable nature of ASFs, especially of fresh milk, fish and eggs, could also lead to supply constraints and consequently higher prices. Even given the option of low-cost imports, these only offer limited scope to bring down prices.⁷

Indeed, high prices are already seen in many countries due to poor productivity in the dairy and poultry sectors. Dairy production, for its part, has some specific constraints: for example, it is poorly suited to tropical climates. In many parts of Africa, keeping dairy animals is severely constrained by tsetse flies. The high price of eggs in many parts of the world is paradoxical, given that poultry are the most widely owned livestock in low-income countries. Unfortunately, homestead poultry production is often hindered by diseases like Newcastle’s and lack of inputs. Countries like India that have achieved larger-scale commercial production with the use of improved breeds, feed, housing and vaccinations have seen marked declines in the prices of eggs and poultry products, even in the face of rising demand.⁷

In South-eastern Asia, innovative “climate-smart” agricultural techniques consisting of low-cost and environmentally friendly farming practices have led to higher incomes for poor households, especially in rural and remote areas, while also increasing the diversity of food items available on local markets. For example, in Lao People’s Democratic Republic, “rice-fish farming” practices combining aquatic products and rice as the main staple have increased household incomes through diversification and more efficient use of inputs.¹⁵⁴ Aquatic animals and plants raised in rice fields have increased dietary diversity in food consumption and represent important and affordable sources of protein and micronutrients to the population.¹⁵⁵

A large body of evidence confirms that there are high returns to public investments in agricultural R&D. When agricultural technologies and new practices are introduced simultaneously, they can significantly raise productivity and reduce food prices in low-income countries. For staple foods, such combined efforts could reduce food prices by up to 49 percent for maize, 43 percent for rice and 45 percent for wheat.¹⁵⁶ A wide range of technologies, including no-till farming, heat-tolerant crops, artificial insemination in livestock and DNA-based approaches to identify and monitor disease-causing agents, can benefit smallholders in low-income countries.^157,158

In spite of the high potential for technological advances, in many low- and middle-income countries, investment in agricultural sector R&D is currently insufficient.¹⁵⁹ For example, in a sample of 70 LMICs, the average number of public sector researchers per million in the country’s population is 4–5 in cereal research, with only 1 researcher each in the cultivation of fruits and vegetables.¹⁶⁰ The focus on staples is a reason for continued high prices, in particular for more perishable food commodities like fruits and vegetables and livestock and fisheries products.

In Ethiopia, rapid economic progress over the past two decades went hand-in-hand with substantial increases in agricultural productivity, spurred by government policies and investment. However, this involved much higher levels of investment towards increased productivity of starchy staples, eventually resulting in a reduction of staple food prices with relatively higher prices for nutritious foods (see Box 17).

However, increasing productivity may not accrue gains on its own. Without access to markets to absorb excess local supply, there is little incentive to increase production as this will only lead to lowering farm-gate prices.¹⁶¹ These lower prices in turn act as a disincentive to increased food production and technological innovation in the sector,¹⁶¹ ultimately leading to higher food prices.

Managing risks in food and agricultural production

Engaging in the food and agriculture sector can be an intrinsically risky endeavour, be it in crop or livestock production, fisheries and aquaculture or forestry. This is particularly the case for poorer family farmers and smallholder producers on marginal lands or those with limited access to technology, capital or other productive resources. In crop production, traditional staple foods generally carry a lower risk compared with the production of higher value and more nutritious foods. For many low-income smallholders, it might be a rational choice to stick with low-productivity, low-risk technological options – but the consequence is that poor households may never produce enough to enable them to provide sufficient diverse nutritious food for their families. This is in stark contrast to the food and agriculture sectors in high-income countries, where producers can purchase insurance to protect their incomes.

Managing risk is an important aspect of food production in all food and agriculture sectors, one that greatly influences what a producer decides to grow, raise or capture. This indirectly affects prices, and thus the cost of diets and how affordable they may or may not be for the consumer. Vegetable production is often identified as a profitable but more risky option for smallholders. The risk factors include: higher levels of capital outlay, like irrigation equipment; potential for harvest losses due to extreme weather conditions; the highly perishable nature of vegetables; changing levels of consumer demand; and volatile producer prices. Other sectors, such as livestock rearing, fisheries or aquaculture also call for substantial levels of capital investment and hence require a good understanding of risk factors before engaging in production.

In Ethiopia, a qualitative study on the smallholder perceptions about the risks of producing vegetables found that the major risks observed by farmers are market price fluctuations, followed by drought and pests.¹⁶⁵ In Malawi and Mozambique, traditional vegetable value chains are exposed to risks not only at the production level, but also in the other stages of the value chain due to poor infrastructure and lack of processing or packaging facilities.¹⁶⁶

In the absence of access to knowledge, information and credit, all of the above are risks that influence food producers’ decisions on whether to invest in crop production, livestock or aquaculture, which ultimately influences the overall availability of nutritious foods and their prices. Many producers will continue growing what they know best, largely staple foods, rather than venture into more risk-prone products or other commodities of higher nutritional content.¹⁶⁷

Those smallholders who have successfully engaged in vegetable production have had several factors in common: access to markets, enhanced access to credit, irrigation infrastructure, technology and knowledge.¹⁶⁸ For many, contract farming is an instrument that can provide certainty in expected returns on production. In India, for instance, contract farming in onions has led to increased yields and overall production levels.¹⁶⁹

Seasonality and climate factors

Prices for most food and agricultural products exhibit significant seasonality, typically peaking just before the harvest, when food supplies are scarce, and dropping thereafter. The seasonality of prices of fruits and vegetables is typically more extreme, with different peaks according to the timing of the harvest. Even as people substitute between foods according to price fluctuations, the lowest possible expenditure needed to meet all nutrient intake requirements still varies significantly due to seasonality, while the cost of calories (largely derived from less perishable staple foods) usually fluctuates less¹⁷⁰ (see Box 18).

When food prices show high seasonality, this may have particular consequences for dietary intake and nutritional outcomes and may also cause even further food price volatility,¹⁷¹ further challenging food security and nutrition. A study of 13 commodities across 193 markets in seven countries pointed to high levels of food price seasonality in African food markets, as measured by the “seasonal gap”. The seasonal gap, defined as the difference between the high price immediately prior to the harvest and the low price following the harvest averaged across years, was highest for fruits and vegetables and lowest for commodities produced throughout the year, such as eggs (Table 10). In some countries, food price seasonality was quite high even for staples such as maize.¹⁷¹

TABLE 10

Fruits and vegetables show the highest levels of food price seasonality in seven selected countries in Africa (2000–2012)

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Climate change is expected to further aggravate seasonality through increased drought frequency, disruption of food production by floods and tropical storms, increasing and more variable temperatures, and more erratic rainfall. Small Island Developing States (SIDS) in particular suffer from these effects of climate change, including as the result of cyclones and hurricanes, rising sea levels and eroding coastlines. These changes exacerbate their already fragile natural environments making it more difficult to produce sufficient food at reasonable cost to meet their dietary needs.¹⁷⁵

Climate change will lead to a general decline in agricultural production over the next two to three decades, turning into a major cost driver of food in the near future. Overall degradation of soil quality and agro-ecosystem conditions is furthermore leading to a general decrease in agricultural production.^176,177 In sub-Saharan Africa, it has been predicted that as climate change affects food production, particularly through average temperature and changing rainfall patterns, the average consumer price of maize and other coarse grains could rise by 150–200 percent over a 20-year period (2010–2030) with the highest price rises to be seen in Southern Africa.¹⁷⁸ Elsewhere, a climate impact study conducted on the five largest countries in Southern Asia suggests that there is likely to be a significant negative impact on food production and agricultural productivity, while food prices are expected to rise. This has important implications for food security and nutrition.¹⁷⁹ Similarly, a long-term study in Malaysia (1980–2017) shows a negative effect of climate change on fruit and vegetable production¹⁸⁰ that might prompt shifts in eating patterns towards even lower fruit and vegetable intakes and increased consumption of highly processed food and beverages that are high in saturated fats, trans fats, sugars and/or salt.¹⁴⁵

Current food consumption patterns and the food systems that support them are both major drivers of negative environmental impacts and climate change, creating a vicious circle. As shown in Section 2.2, these patterns and systems have major ramifications for the state of the environment and climate change. Current food demand patterns create significant hidden social costs in terms of GHG emissions and climate change, estimated to reach USD 1.7 trillion per year by 2030 (Figure 37). However, there is also strong evidence of global climate change leading to increasing climate variability and extremes and unpredictable seasonality, as highlighted in the in-depth climate analysis presented in the 2018 edition of this report. Climate variability and extremes and unpredictable seasonality are exacerbated because these hidden environmental and climate-change costs are left unaddressed. This, in turn, negatively impacts productivity in the food and agricultural sectors, ultimately increasing the cost of nutritious foods and healthy diets.

Cost drivers along the food supply chain

In addition to the challenges of diversifying food production and increasing the productivity of nutritious foods, there are a host of bottlenecks along the food supply chain that must be addressed to deliver a variety of nutritious and safe foods at a lower cost to consumers.

Food losses and waste

Reducing pre-harvest and post-harvest losses in quantity and quality at the production level in the agriculture, fisheries and forestry sectors is an important starting point to reduce the cost of nutritious foods along the food supply chain. This is because losses decrease the overall availability of these foods, while also possibly undermining environmental sustainability. In lower-income countries, where food insecurity is often severe, increasing access to a greater amount and variety of foods is critical.

The effect of a reduction of food losses on access to food will be different for each actor of the food supply chain, depending on the overall price effect. For example, a fall in prices can improve consumers’ access to food, but if not proportionally supported by productivity gains at the production level, it may diminish the food security status of commercial farming households, as they will then receive lower prices for their products.¹⁸¹ This highlights the importance of combining pre-harvest and post-harvest loss reduction at the production level with other investments for productivity gains (as outlined above) as part of comprehensive efforts to increase productivity. Such combined efforts can contribute not only to lower consumer prices, but also to increased profit margins for food producers.

Recent estimates show that around 14 percent of the world’s food is lost during the post-harvest production stage and before reaching the retail level. Global revised estimates of percentages of food wasted every year occurring at the retail and consumer levels, are being compiled by UN Environment Programme.¹⁸¹

All along the supply chain, from production to wholesale and retail, food losses and waste are generally highest for more perishable nutritious foods, including fruits, vegetables and animal products. A recent analysis finds that the losses and waste are higher for fruits and vegetables than for cereals and pulses at all stages in the food supply chain, with the exception of on-farm losses and those incurred during transportation in Eastern and South-eastern Asia.¹⁸¹ For example, looking at only one supply chain stage, fruit and vegetable loss and waste at the retail level are as high as 35 percent in sub-Saharan Africa.

Important causes of losses at the production level include exposure to adverse weather conditions, harvest and handling practices, as well as marketing challenges. Inadequate storage conditions and decisions made at earlier stages of the supply chain (e.g. lack of proper plant health management, inadequate crating or packing of foods) lead to products with a shorter shelf life. Adequate cold storage, in particular, can be crucial to prevent quantitative and qualitative losses of perishable foods. Moreover, during transportation, good physical infrastructure and efficient trade logistics of key importance to prevent food losses.

Generally, reducing food loss and waste entails certain costs. Producers and consumers will only undertake the necessary efforts if the benefits outweigh these costs. For producers, the benefits of reducing food losses by investing in technology or improved practices may be too small in relation to the investment cost. For consumers, the value of their time may be too high to justify efforts to curb waste, such as planning food purchases, meal preparation and managing food stocks.¹⁸¹ Again, the impact of reduction in food loss and waste depends on how their effect on prices is transmitted throughout the food supply chain; some actors may benefit, others may lose out. Public policy needs to create the right incentives for producers to cut food losses and for consumers to reduce food waste in order to maximize social benefits and reduce the cost of nutritious foods.

Technology and infrastructure

Fruits and vegetables and animal source foods are highly perishable, especially fish, fresh milk, meat and eggs. Lack of adequate market infrastructure and limited processing technology can result in food losses and higher food prices, especially for highly perishable foods like milk. As stated above, improved technology and infrastructure in handling, storage and processing (cool storage systems, cold chains, drying techniques, improved packaging) offers opportunities to reduce losses and lower consumer food prices. Certain processing techniques can increase the nutrient content of food and raise the bioavailability of nutrients, including through fermentation, germination and roasting.^182,248

Some of these preservation techniques rely on low levels of technology (e.g. open air or solar drying, or smoking of fish); however, a stable supply of electricity becomes important for cold storage of perishable commodities requiring refrigeration. In sub-Saharan Africa, refrigeration facilities remain inaccessible to most smallholders. In the United Republic of Tanzania, it has been estimated that 25 percent of milk deteriorates because lack of refrigeration facilities; 97 percent of red meat sold in the country has been never been refrigerated.¹⁸³ Highly perishable foods require storage facilities with controlled temperature and humidity conditions. In the absence of these facilities, many producers have little option but to sell their produce immediately regardless of the market price, or face the risk of heavy losses.¹⁸³ Hence, the lack of adequate storage facilities negatively affects smallholders’ incomes, and the availability and cost of fresh foods produced locally.

Another important component of market infrastructure is the overall quality and efficiency of the national road and transportation network, which is critical in getting produce from the farm gate to markets at reasonable cost. Investment in all-weather rural roads is particularly important. This reduces the time it takes to reach rural and urban markets, thus helping to reduce pre-harvest and post-harvest losses, including of perishable fruits and vegetables. In many countries, transport costs are a barrier to increasing the affordability of healthy diets, particularly for lower-income consumers (Box 19). Therefore, investing in road infrastructure would have significant returns in getting nutritious food to the market at lower costs.

BOX 19

Public investments in road networks of selected African countries increase affordability of nutrient adequate diets

Public investments in the road networks of 14 African countries could help raise the affordability of nutrient adequate diets,* especially for the poorest, by means of reducing transport costs by up to USD 50 per household on an annual basis. A simulation of the impact of improvements in road infrastructure on price reductions of key food commodities helped derive increased levels of affordability for country-specific nutrient adequate diets.**

The estimation of the potential cost savings for such a diet, as shown in the figure below, is built on two assumptions. First, an improvement of the road network will decrease average transport costs for a given food commodity relative to the transport cost for the same product in South Africa, the country considered to have the most efficient transportation network in the region.*** Second, the cost reduction is transmitted to the final retail price of the food commodity analysed.

Results. If transportation were more efficient as a result of a better road network, potential savings would amount to USD 7 per capita per year, on average, across the countries analysed. Assuming an average household size of five members¹⁸⁷ in the analysed countries, these savings could amount to USD 35 per household on an annual basis. Given that the composition and cost structure of a nutrient diet is different in each country, the savings effect of the reduced transport costs differ by country. For example, in Burkina Faso, savings per household could be as much as USD 55 per year. In Burkina Faso, Burundi and Mozambique, per capita savings in the diet are close to 1 percent of the annual per capita GDP. In Malawi, Rwanda and Senegal, the effect is less pronounced, with a nutrient adequate diet costing just USD 25 less per household on an annual basis. Given that lower transportation costs could change the relative price of different products, they could also lead to gradual changes in the composition of the diet. For example, in Benin, consumers could start to consume more potatoes as these become more affordable compared with maize.

These results highlight the importance of public investments in infrastructure in support of raising the affordability of a nutrient adequate diet. Different from trade policies, which often generate opposing incentives to producers and consumers, as further explained below (see Box 24 on trade policy in Central America), policies and investments in support of the provision of public goods, like roads, railroads and transport services, may have a positive effect for all actors along the food supply chain.

In Africa public investments to improve road networks can lead to significant annual reductions in the cost of a nutrient adequate diet (2014–2017)

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Overall, small- and medium-sized producers have seen their capacity to engage with markets increase, both at the local and international levels. This trend has been essentially driven by their improved access to local infrastructure (e.g. power grid, roads) and to local supermarkets,¹⁸⁴ along with their proximity to marketplaces in growing urban centres. However, this benefit is often offset by the difficulties that smaller producers face in complying with increasingly standardized procurement processes that accompany trends in systematic “super-marketization” and internationalization of markets.¹⁸⁵ Moreover, poor road networks continue to constrain the existence of well-functioning markets.

As for the food processing industry, there is concern that food policies and the private sector have promoted “inexpensive calories and expensive nutrients”,¹⁸⁶ leading to increased prevalence of overweight and micronutrient deficiencies. This is of particular concern in high-income countries and rapidly growing low- and middle-income countries, where the agricultural sector has become or is rapidly becoming a supplier of raw materials for the food processing industry, rather than a provider of food for direct human consumption.¹⁸⁶ These developments have underscored the need for policy interventions that promote nutrition-sensitive food systems from the production level throughout the food value chain, as discussed in the next section.

The food environment and consumer demand as a cost driver

The food environment is the “physical, economic, political and socio-cultural context in which consumers engage with the food system to make their decisions about acquiring, preparing and consuming food”.³⁵ It is the marketplace where food prices are determined based on supply and demand, where food marketing shapes food preferences, and where consumers form their understanding and expectations of food safety and quality (e.g. through nutrition labelling). Consumer decisions are also important in regard to how much of their household budget is spent on food and on what food items in particular.

Consumption decisions, on the one hand, are based on relative prices and consumer income (or cost and affordability) and consumer preferences. This part of the report focuses on cost and affordability, but, as shall be seen in Section 2.4, the effectiveness of policies to reduce the cost of nutritious food and increase the affordability of healthy diets will also depend on measures shaping of the food environment and other policies that help shift consumer preferences towards healthy diets.

The distance to food marketplaces and the time required to prepare a healthy meal are among the key barriers that prevent many consumers from having access to, and hence deciding to pay a higher cost for healthy diets. These barriers can be seen as cost drivers because people who try to overcome them would have to accept an additional cost on top of the cost of food itself. The concept of “opportunity cost”, which put simply means the loss of other alternatives when one alternative is chosen, can be applied in this context as explained as follows.

Access to markets

In many parts of the world, in both urban and rural areas, physical access by consumers to food markets, especially to fresh fruit and vegetable markets, represents a formidable challenge to eating a healthy diet. This is particularly true among poorer country income groups, who may not be able to access these markets, because of the distance and high transport costs involved. For these country income groups, the opportunity cost of eating healthy is too high, because of the time and the transport cost that they would have to incur, and they end up eating unhealthy food that is available closer to home at a much lower cost.

In such instances, homestead food production can be a good source of fresh foods, add diversity to the diet and lower the cost of a nutrient adequate diet. For example, the Philippines national nutrition survey found that more than half of the green, leafy and yellow vegetables and more than one-quarter of other vegetables consumed were produced by the households consuming them.¹⁸⁸ A simulation of different levels of homestead food production, sales and consumption of vegetables showed that, at optimal levels of sales and own consumption, the proportion of rural households that otherwise would not be able to afford a nutrient adequate diet could decrease from 37 percent to none.¹⁸⁹

Poor road networks or long distances between production and consumption areas are also barriers to domestic trade that prevent well-functioning markets from existing. These constraints often translate into wide-ranging degrees of accessibility to food commodities, and price differences within countries, as seen in countries like the United Republic of Tanzania (Box 20).

In Kenya, as elsewhere, fluctuations in consumer prices of fruits, vegetables and staples are mainly determined by harvest performance, production cycles and transportation costs from the farm gate to the food markets. In Kenya’s vast Arid Lands, food must be transported over large distances, and this becomes more difficult during the rainy seasons when roads deteriorate. Apart from seasonal volatility, food prices increase by about 1.3 percent for every additional hour of delivery time from the market hubs in central parts of the country to the more distant district headquarters, and by 1.8 percent for each hour between the district headquarters and remote markets off the regular transport corridors.¹⁹⁰ These price increases are ultimately passed on to the consumer.

Urban settings and food prices

Population growth, increases in income and urbanization are fundamental drivers of the rising demand for food and changes in people’s diets with effects on food prices. The urban population, in particular, will continue to rapidly rise, with most of the increase seen in small- and medium-sized cities in Africa and Asia. Notably, by 2030, it is expected that the youth (under the age of 18) will make up 60 percent of urban populations,¹⁹⁷ which presents both challenges (e.g. in terms of high youth unemployment in urban areas) and opportunities (e.g. youth engaging in urban agriculture) in regard to providing sufficient access to nutritious foods to rapidly growing urban populations.

A large portion of the world’s urban population lives in informal settlements on the urban periphery, ranging from 20 percent in Latin America to 55 percent in sub-Saharan Africa, and as much as 65 percent for all low-income countries.¹⁹⁸ In low- and middle-income countries in particular, easy access to traditional produce markets remains key to lowering the cost of nutritious foods and providing a wider variety of choices for these foods than in more modern supermarkets. Conversely, in a growing number of megacities worldwide, urban food prices have risen, as it has become more and more difficult and time-consuming to transport fresh produce to market.

The rapid growth of supermarkets in urban settings presents challenges and opportunities for providing access to affordable healthy diets. Supermarkets’ modern and efficient food supply model offers significant opportunities to distribute fresh fruits and vegetables, and animal source and fortified foods widely, to stabilize food prices and to ensure food safety. On the other hand, supermarkets also offer a wide variety of non-perishable energy-dense foods of minimal nutritional value, often high in unhealthy fats, sugars and/or salt, at lower prices than nutritious foods. While governments could put in place measures to stimulate adequate availability of affordable nutritious foods in supermarkets, in large part the development of supermarket chains is stimulated by technological change and consumer demand, which are beyond the control of governments.¹⁹⁹

A promising solution can be seen in the area of urban and peri-urban agriculture, which has gained in prominence as a means for urban dwellers to access fresh and nutritious food items, including fruits and vegetables at reasonable cost, either through own production or through short value chains. For urban farmers, the proximity to markets allows them to reduce pre-harvest and post-harvest losses in vegetables by as much as 30 percent. Twelve case studies across different cities and countries have documented that 80 to 100 percent of the supply of leafy vegetables in these cities is produced through urban agriculture.²⁰⁰ In Ghana, for instance, almost all of the supply of fresh milk, spring onions and lettuce in the city of Kumasi is produced through urban agriculture, while most of poultry, eggs and tomatoes come from peri-urban areas of the city.²⁰¹

Consumer demand as a cost driver

The rapid rate of urbanization, combined with changing lifestyles and increasing involvement of women in economic activities, is leading to structural changes in consumer behaviour and food culture. As such consumer demand is also an important cost driver to consider. These changes are making it more difficult, especially for women with jobs, to be able to afford the time that it takes to prepare a healthy meal, and prior to that, to buy the needed nutritious ingredients. The opportunity cost of eating healthy in the face of these changes is too high, because of the availability of cheap energy-dense fast foods of minimal nutritional value and easy-to-prepare, highly processed foods, already half cooked to reduce the time spent on preparation.¹⁵²

A study for high-income countries suggests that lack of time was the leading barrier to adopting dietary guidance. As cited by adults and in analyses of United States consumer expenditure data, spending at quick-service outlets was strongly and positively associated with hours spent in paid employment. Likewise, low- and middle-income working parents in Europe cope with time pressures by relying more on take-outs and restaurant meals and basing family meals on prepared entrees and other quick options.²⁰²

Time constraints include shopping for food, preparing it and cleaning up afterwards – all time burdens that often fall disproportionately on women. Fruits and vegetables, for example, tend to have shorter shelf lives and require frequent purchases, and need more time for preparation; beans also take a long time to cook. None of these time constraints are trivial. It has been estimated that the labour costs of a healthy diet for a single-headed household recipient of the Supplemental Nutrition Assistance Program (SNAP, formerly the Food Stamp Program) in the United States of America would represent 60 percent of the total cost of food (defined as the sum of the cost of food items and preparation time). Time constraints help explain why even those who can afford a healthy diet spend their income on less healthy but more convenient alternatives.²⁰²

Another structural change in food culture and demand relates to the increase in incomes in low- and middle-income countries. This rise in income leads to a well-documented change in diet composition, including a growing demand for animal source foods in the middle-income classes of those countries in both urban and rural areas.^3,86,203,204 In addition, it is generally accepted that today’s consumers increasingly care about the safety and quality of the food they eat, how their food is produced, and the impact that food production and consumption have on the environment and on society.²⁰⁵ The latter concern is particularly relevant to higher-income consumers. As a result, there is an increased demand by these consumers for “ecological” products that include information about the products’ origins, including the harvest methods used in their production. This is seen in high-income countries, where consumer demand has led to increased production and certification of these ecological products, which has significantly reduced their prices. For example, the organic premium for products like coffee or spinach has shrunk significantly in the past decade. In 2004, organic spinach cost 60 percent more than conventional products; today this differential has been reduced to 7 percent.²⁰⁶

Even with adequate access to various points of purchase, including fresh markets, neighbourhood stores and supermarkets, several factors influence consumer choices from the large variety of foods offered. These include different types of promotion, including price promotions, product packaging and claims, as well as product positioning in stores, all of which are linked to the cost of food items promoted. In addition, there are still other measures that affect the cost of nutritious foods and the cost of energy-dense foods of minimal nutritional value differently, as described next.

The political economy as a cost driver

Food and agricultural policies – as well as other policies, including in the health and environmental realms – have the power, either directly or indirectly, to affect the cost of food. They are not exclusively based on technical considerations. Rather, they are the outcome of a complex decision-making process that can be influenced by a variety of objectives and interests. In particular, the food and agriculture policy framework, which is the focus of this subsection, encapsulates the difficult balancing act required when choosing between actions in agriculture versus other sectors; among different government objectives and fiscal policies; between benefits for producers, consumers and intermediaries; and even between different agricultural subsectors. Generally, policymakers seek to achieve this balance through a set of policies that either provide incentives to agriculture through subsidies or penalizes the sector or some of its actors in one form or another. In doing so, government policy decisions impact directly or indirectly the cost of nutritious foods of different population groups.

TABLE 11

Agricultural production in low-income countries is penalized, while in middle- and high-income countries it is supported (2005–2016)

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This means that in low-income countries, agricultural policy depresses prices at the farm gate level, which, in principle, would favour consumers if it were not for the fact that lower prices effectively discourage agricultural production. Lower levels of production lead to higher consumer prices. In middle- and high-income countries, on the other hand, government policy tends to favour agricultural producers.

When the agricultural sector is penalized (or taxed indirectly) by prevailing government policies, as in the case of low-income countries, the resulting decline in prices negatively impacts the affordability of healthy diets also in rural areas. First, the depressed food prices reduce the income of smallholders, thus compromising their ability to afford nutritious foods. Second, the decline in prices discourages farming activities, which negatively affects consumers, as rural populations are increasingly reliant on local food markets for access to nutritious food. There are further negative effects of indirect taxation of agricultural production as well, including reduced demand for farm labour and reduced wages for unskilled workers in both farm and non-farm jobs. Thus, even though poor households stand to benefit from government policies, if indirect taxation contributes to reduced food prices, suppliers of unskilled labour in rural areas will lose earnings.²⁰⁷ Hence, the net effect on the affordability of healthy diets depends on the relative importance of the agricultural sector. In low-income countries, where the agricultural sector accounts for the majority of employment, it is reasonable to assume that the net impact of agricultural taxation on the affordability of nutritious foods is negative.²⁰⁸

The above is one example of the delicate balancing act between producer and consumer interests. On the one hand, higher food prices serve as incentives for farmers, traders and processors to produce. On the other hand, food prices are also a major determinant of the real incomes of poor producers, who devote a large proportion of their revenues on food purchases.

Impact of trade policies on the cost of food

Trade is a central element to global food security. Agricultural trade has increased substantially over the past decade, resulting in almost 20 percent of all dietary energy supply worldwide being derived from imported food.²⁰⁹ Much of this expansion in food trade and consumption of food imports is driven by low- and middle-income countries. A large proportion of exports are provided by a small number of net-exporting emerging economies. Five countries (China, Democratic People’s Republic of Korea, Japan, Russian Federation and Saudi Arabia) are responsible for about 40 percent of all global food imports. Seven countries (Argentina, Australia, Brazil, Canada, New Zealand, Thailand and the United States of America) account for about 55 percent of total food exports. As a result, the impact of these main players on the international market stability and prices is large.²⁰⁹

Trade policy commonly refers to border policies as well as domestic support measures that affect trade flows. The discussion below focuses on the impact of the former, which include measures that directly affect imports, such as tariffs and non-tariff measures (NTMs), and exports, including export taxes or restrictions. Observers point out that challenges related to escalating food prices may be partly due to trade policies.²¹⁰ In 2015, members of the World Trade Organization (WTO) agreed to eliminate agricultural export subsidies with the objective of creating a fair trade environment for food producers around the world, particularly for those in low- and middle-income countries, who could not compete against their counterparts in high-income countries that artificially boosted exports through subsidies.²¹¹ Nevertheless, some governments continued to put in place export bans and controls, often on ad-hoc basis, in order to reduce and stabilize domestic prices of staple foods. However, such restrictions have often proven to be ineffective in reducing domestic food prices, and tend to increase price instability.^212,213,214 In addition, when trade policies are used to shield the domestic market from unfavourable developments in the world market, these policies have a multiplier effect. Specifically, high food prices may trigger a series of export restrictions that exacerbate the rise of the world food price that, in turn, feeds into even more restrictive policies. Similarly, low food prices may lead exporting governments to set export promotion measures that in turn lower the world price and lead to further promotion measures.²¹⁵ Since the adoption of the “Nairobi Package” by the WTO in 2015, such subsidies are no longer allowed under WTO rules.

Regarding food imports, trade policies affect the cost and affordability of different food items by altering the relative prices between imported and import-competing foods. Trade policies that discourage imports are among the most used policy instruments to protect domestic producers and food processing industries. Generally, tariff barriers remain higher for agricultural products than any other product group, increasing the cost of food in countries applying those restrictions, and leading to a misallocation of resources that reduces global welfare. Worldwide, governments support the production of sugar, rice and animal products the most through interventions, while penalizing the production of more nutrient-rich fruits and vegetables, such as tomatoes and bananas, the most (Table 12).

TABLE 12

Worldwide, governments support the production of sugar, rice and animal products the most through interventions, while penalizing the production of more nutrient-rich fruits and vegetables (2005–2016)

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Besides tariff barriers, governments also implement non-tariff measures, such as sanitary and phyto-sanitary measures (SPS) and technical barriers to trade (TBT). As trade liberalization has progressed over the past decades, the number of regulatory policies pertaining to product quality, health and safety standards has increased. Animal products and vegetables are the product groups most subjected to non-tariff measures, with over 16 000 measures registered in the WTO database for these products alone.²¹⁶ NTMs can negatively affect the affordability of diets. For example, exporters and importers may face additional costs to comply with regulatory requirements, driving up the cost of trade. This in turn would increase food prices and make diets less affordable. On the other hand, NTMs can play an important role in raising food safety and quality levels, and improve the nutritional content of diets. Tariffs and non-tariff measures are a source of concern for food exporting countries that face an uncertain market outlook, which weakens government incentives to prioritize agricultural production as a major source of economic growth and development. A direct consequence of this is the low levels of agricultural investments in infrastructure and innovation.²⁰⁹

Figure 39

Protectionary trade policies protect and incentivize domestic production of staple foods, such as rice, but often to the detriment of nutritious foods in low-income countries

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As mentioned, trade policy often involves significant trade-offs. For example, across many countries in Latin America and the Caribbean, poultry meat imports are subject to import tariffs, shielding domestic poultry producers from cheaper imports from Brazil and the United States of America. Although these policies have been effective in eliminating imports, they have also driven up the local retail price of chicken, making one of the main sources of animal protein less affordable for consumers.²¹⁷

The case of rice within the Eastern Africa Community (EAC) demonstrates a similar dilemma. In Burundi, Kenya, Rwanda and Uganda, the EAC imposes a Common External Tariff on sensitive products, including rice, of up to 75 percent. Although this protects the EAC’s rice farmers and processors from cheaper imports, evidence indicates that this support leaves consumers paying more for rice in the retail market.²¹⁷

Other domestic support measures affecting food prices

Beyond the trade and market policies discussed above, there are other measures that national governments may put in place that influence food prices, which represent trade-offs between supporting agricultural producers and consumers. Managed price policies have been adopted by countries throughout the world. High-income countries, including United States of America and those in the European Union, maintained price measures to support their farmers for several decades during the post-war period, even though recently they have largely replaced them with direct payments decoupled from prices and production.²¹⁸ In middle- and low-income countries, governments still revert to some of these measures to either protect consumers from high food prices or incentivize domestic agricultural production and prevent profit losses. In the former, interventions usually take the form of food price controls, reduction of consumption taxes, interventions to limit monopoly or oligopoly positions and release of food stocks. In the latter, policymakers stimulate production through price-setting mechanisms that fix minimum and reference prices, or commodity board procurement at supported prices.²¹⁹

No matter what the policy objectives are, there will be winners and losers in the population from each of these interventions, and the affordability of healthy diets will be affected as well. For instance, preventing food price increases through price controls may make healthy diets more affordable for the most vulnerable citizens. Nevertheless, the same intervention can reduce incentives for farmers to produce nutritious foods, as retail prices are controlled, subsequently reducing the overall availability of nutritious foods in the country.

Public expenditure and investments

Public expenditure and investments also affect the cost of food. Public expenditure is a powerful instrument by which governments can shape and develop their food systems.^220,221,222 Public spending can be used as an equity tool in reallocating resources in favour of the poorest family farmers and smallholder producers or to address market failures or overcome the under provision of public goods in the food and agriculture sectors.²²²

There is widespread consensus regarding the importance of public spending. It is important to ensure that scarce resources are invested in those areas where returns are higher. Certain types of expenditure that are proven to have high returns, such as agricultural R&D and extension, tend to be sorely underfunded.²²³ Conversely, while subsidies can have positive effects in enhancing productivity, their long-term returns have been estimated to be lower than those of public goods.

According to the public expenditure data²²⁴ in selected sub-Saharan African countries, limited resources available to the region’s governments are mainly absorbed by investments in food production, which continues to take up the largest share of agricultural investments at the expense of other segments of the food system (Figure 40). As discussed, farmers in low-income countries are largely penalized by trade and market policies that suppress prices. Conversely, they seem to benefit from significant budgetary transfers, mainly in the form of input subsidy programmes and a few other farm income support measures.²²⁵ These expenditures are often preferred by policymakers, as they represent an immediate, liquid and targetable benefit for the rural population, which constitutes a large electoral base in these countries. However, input subsidies are also difficult to phase out, even when costs exceed benefits.²²⁶ Spending a large proportion of the budget on input subsidies may not be the most efficient approach to ensure sectoral growth and affordability of food.²²⁶

Figure 40

Public expenditure in food and agriculture favours producer subsidies, with less investment towards efficiency gains across food supply chains (selected African countries, 2005–2017)

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As shown in Figure 40, post-production facilities, like storage and marketing, remain under-supported. Expenditures that benefit consumers (e.g. school feeding and cash transfers) are also limited compared with expenditures targeting producers, although a reversal in this trend is visible in some African countries, more recently. In countries like Ethiopia, Kenya and Mozambique, increasing emphasis has been given to social protection programmes, in particular cash transfers targeting the poorest.²²⁵ Expenditure of this type and marketing and storage expenditures, to a lesser extent, can address constraints faced by the poor in accessing nutritious food. Investments in agricultural R&D have also proven to be highly effective in reducing malnutrition, compared with non-agricultural R&D spending. For example, the introduction of improved seed varieties can lead to a positive supply shock, which decreases prices and increases consumption, leading to an improvement in selected nutritional outcomes.^227,228

Other investments with great potential to enhance affordability of nutritious foods are those in road infrastructure, as noted earlier. Only 16 percent of expenditure, on average, was allocated to infrastructural projects in the countries analysed (Figure 40). However, several studies confirm that improved roads can reduce prices of local crops, with greater effects in less productive areas and moderate food price volatility.^229,230

Although the pro-producer bias in public budgets can partially compensate for the negative nominal rate of protection that producers in low-income countries face, a rebalancing of allocations towards more efficient expenditures with longer-term impacts on food security and nutrition is desirable. Investments in public goods, such as roads and storage infrastructure, and in food assistance programmes (food aid, cash transfers and school feeding, captured under “consumer transfers” in Figure 40) are fundamental to ensuring affordability of healthy diets, when nutrition-sensitive components are included.

Globalization and the transformation of food systems

Food systems worldwide experienced major transformations, in particular during the 1990s and 2000s, as a wave of globalization in the food industry marked by urbanization, rising incomes, market liberalization and foreign direct investment reached the developing world.²³¹ This globalization was accompanied by a massive growth of investments by transnational food corporations and rapidly increasing levels of food sold through supermarkets, referred to as the “supermarket revolution”.²³²

These developments represent a key aspect of the political economy that drive food systems transformation and influence the cost and affordability of food. For example, as economic power becomes increasingly concentrated into fewer transnational corporations in the food sector, these corporations engage in policy-making processes and lobby for a reduction in regulations that apply to them, promote regulations that apply to other sectors (e.g. trade and investment agreements that bind governments to protect corporate investment interests), resist or reject taxes that apply to their products and lobby policymakers for subsidies that benefit their businesses. Thus “market power therefore readily translates into political power”¹⁴⁵ and has kept prices of highly processed foods, often high in fats, sugar and/or salt extremely low.

No doubt, when market power and globalization lead to lower prices of energy-dense foods of minimal nutritional value, this can result in major changes in dietary consumption patterns and nutritional status. This is in particular the case for lower-income population groups for whom these energy-dense foods are more affordable.²³¹

Similarly, the globalization of food systems and expansion of supermarkets present an economic opportunity but one with an accompanying risk of increased marginalization and deeper levels of poverty for smallholder farmers and labourers in rural areas. In Kenya, for example, the rise of supermarkets has provided income opportunities for the rural poor, as smallholders have engaged in contractual arrangements with supermarkets to deliver fresh produce. However, while many smallholders have benefited, others have found the contractual conditions unfavourable and risky.²³³ In these cases, not only can small farmers be left out of business, but traditional local food commercialization routes might also be broken, including for fruits and vegetables. In other parts of the world, contract farming with supermarket chains has brought lower prices, but the prices have also been more stable.²³⁴

In middle-income countries of Asia, in particular in India and South-eastern Asian countries, the penetration of the modern retail sector in the form of supermarkets has been less pronounced than in other countries, such as in Mexico and South Africa.¹⁹⁸ In India, rural business hubs have facilitated linking smallholder farmers to rapidly growing urban markets. Apart from procuring food products from the farmers, these hubs provide services such as farm inputs and equipment, as well as access to credit. Having food processing, packaging and cooling facilities at the same location allows consumers to benefit from economies of agglomeration and, on the whole, reduce transaction costs throughout the food supply chain. This model in India has given rise to rural supermarkets that provide cheaper staple foods.²³² Consumers have been drawn to supermarkets providing fresh fruits and vegetables, eggs, dairy, meats and fish, because they are without food safety concerns linked to traditional wet markets.

Nevertheless, while modern food retail stores and supermarkets have changed food systems worldwide and have had a large influence on how people access nutritious foods, traditional food markets and small, independent retail stores also remain important sources of affordable nutritious foods in many countries. In India, Indonesia and Viet Nam, for example, traditional food retail outlets still represent more than 80 percent of the food retail share, and about 60–70 percent of the food retail share in upper-middle-income countries like China and Turkey.¹⁹⁸

Conclusion

This section has shown that the factors driving the cost of nutritious foods are found throughout food systems in the realms of food production, food supply chains, food environments, consumer demand and the political economy of food. This means that in order for policies to reduce the cost of nutritious foods and ensure affordability of healthy diets, they need to feature prominently in the future transformations of food systems. Only then can the world get back on track to meet the SDG 2 targets to end hunger and food insecurity (SDG Target 2.1) and all forms of malnutrition (SDG Target 2.2) by 2030. This review of cost drivers has been important in identifying the specific policies that can help reduce the cost of nutritious foods and improve affordability of healthy diets, which are presented in the next section. However, due to data availability challenges in quantifying cost drivers of nutritious foods, more research is urgently needed to ensure a more solid knowledge base on which to inform policy.

As seen in this section, some of the factors driving the cost of nutritious foods are a result of environmental degradation and climate change challenges. This, along with the hidden environmental costs discussed in the previous section, provides further justification in addressing the environmental externalities associated with current food systems. This can create an important potential synergy to help reduce the cost of nutritious foods and ensure affordability of healthy diets for all, while at the same time transforming food systems to become more sustainable.

Results from the analyses in earlier sections of this report highlight the many challenges in providing the world’s populations with access to healthy diets to meet their nutrient requirements and lead an active and healthy life. The sobering statistics call for the urgent transformation of food systems towards diets that are affordable, predominantly plant-based and sustainable. To summarize the key results:

• ▸ Estimates of the cost and affordability of diets around the world suggest that at more than 3 billion people cannot afford a healthy diet; more than 1.5 billion cannot afford a diet that meets required levels of essential nutrients; 185 million cannot even access a diet with sufficient dietary energy.

• ▸ By 2030, diet-related health costs linked to NCDs, largely as a result of rapidly rising overweight and obesity levels, could amount to USD 1.3 trillion.

• ▸ Current food consumption patterns pose significant costs to society in terms of GHG emissions, estimated at USD 1.7 trillion per year by 2030.

These estimates, together with the most recent data on food security and nutritional status presented in Part 1 of this report, demonstrate the tremendous challenges policymakers face in transforming their countries’ food systems by 2030. COVID-19 will exacerbate these challenges as it negatively affects food supply chains and people’s access to nutritious foods. In spite of great uncertainty and the likelihood of a deep global recession, countries can take action to soften the impact of the pandemic on food and nutrition security.

This section provides guidance on policy instruments and strategies to prioritize actions and investments. The emphasis is on reducing the cost of nutritious foods and ensuring affordability of healthy diets in the broader context of food systems transformation. Some of the policies and strategies discussed in this section can form a critical part of broader efforts towards strengthening the resilience of food systems against shocks the size of the COVID-19 pandemic. More specific policy recommendations for governments are presented in Box 21.

As elaborated in Section 2.2 of this report, healthy diets can play an important role in an overall strategy towards reducing diet-related health costs and environmental costs. Addressing these “hidden costs” to society requires a range of policy measures and investments beyond the immediate focus of this report.

Setting the stage for effective food systems transformation

Ten years remain to achieve the ambitious SDG targets within the current economic, social and political environment – an environment vulnerable to climate shocks and unexpected consequences of the COVID-19 crisis. With this short timeline, countries must identify and implement policy and investment changes that will transform their current food systems to ensure everybody can afford healthy diets that include sustainability considerations. Urgent action is needed, especially for the poorest in society, who face the greatest challenges.

Key policy challenges must be overcome, including: (i) very high levels of unaffordability of healthy diets; (ii) often deeply entrenched government policies that favour the production, trade and consumption of staple foods over other nutritious foods; (iii) globalized and local food value chains driven almost exclusively by profit motives rather than the provision of foods that contribute to healthy diets and support sustainability; (iv) increased availability of energy-dense foods, often containing a high amount of fats, sugars and/or salt, which has contributed to the rapid rise of obesity and diet-related NCDs; and (v) changes in consumer behaviour and preferences, often influenced by intensive marketing of energy-dense foods, that have increasingly led to unhealthy eating habits, a higher prevalence of NCDs and a high carbon footprint of the diets consumed.

Box 22 provides a roadmap towards rapid and effective transformation of food systems at municipal, national, regional and global levels, including several key high-level policy consultations, analyses and actions.

BOX 22

A roadmap towards ensuring the affordability of healthy diets – key steps in food systems transformation

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During the food systems transformation process recommended in Box 22, the following are important principles to follow.

Ensure context-specific policy instruments and investment strategies

Given the wide diversity and complexity of food systems from municipal to national and global levels, and the interaction between different food systems, each situation will require a context-specific set of coordinated policy instruments and strategies, as well as public and private sector investments for food systems to be transformed. To be effective, proposed policy measures must first recognize the current state of food security and nutrition of any one country or community, as well as the specific food systems context within which the policy recommendations are made.

This includes the identification of country-specific cost drivers of nutritious foods as reviewed in Section 2.3, in addition to a thorough understanding of the critical role food systems play in driving the rural economy, in particular. Equally important, given rapid rates of urbanization and the increasingly complex web of food supply chains expected to deliver safe and nutritious foods to rising numbers of urban consumers, strong rural-urban linkages are critical.

Following an improved understanding of the overall challenges, governments, regional and global institutions in consultation with all concerned actors should work towards putting in place a comprehensive set of policy measures that will enable a rapid and efficient transformation of food systems. This should include a full understanding of the extent to which the political economy and potential trade-offs will either promote or hinder affordability of healthy diets that include sustainability considerations.

Strengthen policy alignment through improved planning and coordination

Given the complexity and diversity of existing food systems, and the political economy that has shaped them in often undesirable ways, concerted efforts are needed across many different sectors of the economy: health, agriculture, environment, forestry, fisheries and aquaculture, the food industry, trade and marketing, finance and development, infrastructure, retail and education. All actors, including government, private sector, research and academia, civil society, the media, and the food producers and consumers themselves, have to work together. This includes actors of the global value chains with monopolistic and oligopolistic power that exert influence on the domestic food systems of countries.

Certain policy measures or investments will have a greater impact on the transformation of food systems than others, prompting some sector representatives to advocate for these measures only. However, given the inter-connectivity of different actions in a food systems context, only concerted efforts across sectors will be helpful. While most investments in food systems are made by the private sector, the public sector holds primary responsibility for providing public goods and enhancing social values by filling gaps (e.g. investment in road networks and social protection mechanisms) and addressing market failures.²⁴² Strengthened governance for food security and nutrition is a priority of the UN Decade of Action on Nutrition and this includes an emphasis on cross-government, inter-sectoral and multisectoral coordination. Most countries (80 percent) report that coordination mechanisms for their national nutrition policies are in place.²⁴³

Consider temporal dimensions of transformation

As short-term interventions aim to meet the immediate needs of the poorest and most food insecure, it is important not to lose sight of the nutritional needs of these most vulnerable during the transformation process, even if it means increasing the country’s environmental footprint. Not meeting nutrient requirements during critical phases of the life cycle, as in infancy, early childhood and adolescence, or during pregnancy and lactation, will have lifelong and intergenerational consequences. Hence the importance of immediate food consumption and nutrition needs being addressed adequately at the beginning of the food systems transformation process, even if it entails certain trade-offs (environmental, in this case).

The public sector has primary responsibility for longer-term investments towards food systems transformation, such as infrastructure for water and roads, and other measures that create the enabling environment for cost efficiencies to be realized along the value chains. Governments can also deploy investment decisions through co-investing, taxing, subsidizing or regulating to encourage private sector investments in food systems for healthy diets, while accounting for their environmental footprint. These investments should be complemented by regulatory and voluntary measures, consumer education and other incentives.²⁴²

Strategies and policies that include both short- and longer-term perspectives are needed to help prioritize investments and interventions, while avoiding unfavourable trade-offs as countries transform their food systems. In spite of the many challenges in ensuring that appropriate policy decisions are made at the right time, many opportunities exist for strengthening food value chains that deliver fresh, nutritious foods at affordable prices in markets around the world. Below, various policy instruments, interventions and investments are suggested that could transform existing food systems towards more affordable healthy diets.

Policy options to reduce the cost and enhance affordability of healthy diets

A rising and ever more urbanized world population, combined with increasing levels of income, is placing tremendous pressure on the food and agriculture sectors to increase production to keep food prices from rising.¹⁰³ In order to offset this upward pressure on prices and increase affordability of healthy diets, food and agricultural policies and incentives must help accelerate productivity and production of vegetables and fruits, and protein-rich foods. Importantly, some estimates suggest that increased agricultural productivity alone will help raise incomes of nearly 80 percent of the world’s extreme poor who live in rural areas, most of whom rely on farming for their livelihoods.¹⁴⁹ The impacts of climate change and natural resource constraints, however, will further challenge the need for expansion in agricultural production. The above trends call for substantial policy changes in food and agriculture, and along the entire food supply chain, in order to meet rising food demand.

While drawing on key messages from earlier sections in this report, a summary of policy options and investments to be considered to transform food systems worldwide towards greater affordability of healthy diets is presented in Figure 41. The remainder of this section elaborates on each of the policy recommendations presented.

Figure 41

Policy options to reduce the cost of nutritious foods and enhance affordability of healthy diets with complementary policies to PROMOTE healthy diets

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Policies and investments to reduce the cost of nutritious foods

Policies focusing on agricultural production. Reducing the cost of nutritious foods and increasing the affordability of healthy diets must start with a reorientation of agricultural priorities towards more nutrition-sensitive food and agricultural production. Public expenditures will need to be stepped up to enable many of the policy decisions and investments needed to raise productivity, encourage diversification in food production and ensure that nutritious foods are made abundantly available. In some cases, this will require expenditure reallocations for a better prioritization and strengthened effectiveness of public expenditures as part of an overall food and agriculture sector strategy. In this regard, it is also essential that governments carefully consider trade-offs in their policy decisions and assess the impact of alternative policy measures towards the ultimate objective of eradicating hunger and all forms of malnutrition. Such a shift should consider the overarching aspects of food and agriculture policy and investments outlined below.

Investment in nutrition-sensitive agricultural productivity increases and diversification. Policy options and incentives to improve access to healthy diets must start at the producer level. Investments that support homestead food production of vegetables, legumes, dairy, poultry, fish and fruit are important to provide greater access to healthy diets in poor rural settings. Access to knowledge in improved and more sustainable farming techniques, including climate-smart production methods, are key to increasing productivity and maintaining profitability, and producing marketable surpluses at reduced costs, while increasing the resilience of food systems.

Policies and investments must also focus on improving nutrition outcomes among the population.^182,244 These include policies that facilitate diversified and integrated food and agricultural production systems, empower women and youth in food and agriculture, and provide incentives for increased production of fruits and vegetables, as well as small-scale livestock, agroforestry, aquaculture and fisheries products.

Agricultural policies that encourage a move away from monoculture towards more integrated production techniques, such as agroforestry and rice-fish farming, should be considered as this helps reduce the cost of production, increase food producers’ incomes and resilience, provide ecosystem services, and increase dietary diversity. In recognition of the positive impact of integrated approaches on food security and nutrition, the inclusion of nutrition objectives in food and agriculture policies and ensuring access for all to safe and sustainable healthy diets are emphasized under the action area on “sustainable, resilient food systems for healthy diets” under the United Nations Decade of Action on Nutrition 2016–2025.²⁴⁵

Promotion of urban and peri-urban agriculture. Production of diverse, nutritious foods should also be expanded in peri-urban and urban settings through investment in horticultural crop production to provide easier access to fruits and vegetables, while reducing the risk of food losses along the shortened food supply chains. The wide variety of urban agriculture production systems, and a general lack of understanding of the relative importance, nature and food security implications of urban agriculture²⁴⁶ make it difficult to provide specific policy recommendations. Meanwhile, in order to ensure that the potential of urban agriculture in supporting food security and nutrition can be fully exploited, appropriate mechanisms of governance and institutional support for urban agriculture, including supportive legislation, need to be developed.²⁴⁷

Avoiding taxation of nutritious foods. In low-income countries, where growth in food production is most needed, the agricultural sectors are often penalized as a result of, for example, exchange rate fluctuations, price controls or weak bargaining power of farmers. Policy interventions that tend to depress prices of agricultural commodities not only reduce farmers’ incomes and incentives to produce, but also reduce the affordability of healthy diets for some of the most marginalized populations (the rural poor). Therefore, policies that penalize food and agricultural production (through direct or indirect taxation) should be avoided, as they tend to have adverse effects on the production of nutritious foods.

Subsidy levels in the food and agriculture sectors should also be revisited, especially in low-income countries, to avoid taxation of nutritious foods. A FAO analysis shows that across a group of 68 countries, subsidies are highest for sugar, followed by subsidies for animal products and staple foods (mainly rice). Among the same group of countries, fruits and vegetables are among the most penalized (through various policy measures that disincentivize production). Governments should conduct an objective review of current agricultural policies to ensure the production of nutritious foods is supported rather than taxed.

Other policy and structural impediments, including a weak private sector in many low-income countries, have limited the supply responsiveness of vegetables and other non-staple foods. In India, policies that promote staple crop production, such as fertilizer and credit subsidies, price supports and irrigation infrastructure (particularly for rice), have tended to discourage the production of traditional non-staple crops, such as pulses and legumes.²⁴⁸ A bias in irrigation infrastructure development in favour of staple crops has been maintained in many other regions. Instead, policies should promote investment in irrigation infrastructure specifically targeting strengthened capacity for all-season vegetable production, and other high-value commodities to increase availability of nutritious foods.

Investment in research, innovation and extension to raise productivity of nutritious foods in the food and agriculture sectors. National food and agricultural strategies and programmes should step up investment in R&D to raise productivity of nutritious foods and help reduce their cost, while enhancing access to improved technologies, especially for smallholders, to maintain adequate levels of profitability. This should be accompanied by research and extension services that make it possible for producers to adopt more sustainable production methods that conserve natural resources, in particular soil and water,²⁴⁹ as well as biodiversity.²⁵⁰ Furthermore, collaboration with regional and international research and extension organizations and networks is important to strengthen capacities of national agricultural research and extension systems, and to facilitate sharing of knowledge and best practices and innovations for increased production and productivity.

Public investment in demand-driven research and extension should be complemented by investment in rural electrification programmes, irrigation infrastructure and increased mechanization to further raise productivity. In parallel with R&D in food and agriculture, low-income countries need to enable and promote inclusive agricultural innovations to meet the rising food demand. Agricultural innovation takes place most effectively in a system where research organizations, extension and advisory services and other key institutions interact with each other and are strongly connected to family farmers, enabling them to raise productivity, strengthen resilience to shocks and enhance sustainable natural resource management.²⁵¹

Innovation in agriculture takes on many possible forms, including inter alia labour-saving mechanization; crop and animal breeding; the use of biological control agents and the management of soil biodiversity to improve soil fertility, in addition to hydroponics to produce food in water-limited areas; the development of vaccines against livestock and aquatic animal diseases; the increased use of information and communication technologies (ICTs); the use of drones for aerial surveys in combating deserts locusts; and novel ways for farmers to access markets.

Policy options along the food value chain. Designing and implementing the aforementioned policy directions, aimed at raising productivity of nutritious foods, also requires taking into consideration the critical aspects of the supply chain (or value chain) of each product. In this regard, the value chain approach is useful for navigating the complexity of food systems and identifying opportunities for enhanced nutrition at different stages.²⁵² For any one food product, all actions along the food value chain ultimately affect the consumer price, and hence the affordability of food (depending on the consumer’s income or purchasing power). Key policy actions and both public and private sector investments can increase agricultural productivity, reduce food losses and enhance efficiencies in food storage, processing, packaging, distribution and marketing across the food value chains, all of which translate into lower food prices. In many countries, larger public and private sector investments in food value chains are needed as food systems are becoming increasingly more complex and intertwined, especially in rapidly growing metropolitan areas.

Modern food supply chains, with increasingly diverse and differentiated food products, have brought tremendous opportunities to “add value” to food items. At the same time, they have increased costs to the consumer. As this report presents various policy options below, it is important to recognize that policies that intervene directly in agricultural production to promote healthy eating habits are unlikely to be effective or efficient if they do not take into account how foods are processed, distributed and marketed throughout the entire food supply chain,²⁵³ and how the intervention will affect each stage. Policy actions and investments that specifically help increase the affordability of healthy diets – as well as healthy diets that also include sustainability considerations – within a food systems context and across the food value chains are discussed below.

Policies and investment for nutrition-sensitive value chains. Globally, there has been a growing interest among governments and development institutions in using nutrition-sensitive value chains as a means to improve nutrition.²⁵⁴ Examples include investments in improved storage, processing and preservation to retain the nutritional value of food products. As discussed above, at the production level, broadening the mix of crops produced and diversifying into agroforestry, livestock and/or fisheries products is also important to raise incomes, as well as nutritional outcomes of small-scale producers.²⁵⁵

The need for stronger policies towards more nutrition-sensitive value chains has been advocated especially for high- and middle-income and rapidly growing low-income countries, where the agricultural sector has become a supplier of raw materials for the food processing industry, and where the food system policies promote inexpensive calories and expensive nutrients.¹⁸⁶ It has also been observed that highly processed energy-dense foods are increasingly marketed and made available in low- and middle-income countries, demanding increased production of ingredients for these foods (primarily refined starches, oil and sugars) while at the same time the supply of nutritious, minimally processed foods is being constrained.²⁵⁶ Among others, these developments have underscored the need for policy interventions that promote nutrition-sensitive food systems from the production level throughout the food value chain.¹⁸⁶

For example, given the unique challenges faced by SIDS, the Global Action Programme on Food Security and Nutrition in Small Island Developing States highlights the importance of developing more resilient and nutrition-sensitive food systems and their value chains. Among others, the nutrition-sensitive approach aims to address growing malnutrition and health costs due to the emergence of and preference for more energy dense and highly processed foods; significant levels of food loss and waste; increased incidence of food safety issues and trans-boundary diseases, as well as environmental and natural resource degradation.¹⁷⁵ In another example, the Smallholder Livelihood Development Project in eastern Indonesia has adopted a nutrition-sensitive value chain approach to address a “nutrition gap” found to be particularly severe for adolescent girls. Under the project, food commodities that could address nutrition gaps of these girls, as well as other family members, were identified – and included bananas, cassava, maize, spinach, sweet potatoes and fish – which also presented a profitable business opportunity for smallholders. The applied nutrition-sensitive approach helped empower women and generate increased income, laying foundations for a local food system that sustainably delivers nutritious foods that contribute to healthy eating habits. Thus investments spanning across multiple value chains helped diversify diets and sources of income.²⁵⁷

Policies and investments to reduce food losses. These policies and investments can increase affordability of nutritious foods in two ways. First, by focusing on the earlier (production) stages of the food supply chain, as this tends to boost supplies and hence reduce food prices at the farm gate.¹⁸¹ This is particularly important for the reduction of losses in perishable commodities, such as fruits and vegetables, dairy, fish and meat. Second, by targeting the parts of the food supply chain where food losses are greatest, as this will more likely have a greater impact on reducing the cost of the targeted food item. The overall price effect will differ from one commodity to the next and also across countries.¹⁸¹ In many low- and middle-income countries, food losses of perishable commodities are greatest where markets are absent, road infrastructure is poor and cold storage facilities are poorly developed. Investment in improved storage facilities, as well as post-harvest preservation and conservation techniques, will not only reduce food losses, but also help maintain the nutrient content of food and improve food safety.

Policies and investment in nutrition-sensitive handling and processing. In addition to food storage, appropriate food handling and processing facilities are central to increasing efficiencies along the value chain. If passed on to the consumer (in the form of cost savings), these efficiency gains contribute towards increasing the affordability of healthy diets. Improved storage, processing and preservation may also increase incomes of food producers, in addition to reducing the negative effects of seasonality on food insecurity and malnutrition.¹⁸² In Indonesia, supporting fishery and aquaculture production, and processing and marketing in coastal and small island communities has led to increased productivity, incomes, dietary diversity, as well as women’s empowerment, as illustrated in Box 23.

Food fortification. More than 2 billion people in the world today suffer from micronutrient deficiencies caused largely by a dietary deficiency of vitamins and minerals. Food fortification of regularly consumed foods (such as iodization of salt), and fortification of staple foods (through biofortification at the production level or through post-harvest fortification) is recommended as a cost-effective measure to reduce these deficiencies.²⁶³ For example, biofortified crops are those which have been nutritionally enhanced using agronomic practices, conventional plant breeding, or modern biotechnology to increase the density of micronutrients, thus ensuring the staple crop component of a diet is as nutritious as possible.²⁶⁴ This is particularly important for the rural poor and small farming families in low- and middle-income countries whose diets continue to be dominated by staple foods and are not yet able to access a diversified healthy diet. Given that fortified foods provide a higher micronutrient content at marginally increased prices, it allows households to reduce the overall cost of a healthy diet. National standards, with quality assurance and quality control systems, as well as regulatory and public health monitoring, are needed to ensure quality fortification in line with international guidelines.^{265,266,267,268}

Investment in road networks, transport and market infrastructure. Improving the national road network, as well as transport and market infrastructure, requires large amounts of public and private sector investment, but this can go a long way towards ensuring greater affordability of healthy diets. Transport costs are a bottleneck to increasing the affordability of healthy diets in many countries, particularly in the lower income brackets. Beyond the farm gate, investment in an array of physical infrastructure can help reduce the cost of bringing farm produce to market, especially of perishable nutritious foods. In addition, improvements of all-weather rural roads and the national road network can facilitate farmers’ access to markets and reduce pre-harvest and post-harvest losses, all of which eventually contribute to reducing consumer prices (see Section 2.3, Box 19).

Furthermore, improvements in physical rural and urban market infrastructure increase access for agricultural producers to markets where they can sell their wares in a competitive and clean environment. It raises competitiveness in price formation and strengthens the food environment where consumers access food, including a variety of fresh produce and other nutritious foods. The potential of these improvements is substantial if one considers the growth of urban markets. For example, in Asia, currently about 60–70 percent of the food supply passes through urban markets,²⁶⁹ while urban food markets in Africa have grown rapidly and now provide half or more of overall food for consumption. In Kenya, more than 95 percent of the fresh fruits and vegetables consumed is grown domestically, mainly by smallholders, and is supplied to rural and urban markets by small and medium-sized enterprises (SMEs) through informal supply chains.²⁷⁰ Policies, as well as public and private sector investments aimed at strengthening road networks and transport and market infrastructure enhances a country’s capacity to raise the variety of food available on rural and urban markets and reduce the cost of nutritious foods.

As was observed in Bangladesh, for example, public investments increased access to markets in strengthening community markets and market-connecting roads, all of which improved food security and nutrition outcomes of targeted beneficiaries.²⁷¹ In Nepal, strengthening linkages between producer organizations of high value crops and local traders also improved food security outcomes of targeted producers.²⁷² And in the United States of America, government incentives to encourage weekly farmers’ markets and regulating local supermarkets to stock fresh produce helped raise access to nutritious food options in “food deserts” – often identified in low-income neighbourhoods where affordable nutritious foods are out of reach.²⁷³

Ensuring trade and marketing policies balance producer and consumer interests. Trade and marketing policies aimed at decreasing the cost of food to consumers, while avoiding disincentives to the local production of nutritious foods, are often difficult to balance. Nevertheless, the efficiency of internal trade and marketing mechanisms are possibly just as important as measures to support international trade – if not more – in determining the cost of healthy diets for both urban and rural consumers, while also ensuring that food safety standards are met. This is particularly relevant given rapid rates of urbanization, the lengthening of food value chains, and generally, increased demands placed on local food systems, in terms of consumer demand for greater diversity in the choice of food commodities available, and for adequate food safety standards and sustainability issues to be addressed.

International trade policies typically affect the affordability of healthy diets by either lowering or raising the relative prices between imported and import-competing foods (Box 24). As discussed in Section 2.3, protectionary trade policies (i.e. import tariffs, non-tariff measures and quotas), as well as input subsidy programmes tend to protect and incentivize domestic production of staple foods, such as rice and maize that mainly provide calories, often to the detriment of nutritious products, such as fruits and vegetables that provide vitamins and minerals. Furthermore, non-tariff measures that impose excessive food safety standards may unduly affect the cost of nutritious foods. This can therefore also have significant adverse effects on the affordability of healthy diets. Hence, it is essential that governments carefully consider the impacts of non-tariff measures on the affordability of nutritious foods, and avoid creating regulatory barriers to trade that negatively affect poor households’ access to a healthy diet. In general, but also at times of food crises in particular, such as during the unfolding of the COVID-19 pandemic, protectionism is likely to increase the costs of healthy diets, and agricultural trade restrictions should therefore not be imposed.

Strengthening food supply chains under humanitarian conditions. Many of the above recommendations can be very challenging in certain contexts when, for example, established food supply chains are disrupted because of major natural or man-made disasters (e.g. large-scale floods, earthquakes, armed conflict or civil strife). Under such circumstances, food supply chains may initially break down, until local marketplaces and strained supply chains start delivering food supplies again to reach vulnerable populations, including displaced populations living under humanitarian conditions. The often limited production capacity of local communities, poor market infrastructure, bottlenecks in supply chains and limited market competition will most likely result in high food prices for some of these most vulnerable population groups with little or no source of income. Limited availability of nutritious foods, such as fresh produce, fish and meat, apart from staple foods provided as food aid, pose further challenges to increasing affordability of nutrient adequate, let alone healthy diets under such conditions. Under these contexts, it is important that key actors across the food value chain help provide better access to nutritious foods at affordable prices to the most vulnerable, as demonstrated with the example of the Kakuma refugee camp in Kenya (Box 25).

Consumer-oriented policies to ensure affordability of healthy diets

Policies to reduce poverty and income inequality. Policies aimed at reducing poverty and income inequality, while enhancing employment and income-generating activities, are also key to raising people’s incomes and hence the affordability of healthy diets. Today, more than 700 million people, or 10 percent of the world’s population, still live in extreme poverty.²⁸⁰ Approximately 80 percent of the extreme poor live in rural areas.²⁸¹ Moreover, according to the analysis presented in Section 2.1, none of these 700 million people can afford nutrient adequate nor healthy diets. “Ending poverty in all its forms everywhere” under SDG 1 remains a major task requiring substantial policy interventions, as well as public and private sector investments across the socio-economic sectors of many countries, in close coordination with in-country efforts addressing SDG 2 and most other SDGs. This is particularly true nowadays, as the impact of the COVID-19 pandemic risks reversing the steady decline in the prevalence of poverty achieved in most countries over the past number of decades,¹⁴² threatening also people’s capacity to access healthy diets.

While there are important synergies between policies enhancing employment and reducing income inequality for increased food security and better nutrition, including social protection, these have been addressed in depth in the 2019 edition of this report. Moreover, that edition comprehensively addressed the challenges in safeguarding food security and nutrition as they relate to measures for also protecting incomes in the context of economic slowdowns and downturns, such as the global economic downturn caused by COVID-19.

This year’s edition of the report also highlights the importance of social protection policies, although exclusively those that are nutrition-sensitive. These types of policies are most appropriate to provide better access to nutritious foods to lower-income consumers and thus raise their affordability of healthy diets. They can be particularly important in the face of adversity, as we are seeing today during the COVID-19 pandemic.

Strengthening nutrition-sensitive social protection mechanisms. In examining the affordability of the three different diets under consideration, previous sections have provided evidence that even energy sufficient diets are out of reach of millions of people due to high cost barriers. Raising the purchasing power of the poorest through various social protection mechanisms is common practice around the world for improved food security, nutrition and health.²⁸² Social protection mechanisms represent a set of policies and programmes that address economic, environmental and social vulnerabilities to poverty, food insecurity and malnutrition by protecting and promoting livelihoods, in particular through the reduction of financial and social barriers to accessing food.²⁸³

These mechanisms can be particularly important in the face of adversity, as we are seeing today during the COVID-19 pandemic. A recent review of social protection policy measures from the World Bank and UNICEF shows that a total of 151 countries have introduced or adapted these measures.²⁸⁴ Cash transfers have been the most common, in additional to in-kind food and voucher schemes, as well as school feeding programmes. A review of policy examples reveals that the number of countries providing some form of social protection mechanism increased steadily throughout the month of April 2020, for example in low-income countries, with some important gaps in Middle and Eastern Africa, including countries with a protracted crisis situation (Democratic Republic of the Congo, Somalia and South Sudan). This is worrisome, considering that the highest prevalence of undernourishment worldwide is found in sub-Saharan Africa.²⁸⁴ Overall, while the increased investment in social protection mechanisms is laudable, this has also led to the overburdening of these mechanisms in many countries.

Especially under these circumstances, social protection mechanisms that are nutrition-sensitive are most appropriate to provide better access to nutritious foods to lower-income consumers, as in school feeding programmes through public procurement. Micronutrient supplementation should be promoted where required,²⁸⁵ and the creation of healthy food environments should be fostered by encouraging consumers to include more diverse, nutritious foods in their diet in order to reduce dependence on starchy staples and reduce consumption of foods high in fats, sugars and/or salt. In El Salvador, for example, policy recommendations to raise the affordability of healthy diets, especially of poor households, included nutrition-sensitive social protection programmes (Box 26).

Cash transfer programmes. Among the different kinds of social protection programmes, the effectiveness of cash transfer programmes depends on: (i) the level of income they complement; (ii) how much of the food affordability gap they close; (iii) the availability of nutritious foods in local markets; or (iv) whether transfers are conditional on the use of a particular service, such as antenatal care. Cash transfers are used in a wide range of programmes including government social safety nets, child grants or old age pensions, as well as food assistance programmes. These last are designed to meet food needs directly, whereas the first three provide a transfer to meet a household’s most immediate income needs, part or all of which can be spent on food.

The contribution of these very different programmes towards meeting people’s affordability of a nutrient adequate or healthy diet is usually limited, because their objectives are typically designed around meeting dietary energy requirements, rather than aiming to provide healthy diets. However, when designed appropriately, social protection programmes can also help make healthy diets more affordable, provide specific services to nutritionally vulnerable groups, and reach under-served populations.²⁸⁷

In sub-Saharan Africa, for example, the implementation of well-designed cash transfers with adequate and reliable transfers has resulted in significant improvements across a range of dietary diversity measures.²⁸⁸ Factors that help improve nutrition outcomes of cash transfer programmes include: easily accessible and affordable food stores,^289,290 a nutrition-sensitive approach and the combination of the transfer with other initiatives such as nutrition education.²⁹¹ Cash transfer programmes can also help improve the dietary diversity of poor farming households through farm-level investments in increased production and diversification.²⁹² Diets can improve even more if the investments are combined with other improvements, such as greater access to markets.²⁹³

In-kind transfers, in particular through conditional or unconditional food distribution, which are currently implemented by over 80 countries²⁴³ represent another way through which social protection mechanisms may have a positive effect on access to and affordability of healthy diets; apart from providing food, these programmes also free up household income to spend on other nutritious foods. Hence, these interventions directly increase household food consumption and intake of dietary energy, while also supporting dietary diversity. Under certain circumstances, the use of cash transfers is more cost-efficient than in-kind transfers, given the cost of procurement and logistics in food distribution. Under other circumstances, economies of scale could offset the logistics costs of in-kind programmes, making them more efficient than cash transfers in achieving food security and nutrition goals.²⁹⁴ Generally, cash transfer programmes are considered an appropriate instrument to increase dietary diversity in well-connected urban or rural contexts, while in-kind transfers are more appropriate for remote areas, where access to markets is severely limited.^294,295,296

In India, for instance, the country’s Targeted Public Distribution System represents the largest social protection programme in the world, reaching 800 million people with subsidized cereals that can be purchased from more than 500 000 fair price shops across the country.²⁹⁷ Evidence of the impact of the programme on dietary diversity and nutrition is mixed, although it showed some positive impact on the intake of macronutrients.^297,298,299 Other studies found that the programme still faces efficiency problems, particularly in regard to targeting food insecure and poor population groups.²⁹⁹

School feeding programmes. Apart from increasing school enrolment, school feeding programmes aim at improving nutrition though access to healthy school meals. School meals provided to millions of children worldwide also represent an important contribution to reducing the cost of food, in particular for low-income families, who already cannot afford healthy diets. As such, school meals represent a transfer of the value of the food distributed to households. It has been estimated that with school closures during the COVID-19 pandemic, more than 320 million children around the world are missing out on school meals. As many of these children depend on the daily meals they receive at school for a large part of their daily nutrient requirements, the pandemic is aggravating the unaffordability of healthy diets to poor households.³⁰⁰

Improving dietary diversity through school meal programmes has been successful in Ethiopia,³⁰¹ while in Ghana, the school menus still face some challenges in offering diverse enough menus to ensure sufficient intake of micronutrients.³⁰² In Brazil, the National School Feeding Programme increased the quantity of fruits and vegetables in its menus and reduced the presence of highly processed foods containing high amounts of sugar and/or salt. It also successfully encouraged local purchases from smallholders through public procurement mechanisms, which added to the success of the integrated programmes.³⁰³ A nutrition-sensitive approach is key to fighting malnutrition through school feeding programmes.²⁹⁵

Linkages with local producers are especially important in the contexts of weak market access and inefficiencies of the food supply chain. Positive synergies associated with predictable and continued demand from schools, as well as other public institutions such as local hospitals, can improve the livelihoods of smallholders, creating shorter supply chains and reducing transaction costs for both producers and consumers.³⁰⁴

Subsidization of nutritious foods. The promotion of healthy eating habits through subsidies on grocery store purchases of nutritious foods, such as fruits and vegetables, can be an effective policy towards raising affordability of healthy diets. Food subsidies are used in many parts of the world to decrease the cost of food for the most vulnerable. While they are generally considered a distortive measure compared with cash transfer programmes,²⁹⁵ targeted food subsidies can be effective in promoting healthy diets.^305,306 A systematic study covering mainly high-income countries found that a decrease of 10 percent in the price of foods that contribute to a healthy diet would increase their consumption by 12 percent.³⁰⁵ In low- and medium-income countries, large-scale untargeted subsidies of staple foods tend to be more common than targeted subsidies of nutritious foods such as fruits or vegetables. Faced with high and rising levels of overweight and obesity, several low- and middle-income countries in Northern Africa, and parts of Western and Southern Asia have been adjusting their food policies, including their food subsidy programmes, to discourage the consumption of products high in saturated and trans fats, sugars and/or salt (Box 27).

BOX 27

Revised fiscal policies aimed at addressing affordability of minimum food requirements and health concerns in Northern Africa and Western and Southern Asia

In countries of Northern Africa and some parts of Western and Southern Asia, there has been a long tradition of food subsidies funded by governments to address poverty and improve food security. Commonly subsidized foods include wheat, wheat flour, bread, oils, rice, sugar and powdered milk.³⁰⁷ These subsidies have been important contributors to increased food intake, providing for example, up to 45 percent of the calorie intake of poor populations in urban Egypt and up to 60 percent in Tunisia.

Food subsidy programmes are, however, expensive – costing, on average, 1 percent of GDP in 2011³⁰⁷ – and have not always been well-targeted to reach those most in need. Furthermore, as many countries in this region have undergone a nutrition transition, many households now suffer from the multiple burdens of malnutrition. Over 20 million children in the WHO Eastern Mediterranean Region are stunted, while half of the region’s adult population is overweight or obese.³⁰⁸ Subsidies have not always been designed to promote or enable access to affordable healthy diets.

Given the high costs and the need to improve support for the poorest populations,³⁰⁹ many countries in the region, such as Algeria, Egypt, Iran (Islamic Republic of), Jordan, Tunisia and Yemen, have revised their subsidy programmes in recent years in favour of better-targeted mechanisms.³¹⁰ This has resulted in elimination of many of the subsidies that were not well-aligned with healthy diets; nonetheless, some subsidies for oils, sugar and white flour or bread have persisted.³¹¹

Faced with high and rising levels of overweight and obesity (figure below), several countries are now using policy instruments to discourage the consumption of products high in unhealthy fats, sugars or salt. Most commonly, taxes have been levied on sugar-sweetened beverages (SSBs) and carbonated or energy drinks. Morocco, Oman, Qatar, Saudi Arabia and United Arab Emirates have implemented taxes at a rate of 50 percent, while Iran (Islamic Republic of) has introduced a 20 percent tax.^312,313,314 In Saudi Arabia, after the introduction of the 50 percent tax on carbonated soft drinks and a 100 percent tax on energy drinks in 2017, per capita purchases declined by 41 percent and 58 percent, respectively, the following year.³¹⁵ In December 2019, the tax was extended to other SSBs that had not been initially covered.

Adult overweight and obesity in selected countries of the Northern Africa and Western and Southern Asia regions in 2017

Fiscal policies are being reinforced by other measures to foster healthy food environments and promote healthy diets. In Saudi Arabia, the package of measures includes, among others, elimination of industrial trans fats,³¹⁶ front-of-pack traffic light labelling on pre-packaged foods and calorie labelling on menus,³¹⁷ an upper limit for salt content in bread,³¹⁸ and a voluntary reformulation programme to reduce salt, sugar and saturated fats in other foods.³¹⁹ These measures have been accompanied by awareness campaigns on what constitutes a healthy diet.

This combination of different approaches to promoting healthy diets is in line with the new WHO Regional Strategy for Nutrition 2020–2030 for the WHO Eastern Mediterranean Region,³⁰⁸ which will guide Member States’ implementation of action over the second half of the UN Decade of Action on Nutrition in the region.

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All of these nutrition-sensitive social policy options can be very effective in helping increase the purchasing power of the poor and vulnerable groups, so as to increase their affordability of healthy diets. Nonetheless, given different starting points and challenges in each country, as well as the potential trade-offs, including those for the livelihoods of people who rely on the rural economy, a combination of complementary policy interventions towards reducing the cost of nutritious foods, while enhancing the affordability of healthy diets is likely to be more effective than any single policy measure.

Complementary policies that promote healthy diets

Earlier parts of this report have highlighted that what people eat, and how that food is produced, not only affects their health, but also has major implications for the state of the environment and for climate change. The analysis presented suggests that, unless we change our current food consumption patterns, the cost in terms of health for people and climate change to society could together amount to USD 3 trillon per year by 2030 – which is an underestimation, given that other environmental costs are not being accounted for. This is a tremendous cost for individuals and for society, and unless addressed by governments worldwide, it not only threatens the future food security, nutrition and health status of hundreds of millions of people, but will almost certainly prevent a number of SDGs from being achieved by 2030.

As has been pointed out, to achieve healthy dietary patterns, large transformative changes in food systems will be needed at all levels. It is important to underscore that, although there are some overlaps, these changes go beyond the policy options and investments that are explicitly designed and implemented to reduce the cost of and increase the affordability of healthy diets. That is to say, other conditions must also be met, requiring a whole range of other policies that are more explicitly tailored to raise awareness and influence consumer behaviour in favour of healthy diets, possibly with important synergies for environmental sustainability (Box 28). Hence the importance of policy coherence and coordination across all relevant sectors and involving all stakeholders of which we made reference at the beginning of this section.

Such a policy framework could be supported at the national level in ensuring that national food-based dietary guidelines (FBDGs) fully consider sustainability dimensions. While some countries still need to develop their FBDGs, existing guidelines could be used to align policies in different sectors (nutrition, health, agriculture, education, fiscal, trade policies, etc.) with national health and sustainability objectives; for example, to help shape food production strategies towards more sustainable practices.

Countries are encouraged to scale up actions to create supportive environments for nutrition during the second half of the United Nations Decade of Action on Nutrition 2016–2025.²⁴⁵ Progress in this area can be facilitated by strengthening nutrition action networks at the global, regional, national and local levels to foster inter- and intra-country cooperation and political commitment.³³⁵

Recommendations for further research. Further research to support policies towards ensuring affordable healthy diets, while also addressing sustainability considerations, is needed. Three specific areas have been identified in Box 29, for which adequate funding should be allocated for successful implementation.

Conclusion

In summary, making healthy diets more affordable for everyone, while reducing the consumption of energy-dense foods of minimal nutritional value and foods with a negative impact on human health and the environment, requires significant transformations of existing food systems worldwide. Given unique country contexts and different starting points for the various transformative processes that need to happen, it is hoped that the recommended policy measures and investments in this last section will prove useful. Furthermore, while acknowledging the data and research gaps, a number of policy options and investments for reducing the cost of nutritious foods and increasing the affordability of healthy diets have been discussed, in particular those with potential for diets to be environmentally sustainable, and whose effectiveness have been proven by a myriad of case studies. The complementary policy environment that needs to be enabled to simultaneously promote healthy diets has also been highlighted, which further justifies the need for policy coherence and coordination across all relevant sectors and involving all key stakeholders.

The guidance provided in this report is in line with key recommendations under the United Nations Decade of Action on Nutrition, 2016–2025, including Action Area 1 covering “Sustainable, resilient food systems for healthy diets”, Action Area 3 on “Social protection and nutrition education”, as well as Action Area 5 on “Safe and supportive environments for nutrition at all ages”. The remaining years of the Decade of Action present an opportunity to accelerate action in these areas.

The analysis conducted and policy recommendations provided should furthermore help set the agenda for the first UN Food Systems Summit, which will take place in 2021. The summit’s overarching goal is to help stakeholders better understand and manage complex choices that affect the future of food systems and accelerate progress towards achieving the SDGs by 2030.

The importance of the policy guidance currently being negotiated under the Committee on World Food Security (CFS) based in Rome towards “Voluntary Guidelines on Food Systems for Nutrition” is also fully recognized. The objective of the Voluntary Guidelines are “to contribute to the transformation of food systems and promoting sustainable food systems to ensure that the food that contributes to sustainable healthy diets is available, affordable, accessible, safe, and of adequate quantity and quality while conforming with beliefs, culture and traditions, dietary habits, and preferences of individuals, in accordance with national and international laws and obligations.”³³⁷ The guidance provided by these Guidelines, once fully negotiated and endorsed, will be of great interest to governments and development partners on the formulation and implementation of a comprehensive set of policies towards the transformation of food systems.