- ➔ Along the development path, income growth, urbanization, globalization and changes in employment are interrelated, occur simultaneously and reinforce each other. All affect food consumption and the composition of diets, giving rise to a nutrition transition.
- ➔ A decline in the prevalence of undernourishment and stunting in children under five years of age and an upward trend in the prevalence of overweight and obesity are salient features of the nutrition transition. These trends are evident across countries, as their economies develop and dietary patterns change.
- ➔ Income growth is a major driver of the nutrition transition, leading to a more diverse food environment and a declining share of staple foods in consumption. A more diverse food supply can provide the basis for better nutrition but can also result in a higher availability of ultra-processed foods including foods high in fats, sugars and/or salt, which can increase the prevalence of overweight and obesity.
- ➔ Trade is an accelerator of the nutrition transition. Its effects on food availability, dietary patterns and resulting nutritional outcomes can be widely heterogeneous across countries, population groups and individuals.
- ➔ Nutrition transition trends vary across countries and do not give rise to a globalized dietary pattern. Over the 1961–2019 period, the broad dietary patterns of high-income countries and emerging economies changed rapidly, with the share of staple foods in total calories available declining fast. During the same period, the dietary patterns of lower-income countries changed at a slower rate.
Structural transformation and the nutrition transition
As countries develop, the relative importance of agriculture in gross domestic product (GDP) and employment declines. A reallocation of economic activities away from agriculture to other more productive sectors such as manufacturing and services takes place, fuelling economic growth. This structural transformation is also evident at the global level. On average, over the past decades, global GDP per capita more than doubled from USD 5 517 in 2000 to USD 12 688 in 2022, while the global share of agriculture in employment declined from 40 percent in 2000 to 26 percent in 2022 (Figure 1.1, panels A and B). Historically, this shift from a predominantly agrarian economy to one in which manufacturing and services play a larger role is also associated with urbanization, deeper integration into global markets and lifestyle changes including shifts in dietary patterns.
FIGURE 1.1Structural transformation and nutrition transition: Main drivers and outcomes, 2000–2022
SOURCES: Authors’ own elaboration based on World Bank. 2024. World Development Indicators: GDP per capita (current US$). [Accessed on 12 April 2024]. https://data.worldbank.org/indicator/NY.GDP.PCAP.CD. Licence: CC-BY-4.0; World Bank. 2024. World Development Indicators: Employment in agriculture (% of total employment) (modeled ILO estimate). [Accessed on 12 April 2024]. https://data.worldbank.org/indicator/SL.AGR.EMPL.ZS. Licence: CC-BY-4.0; World Bank. 2024. World Development Indicators: Urban population (% of total population). [Accessed on 12 April 2024]. https://data.worldbank.org/indicator/SP.URB.TOTL.IN.ZS. Licence: CC-BY-4.0; UNICEF, WHO & World Bank. 2023. Joint child malnutrition estimates (JME). In: WHO. Geneva, Switzerland. [Cited 15 June 2024]. https://www.who.int/teams/nutrition-and-food-safety/monitoring-nutritional-status-and-food-safety-and-events/joint-child-malnutrition-estimates; FAO. 2024. FAOSTAT: Suite of Food Security Indicators. [Accessed on 12 April 2024]. https://www.fao.org/faostat/en/#data/FS. Licence: CC-BY-4.0; WHO. 2024. The Global Health Observatory: Prevalence of obesity among adults. [Accessed on 27 May 2024]. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-obesity-among-adults-bmi-=-30-(age-standardized-estimate)-(-); WHO. 2024. The Global Health Observatory: Prevalence of overweight among adults. [Accessed on 27 May 2024]. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-overweight-among-adults-bmi--25-(age-standardized-estimate)-(-); KOF Swiss Economic Institute. 2024. KOF Globalisation Index. In: KOF Swiss Economic Institute. Zurich, Switzerland. [Cited 12 April 2024]. https://kof.ethz.ch/en/forecasts-and-indicators/indicators/kof-globalisation-index.html; Gygli, S., Haelg, F., Potrafke, N. & Sturm, J.-E. 2019. The KOF Globalisation Index – revisited. The Review of International Organizations, 14(3): 543–574. https://doi.org/10.1007/s11558-019-09344-2; FAO. 2024. FAOSTAT: Trade – Crops and livestock products. [Accessed on 12 April 2024]. https://www.fao.org/faostat/en/#data/TCL. Licence: CC-BY-4.0.
As the economy undergoes structural transformation, the reallocation of resources such as capital and labour across economic sectors increases productivity and income per capita.1 With labour moving from agriculture to fast-growing, non-farm sectors, society becomes more urbanized. With this, the agglomeration of people and firms reduces transaction costs and allows technology spillovers, potentially resulting in further increases in productivity and income per capita in manufacturing and services.2 Although the share of agriculture in GDP and employment declines, agricultural productivity per worker improves and farm incomes increase. Due to rural-to-urban migration and technological improvements, fewer people can produce more food.
Agriculture can play a key role along this development path. It provides resources such as labour to other economic sectors, and it addresses the economy’s food needs.3 Openness to trade plays an important role in sustaining growth rates.4 Food and agricultural trade contribute to the structural transformation process, as cheaper imports can add to domestic food production and facilitate rural–urban migration.5
This structural change of both the traditional and modern sectors of the economy initiates the growth process, leading to sustained reductions in poverty and hunger and in higher standards of living, thereby transforming human lives.a
Along this development path, dietary patterns change, driven by structural transformation’s economic, social and demographic dynamics. This nutrition transition takes place with changes in the types and quantities of foods consumed and the composition of diets. It is also reflected by a change in nutritional outcomes, most importantly, by a decline in the prevalence of undernourishment and the prevalence of stunting in children under five years of age and an upward trend in the prevalence of overweight and obesity.b In many developing countries, this shift from undernutrition to overweight and obesity is the most significant characteristic of the nutrition transition and is also evident in global averages. While the prevalence of undernourishment in the world declined significantly from 12.7 percent to 9.2 percent between 2000 and 2022 (Figure 1.1, panel C), the global prevalence of obesity in the adult population increased from 8.7 percent in 2000 to 15.8 percent in 2022 (Figure 1.1, panel D). Globally, the prevalence of stunting of children under five years of age declined from 33.0 percent in 2000 to 22.3 percent in 2022 (Figure 1.1, panel C). The prevalence of overweight in adults rose from 30.0 percent in 2000 to 43.5 percent in 2022 (Figure 1.1, panel D). In some high- and middle-income countries, over one-third of the adult population is obese. Overweight and obesity are increasing rapidly in countries that have not yet been able to eradicate the various forms of undernutrition, giving rise to multiple burdens of malnutrition.
The nutrition transition is driven by the same interrelated forces that shape the structural transformation of economies and bring about income growth, urbanization, the rise of the modern industry sector and integration in the global economy. The nutrition transition is also linked to increased life expectancy and reduced fertility rates. At the same time, disease patterns move from infectious and nutrient-deficiency diseases to a higher prevalence of overweight and obesity and diet-related non-communicable diseases (NCDs), including coronary heart disease, stroke, diabetes and some types of cancer.6 Between 2000 and 2021, the global prevalence of diabetes increased from 4.6 to 9.8 percent.7
Income growth and the nutrition transition
Income growth is a major driver of the change in food consumption and dietary patterns. Poverty and chronic food insecurity are inextricably linked, and increasing incomes can lift people out of poverty and improve access to food. At low levels of income, a large portion of a household’s expenditure is allocated to food. As incomes grow, the proportion of a household’s budget spent on food declines. For example, household survey data across 46 countries between 1970 and 2007 suggest that, with few exceptions and across all development levels and regions, the poor spend a higher share of their budget on food, compared with richer consumers. On average, the food budget share of the poorest households was found to be 20 percentage points higher than that of the richest households.8
This relationship between income and food expenditure – called Engel’s law – suggests that a part of food consumption is independent of income because it is necessary to sustain life, and is found to be an empirical regularity of economic behaviour prevalent across populations and countries. For example, data suggest that in 2022 in Nigeria, where GDP per capita amounted to USD 4 963, food purchases comprised 59 percent of total consumer expenditure. In the same year, in the Kingdom of the Netherlands, a high-income country, consumers spent 11.8 percent of their total expenditure on food while GDP per capita amounted to USD 59 250. (Figure 1.2).c, 9
FIGURE 1.2Engel’s law: Share of food in total consumer expenditure and GROSS DOMESTIC PRODUCT per capita, 2022
SOURCES: Authors’ own elaboration based on USDA (United States Department of Agriculture). 2024. Data on expenditures on food and alcoholic beverages in selected countries. International Consumer and Food Industry Trends. In: USDA. Washington, DC. [Cited 4 March 2024]. https://www.ers.usda.gov/topics/international-markets-u-s-trade/international-consumer-and-food-industry-trends/#data; World Bank. 2024. World Development Indicators: GDP per capita, PPP (constant 2017 international $). [Accessed on 15 February 2024]. https://data.worldbank.org/indicator/NY.GDP.PCAP.PP.KD. Licence: CC-BY-4.0.
For the poor, as food budgets make up a large part of their income, diets tend to be less diversified compared with high-income consumers. Many low-income consumers’ diets consist of relatively cheaper staple foods to provide adequate calories, with more expensive foods making up a lesser part.d As income grows, dietary patterns shift from being predominantly composed of staple foods to including a higher share of other foods such as more animal-source foods, refined carbohydrates, oils and fats, fruits, vegetables and processed foods. This relationship – known as Bennet’s law – implies that the share of calories from staple foods declines with increasing income and it forms a salient characteristic of the nutrition transition (Figure 1.3).10, 11
FIGURE 1.3Bennet’s law: Share of staple foods in total energy available for human consumption and GROSS DOMESTIC PRODUCT per capita, 2020
SOURCES: Authors’ own elaboration based on FAO. 2024. FAOSTAT: Food Balances. [Accessed on 10 May 2023]. https://www.fao.org/faostat/en/#data/FBS. Licence: CC-BY-4.0; World Bank. 2024. World Development Indicators: GPD per capita, PPP (constant 2017 international $). [Accessed on 15 February 2024]. https://data.worldbank.org/indicator/NY.GDP.PCAP.PP.KD. Licence: CC-BY-4.0.
On average and across countries, the higher the income, proxied by GDP per capita, the lower the share of staple foods in the total calories that are available for consumption. For example, in Mali – a low-income country – the share of staple foods in the total calories available amounts to 73 percent, as compared with a share of 51 percent in the relatively more affluent South Africa, which is an upper-middle-income country (Figure 1.3).
In general, higher food diversity in diets can lead to improved nutrient adequacy of the diet (see Part 3).12 As incomes grow, dietary patterns become more diverse and progressively more people start consuming more meat and fish, milk and dairy products, eggs, fruits and vegetables, and sweets.
Together with the shift towards more diverse dietary patterns, the consumption of processed and ultra-processed foods including those high in fats, sugars and/or salt, which are associated with a higher risk of overweight and obesity, increases (Figure 1.1, panel D). Nutrition experts analysing the nutrition transition in Asia between 1999 and 2012 indicate that while sugar, salt and fat consumption from ultra-processed foods such as carbonated soft drinks, baked goods, and processed culinary ingredients including oils and fats had reached a maximum level or had declined in high-income countries, it was rapidly increasing in the upper-middle- and lower-middle-income countries in the region. This finding indicates that as countries develop economically, consumers tend to opt for more diverse dietary patterns but also for a higher consumption of processed and ultra-processed foods.13 Urbanization and lifestyle changes also support this shift from diets composed of mainly staple foods towards a more diverse diet and higher consumption of processed foods.
Urbanization and nutrition transition
More than half of the world’s population now live in urban areas (see Figure 1.1, panel B). By 2050, this share is estimated to grow to two-thirds. Although urbanization patterns differ both within and across countries, it is expected that Asia and Africa will experience the fastest growth in urbanization.14
Urbanization is an important element of the structural transformation process and is associated with changes in employment, which affect the opportunity cost of time for both women and men and reduce the time allocated to food preparation.15 As urbanization progresses, more women and men work outside the household and spend more time commuting to their jobs. This can affect food preparation in the household, changing dietary patterns and resulting in a higher consumption of processed foods and food consumed away from home.16
Evidence from the 2008–09 and 2012–13 Tanzanian national household budget surveys, which allowed tracing individuals who migrated from rural areas to cities, suggests that relocation from the farm household to cities resulted in a drastic dietary shift from traditional staple foods to pre-prepared or ready-to-eat foods and foods containing high levels of sugar.17 During this period, the urban population in the United Republic of Tanzania was rapidly growing, mainly through migration from rural areas. A survey conducted in 2015 revealed that 61.4 percent of urban dwellers had migrated from rural areas, while 38.6 percent – a smaller share – were born in urban areas.18
However, some researchers argue that the long-term increase in processed food consumption is not due to changes in employment brought about by urbanization but rather to technological improvements and innovations in food processing. Data from the American Time Use surveys, compiled by the United States Bureau of Labor Statistics, suggest that between 1965 and 1995 in the United States of America, technology led to a halving of the time for food preparation for both working and non-working women.19
Nutrition transition and the rise of the modern food industry and marketing
In developing countries, urbanization can cause dietary patterns to change rapidly. This is driven by higher incomes from urban jobs and by the food environment. Food environments comprise the foods available to people in their surroundings as they go about their daily lives. That is, the range of foods available in supermarkets, small retail outlets, wet markets, street food stalls, coffee shops, tea houses, school canteens, restaurants and all the other venues where people purchase and consume food. The food environment determines what food consumers can access at a given moment, at what price and with what degree of convenience and desirability.20 Since the 1980s, the transformation of the food processing industry and the food retail sector has been a major factor in facilitating the nutrition transition in developing countries and emerging economies.
With growing per capita incomes and urbanization in Latin America, Asia and Eastern Europe, supermarkets have spread rapidly, giving rise to the “supermarket revolution” that addressed the increasing demand for more diverse foods in urban areas. For example, in Brazil, the transformation of the food retail sector and the expansion of supermarkets in the 1990s was equivalent to the changes in the food retail sector of the United States over a 50-year period.21 Supermarkets and an expanding food processing industry facilitated the shift in dietary patterns by improving access to meat and fish, dairy and eggs, and vegetable oils as well as processed foods high in fats, sugars and/or salt.
In the 2000s, the supermarket revolution and the transformation of the food processing sector began in Africa. Studies suggest that by 2010, processed foods accounted for 70 percent of all food purchased in value terms for urban consumers in Eastern and Southern Africa, with 60 percent being highly processed.22 In Kenya, purchasing food from supermarkets contributed to a higher consumption of processed and highly processed foods and a lower consumption of unprocessed foods, leading to a higher probability of being overweight or obese among adults.23
Globalization, trade and the nutrition transition
Across countries, the supermarket revolution and the expansion of the food processing industry have been fuelled by foreign direct investment (FDI). Since the 1980s and 1990s, capital market liberalization in countries such as Argentina, Brazil, Mexico and the Republic of Korea has attracted substantive investments in the food retail sectors and food processing industries of those countries, while significant foreign investments flowed into China and Eastern Europe as soon as privatization policies were initiated.24 In African countries, after the privatization of the parastatal food marketing boards, which had a significant share of the food processing sector, small and medium enterprises, as well as larger companies and supermarkets, proliferated during the first decade of the new millennium.25 Some researchers suggest that FDI levels were more strongly associated with rising obesity in low- and middle-income countries, compared to the influence of international trade (see Box 1.1 for a discussion on the impacts of FDI on nutrition).26
BOX 1.1Foreign direct investment and nutrition
Trade in food and agricultural products has been a critically important component of the deep transformation of agrifood systems associated with globalization, and a key component of global, regional and domestic agrifood systems. Trade and investment liberalization also shapes investment patterns across country borders, affecting food processing, retail and promotion. Increased investment across borders has played a fundamental role in integrating country economies and has been a critical driver of changes to the structure and nature of agrifood systems – and the nutrition transition.
There are a range of options for foreign companies to enter new markets. These include through franchise agreements, cash and carry wholesale trading, strategic licensing agreements, manufacturing and wholly owned subsidiaries, and through foreign direct investment (FDI). FDI is defined as an investment made by a company from one country into a company (new or pre-existing) in another country, and one in which the original company owns a substantial interest (although not necessarily a majority interest). In this way, the foreign enterprise creates, or joins, what is described as a transnational corporation.
For companies, FDI provides a means to create demand by advertising and marketing products while at the same time more efficiently adapting to local consumer characteristics. FDI has become one of the preferred ways by which many company types, including transnational food and beverage corporations, enter new markets, and policymakers globally generally consider FDI a critical part of economic growth, thus seeking to attract FDI into their economies. With FDI, processed foods can often be produced in the host country for less than the costs associated with export (which entail transport and storage, as well as the navigation of tariff and non-tariff barriers), particularly when the host country has the raw materials for production.
The benefits of FDI to country economic development include the provision of non-debt servicing foreign exchange, job creation and increasing employment, enhanced foreign relations, increased export capacity, enhanced technology transfer and imitation, and a licensing agreement. FDI is a highly cost-effective way for transnational food and beverage companies to reach foreign markets. The large shift into FDI in food processing in the 1990s and beyond was characterized by the companies of high-income countries investing in the markets of low- and middle-income countries, which particularly affected (ultra-) processed food and beverage products in the host market (more so than products produced through primary processing). FDI into the food processing of confectionary and sugar-sweetened beverages was significant. A study describes how in Poland, for example, confectionary attracted more FDI in the 1990s “than FDI in meat, fish, flour, pasta, bread, sugar, potato products, fruits, vegetables, vegetable oils and fats put together”, and in Mexico, approximately three-quarters of the FDI is in processed food products.56
In the 1970s, the primary focus of FDI into the agrifood system was on the raw commodities of agriculture (e.g. oil crops and cereals) for export. In the 1980s, the focus shifted onto food processing and retailing. Transnational food and beverage companies invested in manufacturing facilities in new countries for products such as confectionary, dairy products, baked goods, snacks and sugar-sweetened beverages. In the late 1990s, FDI into primary agricultural production surged again. In the 1990s, the global regulatory environment for FDI became significantly more liberal, with many new regulations forged in trade and investment agreements, and a proliferation of bilateral and regional trade agreements. As with trade in goods and services, fewer barriers and more incentives to investment facilitated corporate expansion by enabling transnational companies to reduce costs, increase market power, and obtain efficiencies in marketing and distribution.
Companies also started to use new cross-border strategies (of investment, commerce and collaboration) to expand their influence. Such changes led in the 1990s to greater inflows of FDI into low- and middle-income countries – in fact, growing more than six-fold in a decade. FDI became considerably more important than trade regarding agricultural and food products. Compared to trade, FDI has advantages as it enables companies to be located closer to customers to circumvent import tariffs, tailor products to local consumer preferences and more easily comply with national regulations.
The FDI-trade relationship is also context-specific, and it is important to note that FDI and trade in agricultural and food products are substitutes in some cases and complementary in others. In the food and agricultural sector, there was particularly intense investment into food processing. Globally, food processing became the principal recipient of agrifood-system-related FDI, with soaring investment into outlets selling processed foods.
The first years of the new millennium experienced a sharp decline in FDI flows because of political and economic disruptions in major recipient countries. The ensuing recovery in FDI flows came with some changes: the emergence of increasingly protectionist measures; low- and middle-income countries increasing their share of outgoing FDI and with it the importance of South–South flows; small and medium enterprises also being drawn into FDI; institutional investment funds also becoming a novel component of FDI, particularly in energy; and greater importance of FDI in agriculture.
FDI into food retail also took off in the mid-1990s and 2000s leading to the “supermarket revolution” and similar trends in food service restaurants, with companies making significant investments and consequently increasing the number of food service outlets. Much of this FDI went to high-income countries, but it also went in increasing proportions to low- and middle-income countries, where spending on meals outside the home gradually increased.
The supermarket revolution was characterized by supermarkets in Europe, the United States of America, Japan and in the richer low- and middle-income countries making large investments, particularly in the markets of other low- and middle-income countries. Prior to the 1990s, supermarkets occupied only a tiny niche of the retail sector in most countries, but by the late 2000s this had changed dramatically. Many high-income country retailers joined the ranks of the top 100 largest holders of foreign assets globally.
The changes were driven by saturation and intense competition in home markets, weak competition and higher margins to be made in the markets of low- and middle-income countries, and the increasing use of cars and refrigerators in many low- and middle-income countries, which facilitated weekly shopping, with supermarkets able to sell products at low cost due to economies of scale in procurement. Institutional and regulatory reforms were a key facilitator of the changes. The regulatory environment for modern retail shifted to one far more facilitatory, coupled with the modernization of supermarket procurement systems, itself driven by practices from transnational supermarket chains, which reduced costs and increased the competitiveness of supermarkets relative to traditional retailers, and of transnational supermarkets relative to domestic chains.
The impact of FDI on local competitors is mixed, but in the case of the United States-based fast-food chains, it led to their near total dominance in many countries. In other cases, the entry of transnational food and beverage companies stimulated local competitor development by introducing new standards, products, technologies, marketing innovations and management concepts. The growth in supermarkets also opened a key channel for the sale and purchase of processed food products. Multinational retailers have an interest in selling processed products with long shelf lives and minimal waste. Companies developed sophisticated promotion or marketing strategies, resulting in processed foods becoming high-value items by targeting high-income consumers, lowering prices over time, expanding the market base and out-competing other companies. In Brazil, for example, prices of processed foods declined by 30 percent between 1994 and 1997. Despite such trends in food service and retailing, it is worth noting that in many low- and middle-income countries, especially countries in Africa and Asia, perishable products such as meat, fish and vegetables continue to be accessed primarily from traditional or informal outlets. This is often the case even in countries where supermarkets are now commonplace.
Companies may also expand their investments across multiple points of the agrifood system. The processes of trade and investment liberalization have resulted in companies being able to exert influence more easily over the length of food supply chains through processes of vertical integration, and to more easily horizontally integrate and increase control through mergers, acquisitions and joint ventures. With global vertical integration, a company brings together the entire process of producing, distributing and selling a particular food under its control by buying and contracting other companies and services worldwide.
Such vertical integration reduces transaction costs associated with having different suppliers and creates economies of scale, thus providing an important avenue for company growth, and for agrifood companies, resulting in greater market power. Such processes of vertical integration have been a key driver behind the dramatic changes in the global agrifood system, with marked increases in the supply of the types of foods associated with the nutrition transition.
SOURCE: Walls, H. (forthcoming). Foreign direct investment: The nutrition transition, and its relationship with trade liberalization and trade agreements – Background paper for The State of Agricultural Commodity Markets 2024. Rome, FAO.
Increasing foreign investment flows is one of the many dimensions of globalization that results in a more connected and interdependent world. The term globalization is often used to describe the process of interaction among economies, cultures and populations across the world, brought about by international trade, technology spillovers, improved communication and flows of investment, people and information. The KOF Globalisation Index – a widely used measure of the economic, social and political dimensions of globalization – suggests that globalization has strengthened significantly since 2000, with the upward trend slowing down in 2020 due to the pandemic (see Figure 1.1, panel E).e, 27
As with FDI in food retail and processing, other dimensions of globalization can affect dietary patterns and the nutrition transition.28 Trade is central to the globalization of food and agriculture. For example, following the first European contact with America at the end of the fifteenth-century, trade brought maize, potatoes and tomatoes from the New World to the Old World, and rice, barley and sugar cane from the Old World to the New. The range of foods exchanged across the Atlantic profoundly changed food production and dietary patterns.29
Since 2000, global food and agricultural trade more than doubled in volume and almost quintupled in (nominal) value, rising from USD 400 billion in 2000 to USD 1.9 trillion in 2022 (Figure 1.1, panel F). This growth in trade is the result of several drivers. Increases in income in both developed and developing countries have fuelled trade expansion in food. Lower transport costs have made it cheaper to trade. The decline in import tariffs and more transparent and predictable trade policies – resulting from the World Trade Organization (WTO) Agreement on Agriculture that entered into force in January 1995 and many bilateral and regional trade agreements – have also been key drivers in promoting food trade.30
Trade can help balance food supply and demand globally by moving food from surplus to deficit areas, thus fostering food security globally. Higher food imports can increase the availability of calories and nutrients in a country and, by lowering prices, allow for better access to food. At times of shortages caused by extreme weather events, trade can help stabilize food supplies and prices (see Part 2). Global markets contribute to the availability of a variety of foods enabling dietary diversity, accelerating the nutrition transition and impacting nutritional outcomes (see Part 3).31 At the same time, trade can increase the availability of ultra-processed foods that are high in energy density and high in fats, sugars and/or salt, shaping dietary patterns associated with overweight and obesity (see Part 4).
The nutrition transition in rural areas
While higher incomes, urban residency, market integration and sociocultural shifts have been major drivers of change in dietary patterns in urban areas, it is now clear that the nutrition transition is also taking place in rural areas. An increasing body of research shows that, in low- and middle-income countries, rural areas are rapidly catching up with the nutrition transition. A large-scale population study across 200 countries and territories indicates that between 1985 and 2017, the rate of body mass index (BMI) growth in rural areas was equal to or higher than that of cities in most low- and middle-income countries.f, 32
As the nutrition transition permeates rural areas, evidence is emerging that in many high-income countries, rural residents are currently more likely to be overweight and obese than urban residents. Examples include rural residents in Australia,33 Denmark,34 and the United States.35, 36 Rural areas in low-income countries appear to follow similar trends. Recent research undertaken by the Food and Agriculture Organization of the United Nations (FAO) revealed that rural households purchase most of the food they consume, and that processed and ultra-processed foods are easily available in markets in remote rural areas across all 11 African countries studied.37 This indicates a growing convergence between rural and urban diets in low-income countries, owing to the availability of processed foods in small rural food shops.
Multiple burdens of malnutrition
As the nutrition transition is occurring more rapidly in low- and middle-income countries than it did in high-income economies, overweight and obesity are increasing rapidly in countries that have not yet been able to eradicate hunger. Multiple forms of malnutrition now exist, cutting across socioeconomic classes, including the coexistence of undernutrition and overweight and obesity among individuals and households within populations.38
The existence of multiple forms of malnutrition is evident in low- and lower-middle-income countries, owing to rapid increases in overweight and obesity and relatively moderate reductions in stunting, which was initially at high levels. The recognition of the need to renew efforts to tackle malnutrition in all its forms culminated with the proclamation of the United Nations Decade of Action on Nutrition in 2016 (Box 1.2).
BOX 1.2United Nations Decade of Action on Nutrition, 2016–2025
The Decade of Action on Nutrition was recommended at the Second International Conference on Nutrition (ICN2), co-hosted in November 2014 by FAO and the World Health Organization (WHO). The Rome Declaration on Nutrition and its companion Framework for Action were adopted, outlining a common vision for global action to eradicate hunger and end all forms of malnutrition and recommending policy commitments.57
In 2016, the United Nations General Assembly proclaimed the period 2016–2025 as the UN Decade of Action on Nutrition (“Nutrition Decade”), committing UN Member States to the sustained and coherent implementation of policies, programmes and increased investments to eliminate malnutrition in all its forms, everywhere, leaving no one behind. FAO and WHO co-lead the implementation of the Nutrition Decade in collaboration with the World Food Programme (WFP), the International Fund for Agricultural Development (IFAD) and the United Nations Children’s Fund (UNICEF).
The Nutrition Decade’s Work Programme58 embraces six cross-cutting and connected action areas derived from the recommendations included in the ICN2 Framework for Action: (a) Sustainable, resilient food systems for healthy diets; (b) Aligned health systems providing universal coverage of essential nutrition actions; (c) Social protection and nutrition education; (d) Trade and investment for improved nutrition; (e) Safe and supportive environments for nutrition at all ages; and (f) Strengthened governance and accountability for nutrition.
The Nutrition Decade’s Work Programme stresses that trade policies and trade agreements should support nutrition policies and programmes and not negatively impact the right to adequate food. It underlines the importance of achieving global food security and nutrition targets through opportunities identified in trade and investment policies, improving access to a safe and nutritious food supply through appropriate trade agreements and policies. Work in this action area is based on the ICN2 recommendations related to creating an enabling environment for effective action and international trade and investment.
The joint FAO/WHO Secretariat of the Nutrition Decade convened the Nutrition Decade’s Mid-term Review in 2020 and 2021.59 During the review period there has been increasing recognition of the need for trade policy and nutrition action coherence, and the importance of governance and cross-sectoral cooperation.60 It was acknowledged that trade can expand consumer choices and contribute to healthy diets ensuring sufficiently available quantities of diverse, nutritious foods all year round. Imports can be a source of minimally processed nutritious foods with a longer shelf life that can contribute to offsetting the seasonal scarcity of perishable foods, but also of ultra-processed foods that are high in energy density, fats, sugars and/or salt. Trade can contribute to positive nutrition outcomes through its support to livelihoods and income generation, particularly for those engaged in primary food production.
The review also proposed priority focus areas for the remaining years of the Nutrition Decade such as considering using trade policy, including instruments such as tariffs, to improve the food supply, strengthening regional partnerships among countries and leveraging existing regional economic groups, improving data collection and developing tools to better understand trade policy impacts on nutrition.
Since 2000, in lower-middle-income countries, the prevalence of both obesity and overweight followed an upward trend, increasing to 12.1 and 36.3 percent respectively by 2022. In the same year, 13.4 percent of the population in lower-middle-income countries was undernourished, while 28.5 percent of children under five years of age were stunted. Since 2000, in low-income countries, the prevalence of overweight has been increasing where economic downturns, conflict and weather extremes have reversed the decline in the prevalence of undernourishment (Figure 1.4).
FIGURE 1.4The burden of undernourishment and multiple forms of malnutrition: Selected nutritional outcome indicators, 2000–2022
SOURCES: Authors’ own elaboration based on FAO. 2024. FAOSTAT: Suite of Food Security Indicators. [Accessed on 12 April 2024]. https://www.fao.org/faostat/en/#data/FS. Licence: CC-BY-4.0; UNICEF, WHO & World Bank. 2023. Joint child malnutrition estimates (JME). In: WHO. Geneva, Switzerland. [Cited 15 June 2024]. https://www.who.int/teams/nutrition-and-food-safety/monitoring-nutritional-status-and-food-safety-and-events/joint-child-malnutrition-estimates; WHO. 2024. The Global Health Observatory: Prevalence of obesity among adults. [Accessed on 27 May 2024]. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-obesity-among-adults-bmi-=-30-(age-standardized-estimate)-(-); WHO. 2024. The Global Health Observatory: Prevalence of overweight among adults. [Accessed on 27 May 2024]. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-overweight-among-adults-bmi--25-(age-standardized-estimate)-(-)
Nutrition experts suggest that, at the country level, the existence of multiple forms of malnutrition is mainly driven by the rise in overweight and obesity in high-income households, due to the accessibility of ultra-processed food and beverages that are often high in energy density and in fats, sugars and/or salt.39, 40 Indeed, economic inequalities in rapidly developing low- and lower-middle-income countries can contribute to multiple burdens of malnutrition. A study analysing longitudinal trajectories in stunting and overweight in children in Ethiopia, India, Peru and Viet Nam, suggests that a child’s likelihood of being stunted or overweight depends on the income level, urban or rural residence and maternal education level.41
