The Nutrition Transition
MOBILISING THE FOOD CHAIN FOR HEALTH
Workshop
25-26 OCTOBER, 2012, OECD CONFERENCE
CENTRE, PARIS
Prakash Shetty and Josef Schmidhuber
Overview
Overview
• Part I: What makes a healthy diet?
• Part II: What is the nutrition transition?
• Part III: NCDs: The extent of the problem
and its main manifestations
• Part IV: Nutrition transition, NCDs and the
key drivers
–
–
–
–
Ageing populations, urbanization and income growth
Phenotypic and genotypic predisposition
Agricultural policies?
… many more!
The Nutrition Transition
1. What makes a healthy diet?
http://www.fao.org/docrep/005/ac911e/ac911e00.htm
1. What makes a healthy diet?
Dietary Intake Ranges (1)
The Nutrition Transition
(as a share of total energy intake)
Dietary Factor
Total Fat
Recommendations (WHO/FAO)
15 - 30%
Polyunsaturated FA
6-10 %
Saturated FA
<10 %
Trans FA
<1 %
Total Carbohydrate
Free sugars*
Protein
55 – 75 %
<10 %
10 - 15%
* “Free sugars” refers to all monosaccharides and disaccharides added to
foods, plus sugars naturally present in honey, syrups and fruit juices
1. What makes a healthy diet?
The Nutrition Transition
Dietary Intake Ranges (2)
(in g or mg/person/day)
Dietary Factor
Cholesterol
FAO/WHO
Recommendations
< 300 mg/day
Sodium chloride
<5 g/day
(sodium)
(<2 g/day)
Fruits and vegetables
Total dietary fiber/Non-starch
polysaccharides (NSP)
> 400 g per day
(>25 g, or 20g/d of NSP) from
whole grain cereals, fruits, and
vegetables
http://www.fao.org/docrep/005/ac911e/ac911e00.htm
Overview
Overview
• Part I: What makes a healthy diet?
• Part II: What is the nutrition transition?
The shape of things to come ...
The Nutrition Transition
The Economist, December 2003
The Nutrition Transition
The Nutrition Transition
The Nutrition Transition
The Nutrition Transition
The Nutrition Transition
The Nutrition Transition
More fat and more saturated fat
The Nutrition Transition
The Nutrition Transition
The Nutrition Transition
The Nutrition Transition
More Cholesterol
The Nutrition Transition
The Nutrition Transition
The Nutrition Transition
The Nutrition Transition
More sugar, mostly hidden
The Nutrition Transition
The Nutrition Transition
The Nutrition Transition
Overview
Overview
• Part I: What makes a healthy diet?
• Part II: What is the nutrition transition?
• Part III: NCDs: The extent of the problem
and its main manifestations
The Nutrition Transition
AT2050/80: provisional nutritional outcomes
(global averages/aggregates)
undernourished
% of population
with
kcal/person/day
obese
%
million
>2700
>3000
%
million
2005/07
13
844
57
28
9
570
2050
4
330
91
52
15
1400
2080
2
150
98
66
21
2000
The Nutrition Transition
Deaths Attributable to 16 Leading Causes
in Developing Countries, 2001
Yach, D. et al. JAMA 2004;291:2616-2622.
Copyright restrictions may apply.
Global estimates of Hunger and Childhood
malnutrition
The Nutrition Transition
Almost 870 million people are chronically undernourished (FAO, 2012)
Childhood Malnutrition:
Developing Countries:
Underweight
27 %
148 million
Stunted
31 %
175 million
Wasted
8%
44 million
Low birth weight
17 %
Unicef
2005
(UNICEF
2005)
The Nutrition Transition
Micronutrient malnutrition
Micronutrient
Malnutrition
Global Estimates:
Vitamin A deficiency
100 -140 million children
Iron Deficiency
2.0 billion women
(96 million pregnant)
Iodine deficiency
740 million
(Micronutrient Initiative Report 2001)
Burden of Disease attributable to Iron Deficiency
The Nutrition Transition
(expressed as percent DALYs)
Overview
Overview
• Part I: What makes a healthy diet?
• Part II: What is the nutrition transition?
• Part III: NCDs: The extent of the problem
and its main manifestations
• Part IV: Nutrition transition, NCDs and the
key drivers
–
–
–
–
Ageing populations, urbanization and income growth
Phenotypic and genotypic predisposition
Agricultural policies?
… many more!
The key drivers
Ageing populations
Robust income growth for the last 5 decades
45
GDP, Trillion US$ (2004)
The key drivers
40
35
30
25
20
15
10
5
0
High income
RoW
Source: World Bank
GDP, trillion, $2004
percent per annum
The key drivers
GDP Growth to continue
High-Income GDP (left axis)
High-Income Rate (right axis)
Developing GDP (left axis)
Developing Rate (right axis)
Source: World Bank
Urbanization to further accelerate over
the next 40 years
7.00
6.00
Billion people
The key drivers
5.00
Rural
Urban
4.00
3.00
2.00
1.00
—
Source: UNPD, 2011
The key drivers
Urbanization
Changing food marketing chains and food habits
• Access of metropolitan areas to international
food markets
• Formalization of the food chain, supermarkets
• Opportunity costs of food preparation: No time
to prepare food, limited time to eat
• Convenience and fast food (salt, fat, sugar)
Expending calories
• Sedentary lifestyles (public and private
transportation, lifts, piped water, TV)
Rural - Urban differences in Obesity prevalence
25
Rural
20
PREVALENCE ( % )
The key drivers
Urban
15
10
5
0
Vietnam
China
Indonesia
The key drivers
Urban-rural difference in chronic disease risk in
developing countries
Urban (%)
Rural (%)
Reference
NIDDM
prevalence
8.2
2.4
Ramachandran
(1998)
CHD
prevalence
46.1
5.0
Chadha et al.
(1990)
Cancer
incidence
118.8
57.6
Gopolan (1997)
Source: Shetty, P. in Macbeth and Shetty
The key drivers
Genotypic and phenotypic
predisposition
• Unmasked by urbanization, sedentary lifestyles
and excess food consumption
• Thrifty gene (Pima Indians, South Pacific)
• Barker hypothesis and epigenetic effects
The key drivers
Agricultural policies?
The CAP?
OECD support policies more generally?
What about biofuel policies?
Principal policy effects of the CAP
2001/03
The key drivers
MILLION €
€/PERSON
1. Taxes

Taxes through higher prices than world
prices

Other taxes on consumers
-51,904
-136.8
-698
-1.8
2. Subsidies

Subsidies from taxpayers to consumers
3,762
9.9

Excess feed cost (not relevant as a food
tax/subsidy)
570
1.5
-48,271
-127
Net effect (total tax)
Source: own calculations (JS) based on OECD
Price tax effect of the CAP by Commodity
(main commodities only)
1986-88
2001-03
Total
(million €)
per person
(€)
Total
(million €)
0
0.0
0
0.0
0
0.0
900
2.7
262
0.7
0
0.0
6254
18.4
1343
3.7
157
0.4
Rice
377
1.1
317
0.9
180
0.5
Potatoes
619
1.8
900
2.5
444
1.2
Coarse grains
7043
20.7
2703
7.4
559
1.5
Sheep
2497
7.4
1376
3.8
1113
2.9
Sugar
2699
7.9
2100
5.8
2739
7.2
Poultry
2950
8.7
3995
11.0
3179
8.4
Pork
4473
13.2
2973
8.1
4401
11.6
Beef
10208
30.1
7205
19.8
10470
27.6
Milk
16667
49.1
17278
47.4
16373
43.2
Total
54686
161
40452
111
39615
104
Oilseeds
The key drivers
1994-96
Eggs
Wheat
per person
(€)
Total
(million €)
per person
(€)
Source: own calculations (JS) based on OECD
Consumer subsidies through the CAP
Transfers from EU Taxpayers to EU consumers (million Euros)
1986-88
1994-96
2001-03
The key drivers
million Euros
Total
4387
4146
3762
Cereals
310
286
249
Oilseeds
32
0
0
-361
-138
248
-65
-24
99
1
67
157
2169
1549
1035
Olive oil
388
365
26
Cotton
723
1100
874
1126
986
1330
Sugar
Sugar storage levies (net)
Sugar chemical industry levies (net)
Milk and butter
Fruits and vegetables
Source: own calculations (JS) based on OECD
CAP Consumer subsidies for milk
1986-88
1994-96
2001-03
The key drivers
(million Euros)
Milk and butter, total
2,169
1,549
1,035
Other measures relating to butterfat
232
645
454
School milk
165
130
77
Aid for SMP for use as feed for calves
901
438
246
Aid for liquid skimmed milk for use as feed for calves
112
24
0
0
0
0
Aid for liquid skimmed milk for use as feed for animals
other than calves
179
0
0
Aid for skimmed milk processed into casein
580
311
258
Aid for powdered milk with 10% fat for use as feed for
calves
0
0
0
Other Aid (milk)
0
0
0
Aid for SMP for use as feed for animal other than calves
Source: own calculations (JS) based on OECD
Food taxes?
The key drivers
• Through agricultural policies
• Through direct food taxes
Vertical price transmission:
The impact of the CAP with high margins
US$/t
450
The key drivers
400
T
350
300
T
+34$=10%
P
Pconsumer+T
consumer-2
Pconsumer
Pconsumer
M1 = M2
250
200
150
T T +34$=20%
Pincentive
Pincentive
Pmarket
P +T
PSE-R
PSE-R/CSE-R
market-2
Pmarket
P
PSE-M
PSE-M/CSE-M
market
Pborder
P
border
100
Source: Schmidhuber and Britz, 2002
Vertical price transmission – the empirical evidence
EU-15, 1996, 1.25 €/$ x-rate
(Data based on OECD and World Bank, own calculations)
1400
Value of final food expenditure
= US$
1014 billion
1200
1000
billion US$ 1996
Food taxes: efficiency and effectiveness
Food value chain in the EU
800
Margin/value added for marketing, processing, etc = US$
780 billion
600
400
200
CAP - CSE tax on consumption
=
US$ 48 billion
Value of consumption at world prices, primary products =US$
0
Year=1996
139 billion
Food taxes: efficiency and effectiveness
How elastic is food demand?
Food taxes: efficiency and effectiveness
Impacts of an (ad valorem) tax on food with
elastic and inelastic demand
Inelastic demand
Elastic demand
(Rich consumer)
(Poor consumer)
Si
P1
Po
T
P1
Po
D’i
q1 q0
Sd
T
D’d
Di
q1
q0
Dd
Food taxes: efficiency and effectiveness
Policy instruments: Effectiveness of food taxes
Food taxes: efficiency and effectiveness
Impacts of a tax on “food” on “overweight/obesity”
body weight (output)
Food (input)
Rich consumer
(IC)
Si
P1
Po
T
D’i
Q1=DES1
BMI0
BMI1
Di
Qo=DES0
DES
DES1 DES0
DES
Food taxes: efficiency and effectiveness
Food taxes: some pros and cons
–
–
–
–
+
+


Higher farm prices ineffective means to change final consumer
prices (high margins in vertical price transmission).
Low price elasticities for food demand make food taxes in
general ineffective in reducing consumption.
Regressive on consumers with high calorie needs.
Untargeted, unfair: all consumers bear the price of higher food
prices while only the obese/overweight cause the external costs
(violates the “polluter pays principle”).
But low elasticities mean high tax revenues which could be used
for nutrition education, prevention, and other measures.
Food taxes can be effective, where there are healthy substitutes
(e.g. low-sugar soft drinks); high elasticity of substitution would
require only a small tax on unhealthy food of a small subsidy on
the healthy food.
No general food tax, but specific taxes on unhealthy foods
possible.
Part of a policy mix but not a stand-alone measure.
Conclusions
• Emerging epidemic of obesity (and its co-morbidities) not
confined to the developed world
• Determinants of the emerging epidemic of global obesity
are complex and include macro and micro level drivers
and individual and environmental factors
• Strategies that are developed to reduce the global burden
of obesity will need to address a complex range of
individual and environmental determinants.
Thank you
Conclusions and outlook
Conclusions and Outlook
1.
EU diets have become increasingly unhealthy, the quality of the
Mediterranean Diet is gradually deteriorating.
•
•
•
•
•
2.
3.
4.
5.
6.
The EU diets are too rich in calories, fat, sugar, cholesterol and saturated fats.
Dietary fibre as well as fruit and vegetable consumption have increased over
time, but some countries still show deficits.
Consumption of polyunsaturated fats has increased, but largely through a
widening of the ω-6/ω-3 ratio.
The total glycemic load of the EU diets has increased with carbohydrate
consumption, but remained low compared to NENA countries.
There has been a growing convergence in diets, new member countries move
towards EU-15 diet, albeit some country specific features remain.
Overall, CAP provides a net tax on food consumption, albeit some subsidy
elements are important.
As a tax on primary consumption, the demand curbing effects of the CAP
remain limited; CAP effects are to be seen against: (i) low vertical price
transmission; (ii) high margins for processing and marketing; and (iii) low
demand elasticities.
Taxes on final consumption can be more effective, but only where healthy
substitutes exist.
Food taxes on inelastic demand can be used as a revenue source for more
effective measures (education, etc.)
No single policy measure likely to be sufficient, need for an appropriate
policy mix.
Fast food, soda and obesity
Are diets converging and how to measure
convergence?
The Nutrition Transition
The Consumption Similarity Index (CSI)
CSI j ,k
95 Cal


Cal
1
ij
ik 
 1 

2  i 1 Cal j Calk 
where i=1 to 95 food items of FAO’s SUA data base;
Calij and Calik are the calories from individual products i in country k and j;
Calj and Calk is the total calorie availability per person in country j and k.
The Nutrition Transition
Towards an increasingly homogenous diet?
The Nutrition Transition
The CAP distorts relative prices –
both vis-à-vis world markets and within the bundle of consumption goods
The key drivers
Domestic-to-international
distortions
EU prices to international prices
(ratios)
Internal distortions of relative
prices
(relative to EU wheat prices)
1986-88
1994-96
2001-03
1986-88
1994-96
2001-03
Wheat
2.14
1.14
0.98
1.0
1.0
1.0
Rice
2.43
1.84
1.32
1.1
1.6
1.3
Coarse grains
2.33
1.41
1.05
1.1
1.2
1.1
Oilseeds
1.00
1.00
1.00
0.5
0.9
1.0
Potatoes
1.17
1.15
1.10
0.5
1.0
1.1
Milk
2.76
2.14
1.84
1.3
1.9
1.9
Beef
2.25
1.63
2.54
1.1
1.4
2.6
Pig meat
1.38
1.17
1.25
0.6
1.0
1.3
Poultry
1.79
2.07
1.55
0.8
1.8
1.6
Sheep
2.86
1.59
1.36
1.3
1.4
1.4
Eggs
1.40
1.22
1.04
0.7
1.1
1.1
Sugar
3.32
2.13
2.75
1.6
1.9
2.8
The Nutrition Transition
Global prevalence of Vitamin A
Deficiency