BRINGING AGRICULTURE TO THE TABLE - HOW AGRICULTURE AND FOOD CAN PLAY A ROLE IN PREVENTING CHRONIC DISEASE RACHEL NUGENT, PHD, CHAIR - CHICAGO ...
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Bringing Agriculture to the Table
Bringing Agriculture
to the Table
How Agriculture and Food Can Play
a Role in Preventing Chronic Disease
Rachel Nugent, PhD, Chair
332 South Michigan Avenue
Suite 1100
Chicago, Illinois 60604
thechicagocouncil.org
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Design: Addison www.addison.com
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Bringing Agriculture
to the Table
How Agriculture and Food Can Play
a Role in Preventing Chronic Disease
Rachel Nugent, PhD, Chair
Sponsored by
1
The Chicago Council on Global Affairs is a leading independent nonpartisan orga-
nization committed to influencing the discourse on global issues through contribu-
tions to opinion and policy formation, leadership dialogue and public learning.
The Chicago Council provides members, specialized groups and the general public
with a forum for the consideration of significant international issues and their bear-
ing on American foreign policy. In addition to remaining the premier platform in the
Midwest for international leaders in foreign policy, the Chicago Council strives to
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for the corporate community and to broaden and deepen the Chicago Council’s role
in the community.
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RESPONSIBILITY OF THE AUTHOR AND MAY NOT REFLECT THE VIEWS OF HER
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tance to global affairs. Authors are expected to “benchmark” their findings against
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2 The Chicago Council on Global Affairs
Foreword & Acknowledgments
FOREWORD
Major themes in understanding the nor has it been convincingly put into the oldest and most prominent interna-
global agriculture and food system are action in the preparations for the High- tional affairs organizations in the United
long-standing abundance, uneven distri- Level Meeting. States. Independent and nonpartisan, The
bution, and the rising energy density of Chicago Council is committed to influenc-
food in the form of greater production In the decades to come, the agriculture ing the discourse on global issues through
of animal-based foods and greater pro- and food system will need to change contributions to opinion and policy for-
cessing of all foods. The first two themes to meet the related challenges of ris- mation, leadership dialogue, and public
have been thrown into sharp relief with ing demand, accessibility and afford- learning. The Council believes that its
recent increases in food prices, raising ability, and improved nutrition and midwestern base and knowledge of agri-
anew the question: can total food pro- health. Burgeoning population and rising cultural issues contribute to the value of
duction meet demand in the decades incomes will continue to raise demand for this report and to international discourse
ahead, and how will the poor fare? A sec- more food and increasingly diverse diets. on foreign policy issues.
ond, and related, question is also taking At the same time, persistent economic
deprivation and undernutrition in some
center stage: will natural resource limita- ACKNOWLEDGMENTS
tions eventually put a halt to food supply areas of the world will require more effi-
The Chicago Council would first like to
growth? Both answers vitally depend on cient distribution and greater access.3 The
thank Project Chair, Rachel Nugent, for
choices made now and are the subject system will need to meet these demands
her vision throughout the project’s very
of ongoing policy discussions and actions. in spite of increased frequency of natural
demanding six-month process. Dr. Nugent
The third theme has received less atten- disasters, shifting climate patterns, and
brings a passion for the very complex
tion but prompts a no less important growing resource scarcity, particularly of
issues surrounding the intersection of
inquiry: how can the global food supply arable land and water.
agriculture, diets, and health and is partic-
help people be healthy? ularly dedicated to advancing the voice of
This report offers an integrated look at
agriculture, food, nutrition, and the grow- vulnerable populations in the developing
A High-Level Meeting convened by the
ing threat of diet-related chronic diseases. world and advocating for more attention
United Nations General Assembly in late
It presents analysis and recommenda- and donor support to combating NCDs.
September 2011 focuses on actions to
tions suggesting that the farm and food Her longtime interest in these issues,
prevent and control noncommunicable
systems across the globe are dynamic and technical expertise, and willingness to
diseases (NCDs) worldwide, especially
robust, capable of producing adequate explore new fields and points of influence
in low- and middle-income countries.
food to meet people’s needs for the fore- were essential to framing the project. It
Leaders have urged a multisectoral
seeable future, but in need of significant speaks to the energy of Dr. Nugent and
response to NCDs, naming agriculture
course corrections as well. the regard she has earned in the interna-
and food production among the impor-
tional community that the project was
tant sectors in which policies should be
The Healthy Agriculture, Food, and able to garner the support and assistance
developed to support health objectives.
Noncommunicable Diseases project of key players in international organiza-
The UN resolution calling for the meeting
builds upon The Chicago Council on Global tions, academia, advocacy groups, and
emphasized the use of indicators to moni-
Affair’s previous work on agriculture, research communities.
tor development progress and specifically
development, and food policy, including
urged integrating indicators for NCDs The Council extends its deepest appre-
the 2006 task force report, Modernizing
within the system already in place to track ciation to the members of the Advisory
America’s Food and Farm Policy: Vision
the Millennium Development Goals. But Group: leaders and experts in the fields of
for a New Direction; the 2009 report,
measurements to track progress in build- agriculture, nutrition, health, economics,
Renewing American Leadership in the
ing health outcomes into agriculture and business, public policy and the environ-
Fight Against Global Hunger and Poverty;
nutrition policy are not simple to agree ment. Each member’s distinct back-
and the recently released Progress Report
upon, or to implement.1 The “whole-of- ground, technical expertise, and views on
on U.S. Leadership in Global Agricultural
government approach”2 to respond to the issues provided essential background
Development. Founded in 1922, The
NCDs is not yet well defined by the UN for cross-sectoral examination of food
Chicago Council on Global Affairs is one of
3
and NCDs. I would like to thank them for Credit is due to several members of The Ellen Hunt expertly managed structural
their time and willingness to share their Chicago Council staff who played key edits of the reports, while Carole Palmer
expertise and exchange ideas and reac- parts in planning and implementing the of Creative Services, Inc., copyedited the
tions candidly during and following their project and creating the final report. final report. Consultant Reilly Lambert
meeting in Chicago. They serve as ambas- Lisa Eakman, Executive Director, Global finalized and formatted references.
sadors to their fields in the future dia- Agriculture & Food Policy, was instrumen- Consultant Aimee de la Houssaye fact-
logue between the agriculture, agrifood tal in scoping the project and assembling checked the report. Other Chicago Council
business, nutrition, and health fields. the project team and provided guidance staff, including Jo Heindel, Sam Skinner,
and expertise throughout the duration Elisa Miller, Elizabeth Lulla, Diane Gilbert,
The report was greatly strengthened by of the project. Elizabeth Ramborger, and Tyler Strom also made valuable
the suggestions provided by the Technical Senior Project Manager, adeptly man- contributions.
Review Panel. Drs. David Pelletier, David aged the day-to-day operational support
Nabarro, and K. Srinath Reddy offered for all aspects of the project, organized Finally, The Chicago Council would like to
invaluable feedback and guidance during the research and drafting process, and express its deep appreciation and thanks
the finalization of the report narrative. provided input on the project’s materi- to PepsiCo for the generous support that
als and final report. Maggie Klousia, made this project and report possible.
The Council extends thanks to the senior
Senior Program Officer, and Sung Lee,
industry representatives; numerous lead-
Senior Editor and Research Analyst,
ers in the NGO, advocacy, and think-tank
played key roles in providing background Marshall M. Bouton
communities; and to the academics and
research and materials to the project President
international development practitioners
team. Consultant Marya Khan contrib- The Chicago Council on Global Affairs
who made themselves available for useful
uted to the report drafting and provided
conversations with the project chair and
technical research, data analysis, and
team. These individuals provided essen-
development of the report’s figures
tial information and helpful insights that
and charts. Research assistants Asta
informed the final report.
Schuette, Ashwin Parulkar, and Joshua
The Council is grateful for the support of Scheinberg provided key inputs at vari-
the Leverhulme Centre for Integrative ous junctures of the project, including
Research on Agriculture and Health literature reviews, project framing docu-
(LCIRAH), based at the London ments, data collection, and report ele-
International Development Centre. ments. Intern Robyn Jacobs cheerfully
Director Jeff Waage, Administrator and efficiently contributed to research,
Catherine Leigh, and Alan Dangour of obtaining permissions for data use, and
the London School of Hygiene & Tropical development of the final report’s figures,
Medicine graciously facilitated a side charts, and appendices, as well as provid-
event for this project at the LCIRAH work- ing invaluable support to the meeting
shop on Measuring Effects of Agri-Health of the Advisory Group in Chicago. Editor
Interventions in London.
4 The Chicago Council on Global Affairs
Chair and Advisory Group
Chair Advisory Group
Rachel Nugent Pamela Anderson Samuel C. Scott III
PhD, Senior Research Scientist, Director General, International Potato Retired Chairman and CEO, Corn Products
Department of Global Health, Center, Consultative Group on International International, Inc.
University of Washington Agricultural Research
Robert L. Thompson
Donna Barry Visiting Scholar, School of Advanced
Advocacy and Policy Director, Partners In International Studies, Johns Hopkins University;
Health Senior Fellow, The Chicago Council on
Global Affairs; Professor Emeritus of
Louise O. Fresco Agricultural Policy, University of Illinois at
Distinguished University Professor, University Urbana-Champaign
of Amsterdam
Ricardo Uauy
Joyce Kinabo PhD, MD, Professor of Public Health Nutrition,
Professor of Human Nutrition, Department London School of Hygiene and Tropical
of Food Science and Technology, Sokoine Medicine
University of Agriculture
Jean Lebel
Director, Agriculture and Environment,
International Development Research Centre
J. Stephen Morrison
Senior Vice President and Director, Global
Health Policy Center, Center for Strategic &
International Studies
Dariush Mozaffarian
MD DrPH, Co-Director, Program in
Cardiovascular Epidemiology and Associate
Professor of Medicine, Brigham and Women’s
Hospital and Harvard Medical School
Associate Professor of Epidemiology, Harvard
School of Public Health
Robert Paarlberg
Betty Freyhof Johnson Class of 1944 Professor
of Political Science, Wellesley College; Adjunct
Professor of Public Policy, Harvard Kennedy
School of Government
Per Pinstrup-Andersen
H.E. Babcock Professor of Food, Nutrition and
Public Policy; Professor of Applied Economics,
Cornell University
Michael Roberts
CEO, LYFE Kitchen
5
Table of Contents
Foreword & Acknowledgments 3
Chair and Advisory Group List 5
Executive Summary 9
Introduction: The Food System and Health 13
Sidebar: What the UN High-Level Meeting Might Accomplish 14
Case Study: Burkina Faso 15
1
Trends in Agriculture & Health 17
Figure 1: Global Map of Age — Standardized Deaths 18
Figure 2: Age — Standardized Deaths in Selected Countries 18
Figure 3: Over- and Undernutrition in World Regions 19
Figure 4: Over- and Undernutrition in Selected Countries 19
Sidebar: What is a Healthy Diet? 20
Figure 5: Per capita Caloric Intake 22
Figure 6: Per capita Protein and Fat Intake 23
Figure 7: Country Model 24
Figure 8: BMI Trends 26
Figure 9: Dietary Consumption by Income Level 27
Sidebar: Street Food 28
Figure 10: Agricultural Production Index 29
Sidebar: Agriculture and the Environment 30
Figure 11: Global Production of Meat and Fruits and Vegetables 31
Figure 12: Drivers Affecting Health 34
Case Study: Bangladesh 35
6 The Chicago Council on Global Affairs
2
Bringing Agriculture to the Table 37
Figure 13: Food Supply Chain 38
Sidebar: Food Aid, Nutrition, and Health 38
Figure 14: Food Value Chain 40
Sidebar: Subsistence and Smallholder Farmers 42
Sidebar: The Power of Tomatoes 43
Sidebar: International Food and Beverage Alliance 44
Sidebar: Danone 45
Sidebar: Walmart 46
Sidebar: Archer Daniels Midland 47
Figure 15: Mutual Metrics 48
Sidebar: General Mills 49
Case Study: Brazil 51
3
A Collective Call to Action: Aligning Agriculture and Food with Health 53
Figure 16: Recommendations for National Governments 54
Figure 17: Recommendations for International Institutions 55
Figure 18: Recommendations for Donors 56
Figure 19: Recommendations for Agrifood Businesses 57
Figure 20: Recommendations for Consumers and Their Representatives 58
Case Study: United Kingdom 60
Chair and Advisory Group Biographies 63
Technical Review Panel Biographies 67
Glossary 69
End Notes 71
References 77
7
8 The Chicago Council on Global Affairs
Executive Summary
The agriculture and food system plays a significant role in the
illness and early death that arise out of the imbalanced diets,
empty calories, and overconsumption that are rampant in
high- and middle-income countries and increasingly apparent
in the nutrition and epidemiological transitions under way in
developing countries. This report describes the links between
agriculture and health and demonstrates that agriculture’s
long-term success in surpassing the growth of demand with
greater production—though not yet in Africa—is a necessary
but not sufficient response for modern societies. Long-term
human and environmental health should also be goals of
agriculture. Food and agriculture must play a role in reversing
recent trends that have the potential to stall or reverse the
economic and health advances seen in developing countries
in the last 40 years. 4
While the benefits of the globalized food agriculture capacity in the world today diseases and persistent infectious and
system are apparent—greater choice for into a system for increasing longevity childhood diseases. A related trend in
consumers, greater nutritional diversity, and well-being of humans as well as the these countries is the “dual burden of
and lower cost—the risks are increasingly health of the planet. malnutrition,” in which hunger is com-
apparent as well. The present system monplace, especially among children,
should be credited with making food The shift from early death due to commu- while incidence of overweight, obesity,
more widely available and affordable to nicable disease to much longer lives and nutrition-related NCDs are increas-
large portions of the world. Yet recent and eventual death from chronic NCDs ingly occurring among adults.
trends in food production, processing, is primarily a story of success: technologi-
trade, marketing, and retailing contribute cal, social, and economic. The success The food price “crisis” of the last few years
to the rising occurrence of diet-related story may not have a happy ending, amplifies preexisting inequities in food
noncommunicable diseases (NCDs) however. Changing dietary patterns and distribution and focuses international
around the world. This report is principally lifestyles—spurred by urbanization, the concerns on the poor. Beyond temporary
concerned with the health risks imposed liberalization of markets, demographic shocks, the food system is undergoing
by a modernized food and agricultural shifts, and omnipresent marketing— long-term change that affects nearly
system and evidenced in the climbing have contributed to increased prevalence everyone, including the poor. An ever
global rates of chronic NCDs, and how to of overweight and the chronic diseases greater share of farm output enters the
use innovation, policy levers, and public that accompany it. Low- and middle- commercial food system, with multiple
and private sector leadership to trans- income countries are confronting a “dual transformations of food and many
form the highly sophisticated food and burden” of rising diet-related chronic actors intervening between farmer and
Executive Summary 9consumer. While global commercializa- In the developing world, what the World Recommendations
tion provides a great variety of food and Bank calls “an emerging new agriculture”6
If farm and food systems are to meet
beverages to most people, it also offers is ocurring. It has several features: fast-
those needs, they must produce afford-
more products in processed and packaged paced institutional and technological
able, diverse, and healthy food. Decision
forms containing a wide array of ingre- change in markets, involvement of the
makers at all levels, both public and
dients, including salt, sweeteners, and public and civil society in connecting poor
private, must participate in steering the
oils. Consumption of excess amounts of and small farmers to consumers, and a
food environment in such a direction.
those ingredients and products, combined far-reaching private sector taking on new
The most important decision makers are
with other lifestyle changes, manifests in roles in the food value chain.7
national and international policymakers,
adverse health outcomes.
agrifood businesses, donors in agriculture,
Related to the trends in agriculture, food If farm and food systems are to nutrition, and health, and, of course, the
consumer. They must all contribute in
system products have also become more meet human needs and contribute
commercial, more global, and more the areas of governance, policymaking,
to human health and longevity,
complex. Great improvements in variety, increasing knowledge through research
they must produce affordable, and technology development, financing,
quality, and availability have been accom-
diverse, and healthy food. and personal behavior choices. Creative
panied by declining localization and tradi-
tion. These trade-offs may be desirable ideas and leadership are the first ingredi-
if food systems are delivering affordable ents in the mix. This report recommends
There is no good health without good
and healthy food. But, except for the well- the following actions:
nutrition, and good nutrition depends
off few who can afford it, this is not the on agriculture. Yet public agriculture and
case. The affordability of modern diets health agencies interact little and are To improve governance and
measured by cost per unit of energy, or guided by distinct and sometimes contra- strengthen links between agriculture
kilocalorie, is increasing. But energy is not dictory objectives. Agriculture agencies and health:
the only measure of what a food system and ministries aim for greater food and
should produce. People around the world • Government policies should be aligned
feed production with available resources
are consuming more calories but their across sectors
and technology, while health ministries
health is worsening. focus on disease control. Nutrition objec- • A supra-ministerial body should lead a
tives and outcomes play a role in both cross-sectoral dialogue in countries
Agriculture and food systems across
agencies but are often secondary to the
the globe are interacting directly with • Metrics should be developed to guide
main political and technical concerns in
consumers to present a wider variety of operational programs in agriculture
those two sectors. This report explores
dietary choices. Farmers and their farms and health toward common goals
the potential for defining new indica-
remain as varied as they were a century
tors that connect agriculture and health • Donors should facilitate cross-sectoral
ago, but the path from “farm to fork”
through progress in improving nutrition. programming and planning
is now through an increasingly complex
food system that brings more food diver- Policymakers are challenged to better • Value chain analysis should be used
sity and more common food buying leverage agriculture to produce desir- to identify commercial opportunities to
and eating experiences to consumers able health and nutrition outcomes. improve the healthiness of the food
across the globe. Population needs will vary and pro- supply
grams targeted at the poor and other • Norms and standards should be devel-
In the developed world, market-driven
special groups are still needed. But for oped for the food sector that improve
modernization, basic and applied agri-
the vast majority of consumers globally, nutrition and health
cultural research, and subsidies have led
the commercial food system must be
agriculture to remarkable progress in two • Governments should work with busi-
encouraged—and even directed where
generations. Largely but not exclusively ness to encourage affordable healthy
necessary—to meet society’s food and
due to the Green Revolution in Asia, crop options for food retailing
health needs.
yields rose 70 percent in developing coun-
tries between the 1960s and 1990s. Per
capita food consumption in developing
countries rose 28 percent in that time.5
10 The Chicago Council on Global AffairsPolicy opportunities to improve Research, education, and technology Financing is needed to:
health through agriculture and development can contribute by:
food include: • Build incentives into social insurance
• Including food and health linkages in programs that encourage healthy nutri-
• Using fiscal, trade, and regulatory nutrition, health, and agricultural sci- tion behaviors
instruments to support production and ence education at all levels and priori-
• Provide support through international
consumption of healthy food where tizing this research to better calibrate
organizations to countries seeking
feasible and effective policies
to align their agricultural and health
• Governments should measure and • Conducting operations research on policies
evaluate the contributions of agricul- “nutrition-sensitive” agriculture
• Provide support to countries for
ture and food to diet and health
• Conducting research on how diet- multisectoral planning and strategy
• Agrifood businesses should define a related NCDs affect economic develop- development
value chain for each major product and ment prospects
• Support agrifood business managers
work with suppliers and customers to
• Adapting and developing low-cost that meet health and nutrition goals
maximize private and social values
technologies for primary processing
• Agrifood businesses should build that retain nutrient values
Incentives to support positive
capacity in low-income countries to
• Developing local solutions to post- personal nutrition behavior should
comply with food safety standards
harvest food losses be introduced by:
• International organizations should
• Requiring and funding evaluations of • Donors with programmatic opportuni-
develop technical teams that work
agriculture program impacts on health ties to link agriculture and health
cross-sectorally to support develop-
ment assistance efforts • Providing farmers and farmer organiza- • Agrifood business through efforts to
tions with tools to reduce financial risk share healthy eating values
• International organizations should
prepare model policies to regulate the • Investing in product reformulation that • Consumers and businesses to reduce
food industry that can be adapted to demonstrates increased nutritional food waste
country conditions benefits
• Consumers’ representatives to apply
• Nutrition assistance programs should • Improving knowledge of the food sup- knowledge about cognitive and behav-
be designed to detect and respond to ply in developing countries ior change to encourage healthy eating
the existence of dual malnutrition in
countries and households
• Food aid should be sourced locally
where possible to meet nutrition needs
• Consumers should seek and support
food and beverage companies that
commit to health goals and work with
them to build political will
Executive Summary 1112 The Chicago Council on Global Affairs
Introduction: The Food
System and Health
Today, the global agriculture and food system is challenged
to meet monumental needs. As populations grow and
incomes rise, the world’s farmers, ranchers, and fishers are
being asked to produce more food to meet growing demand.
They will need to increase production at the same time that
resources become more scarce and natural disasters more
frequent. As complex as these challenges are, the agriculture
and food sectors will miss a tremendous opportunity to
advance society’s well-being if they limit their objectives
to producing more food sustainably: they must also feed
the world nutritiously.
Food variety and abundance are not in an environment of dual malnutrition. to achieve good nutrition for the largest
universal experiences. About 900 million However, the threats posed by rapidly number of people in diverse settings,
people in the world live on less than $1.25 worsening health and the rise of dual mal- discussions focus on the subsets of the
a day and are undernourished. At the nutrition demand that the world recognize population that are over- and undernour-
same time, more than 1.4 billion people8 these problems and respond. Cooperation ished, leaving out the growing risks faced
are overweight or obese, with the num- and dialogue must now extend to the full by the 5 billion other people in the world.
ber of people suffering from diet-related spectrum of malnutrition—both over- and Although there has been some coop-
diseases skyrocketing. In many parts undernutrition—and focus on finding eration between agriculture and health
of the world, these problems coexist, solutions that can benefit the health of all. experts to find solutions to chronic food
creating a “dual burden” of malnutrition One essential solution to both these prob- insecurity, it has been difficult for the
and disease for the countries in which lems is good nutrition. And good nutri- two sectors to find a language to identify
they occur. The health conditions create tion depends, ultimately, on the food and common goals.
economic and social costs that threaten agriculture system.
development in low- and middle-income This report argues that the agriculture
countries. Almost one-third of chronic Although many in the health sector are and food system is well positioned to play
disease deaths occur to people under discussing how to mitigate the growing a critical role in curbing the global rise in
60 years old in low- and middle-income burdens of chronic disease and nutri- diet-related noncommunicable diseases
countries, more than twice the age-stan- tional deficiencies, little is said about how (NCDs). It describes the linkages between
dardized rate in high-income countries. agriculture and the food system can help what people consume and agricultural
Under a “business-as-usual” scenario, resolve the problems. The agriculture production, the food system, and the poli-
chronic diseases are projected to rise by and health sectors often work separately cies affecting them. It outlines opportuni-
15 percent by 2020.9 and define success differently. While the ties to marshal the agriculture and food
health community discusses diet qual- system’s global reach, innovation, policy,
It is challenging to create food and ity, the agriculture and food community and public and private leadership to trans-
agriculture policies that support good generally measures nutrition based on form the world’s highly sophisticated food
health, and even more difficult to do so caloric intake. Instead of focusing on how and agricultural capacity into a system
Introduction 13for increasing health and longevity. While
acknowledging that individuals have a What the UN High-Level Meeting Might Accomplish
clear role and responsibility to make food The UN High-Level Meeting on NCDs in September 2011 is prompting a reap-
choices that contribute to their health, praisal of the causes of conditions affecting people’s health around the world
this report focuses on how the agriculture and a search for solutions to the rising problem of chronic diseases. The call for
and food system can make healthy foods multisectoral involvement is strong, but the details of how it would happen and
more available and affordable to consum- where it would lead are largely missing. Nonetheless, a coalition could be fash-
ers at all income levels. Although under- ioned that would include the agricultural and food sectors as important deter-
nourishment is part of this equation, minants of people’s health. A measure of the meeting’s success will be whether
and the scope of the problem global, the it creates a momentum to develop broader government and private sector
report addresses how the agriculture and measures to build stronger nutrition and health objectives into the agricultural
food system can contribute to reducing and food systems.
overnutrition in low- and middle-income
countries, where the prevalence of diet- A number of organizations, including advocacy groups (NCD Alliance),10 scholars
related NCDs is expected to rise most writing in major health journals (the British Medical Journal, The Lancet), 11 and
quickly in the decades to come. think-tank reports, 12 have laid out “asks” in advance of the UN High-Level
Meeting on NCDs. They focus on leadership and international cooperation in
regard to the prevention and treatment, and monitoring and reporting, of diet-
Good nutrition depends, related NCDs. The asks have generally been proposed by and for the health
ultimately, on the food and community, although they do acknowledge the importance of cross-sectoral
agriculture system…. Much more collaboration. The food and agriculture-related requests from among the
is needed than adjustments to many recommendations that might be considered by countries attending the
agriculture and food policy. September 2011 meeting are:
By 2025, reduce salt intake to less than 5g per person per day. Specific priority
Now is the time for the agriculture and interventions include mass media campaigns and voluntary actions by the
food sectors to take on this challenge and food industry to reduce salt consumption.
be more fully integrated into conversa-
tions on diet-related chronic disease. As
Cross-sectoral coordination to align national policies on agriculture, finance,
a result of the 2007–08 food price crisis
trade, industry, transport, urban planning, and education to collectively
and continual commodity price volatility,
address the NCDs epidemic.
the international community has rallied
to support emerging agriculture and food
Mass media campaigns, food taxes, subsidies, labeling, and marketing restric-
systems, primarily those in Africa and
tions to address unhealthy diets and obesity.
Asia. As new programs are rolled out, the
international community has the oppor-
Other interventions that have been mentioned, although not prioritized,
tunity to design them to meet mutual
include providing incentives for the production, distribution, and marketing of
goals of enhancing agricultural produc-
vegetables, fruit, and unprocessed food through trade and finance measures.
tion, increasing food access, and support-
ing healthy populations.
Given the far-reaching health and eco-
It is highly likely that heads of state and ministeries attending the meeting will
nomic impacts of NCDs, it is crucial to
endorse at least some of these actions, and then the task will be up to govern-
address the growing epidemic of diet-
ments and others to carry out. The NCD-oriented UN-watchers believe strongly
related chronic conditions. The agriculture
that the meeting must produce two things to have much impact on the growing
and food system sectors must be part
chronic disease health burden in the world: deadlines for action among global
of a cross-sectoral solution. If govern-
actors such as donors, and UN and development assistance funding for resource-
ments, civil society, and industry can work
poor countries to apply to their needs to tackle NCDs. The “asks” raised at the
together to make more nutritious foods
high-level meeting, and many others proposed in this report, will be more swiftly
widely available, they can help to trans-
and credibly implemented with broad-based efforts that are based on a unity of
form the health and economic prospects
purpose among different sectors in society.
of millions.
14 The Chicago Council on Global AffairsThis is the story of a typical person living mainly of smallholder farmers—need
in Burkina Faso, in West Africa. A low- improved farming technologies and train-
Burkina Faso income, land-locked country with little ing, and access to roads, transportation,
infrastructure development, Burkina Faso markets, electricity, schools, and health
is predominantly rural and relies mainly facilities to improve their livelihoods.
on subsistence and small commercial Rural roads, for example, reduce transport
agriculture. Eighty percent of the popula- costs and enable farmers to bring crops to
tion in Burkina Faso lives in rural areas, market. They also increase access to hos-
and 92 percent is employed in agriculture, pitals, leading to improvements in health.
with women comprising 47 percent of
the labor force.27 Sorghum, millet, and Burkina Faso is one of few countries
maize are the main staple crops culti- attempting to address links between
vated, although the demand for rice agriculture, nutrition, and health with
and wheat is increasing in urban areas.28 coordinated policies. One of the objectives
Research among women in the capital, of the country’s National Nutrition Policy
Ouagadougou, has shown that diets is to reduce the incidence of chronic
consist mainly of starchy staples and veg- diseases related to nutrition.34 Burkina
etables.29 Ready-to-eat foods purchased Faso is also a member of the Economic
A Snapshot of Agriculture and Health in Community of West African States
outside the home constitute a consider-
Burkina Faso
able portion of the diet, accounting for (ECOWAS). Agriculture and health min-
46 percent calorie intake, 52 percent of istries in ECOWAS states are developing
“I live in a rural community in Burkina
fat intake, and as much as 72 percent ways to address agriculture, food, and
Faso.13 I am 17 years old14 and have not
of sugar intake.30 health in an interrelated way.35 However,
completed primary school.15 I am a
ensuring the national capacity and
farmer,16 and my annual income is equiva-
In Burkina Faso, 9 percent of the popula- resources to implement these policies will
lent to $1,260.17 My family grows most
tion remains undernourished,31 and 35 per- be a significant challenge.
of our own food,18 but our village suffers
cent of five-year-old children are short for
from frequent droughts,19 and we do not
their age as a result—a condition termed
always have enough food to eat.20 My diet
“stunting.32” The burden of disease
consists mainly of sorghum, millet, and
maize.21 Sometimes I also eat peanuts, encompasses mostly infectious diseases,
maternal and perinatal problems, such as
potatoes, beans, yams, and okra—and
eclampsia, and nutritional deficiencies.
occasionally eggs or fish.22 I most likely
However, 45 percent of the population
will have about five children,23 and I expect
suffers from high blood pressure, a pre-
to live until my mid-50s.24 I am likely to
cursor to stroke and heart disease.33
suffer from a communicable disease, such
as malaria, during my lifetime or a compli-
Investments in infrastructure are key for
cation in childbirth.25 However, I am just
countries at this stage of development.
as likely to die from a noncommunicable People in rural communities—comprised
condition such as heart disease.”26
This report is intended to be aspirational, Much more is needed than isolated or take time, effort, and political will—and
while acknowledging that it takes time single-commodity adjustments to agri- the results are uncertain. However, it is
to change some of the detrimental condi- culture and food policy. A larger-scale urgent to begin now: every day that cur-
tions that have arisen in those sectors, and more coherent effort is required to rent health trends continue, it is harder
just as it took time to create the condi- reverse the rise in chronic diseases glob- to reverse course.
tions. The recommendations offered ally. A major UN summit on health is
here go well beyond the agriculture and an opportunity to commit to a “whole
food-related “asks” at the UN meeting on of society” approach to human health,
NCDs. They are developed with the per- a central part of which is “whole of gov-
spective of what food and agriculture can ernment” healthy policies that unite
feasibly contribute to improve health. many ministries for the common goal of
population health. These changes will
Introduction 1516 The Chicago Council on Global Affairs
1 Trends in Agriculture & Health
Since the nineteenth century, modernization has improved
the health and well-being of societies. Thanks to advances in
public health—including improved sanitation, immunization
against childhood diseases, and the introduction of antibiotics
in the mid-twentieth century—deaths due to infectious
diseases have declined dramatically. As a result, people are
living longer lives and dying from chronic noncommunicable
diseases, many of which accompany old age.
Noncommunicable diseases (NCDs)—the anticipates that NCDs will continue middle-income countries occur below
main ones associated with diet are heart to rise quickly in these regions, with age 60, whereas only 13 percent occur in
disease, respiratory illnesses, diabetes, Africa, South-east Asia, and the Eastern high-income countries at such a young
and some cancers* —caused 63 percent of Mediterranean expected to experience age. A Burkinabe man is more than three
all global deaths in 2008 and are the lead- over a 20 percent increase between times as likely to die from heart disease
ing cause of mortality in low- and middle- 2010 and 2020.39 or diabetes than an Englishman of the
income regions, with the exception of same age. This confirms that aging is
Africa. Middle-income countries experi- One of the most significant and alarm- not the only driving factor in the rise of
ence the greatest number of NCD deaths ing aspects of NCDs in low- and middle- NCDs globally.
and show the fastest rise in prevalence. income countries is that they affect
In low-income countries, communicable people at a younger age than they do in Unhealthy diet is a major cause of
diseases are still the most common cause high-income countries. Figure 1 shows NCDs. According to the World Health
of death, but NCDs are projected to out- death rates for same-age people from Organization (WHO), the specific dietary
number deaths from communicable dis- heart disease, and Figure 2 shows death contributors to NCDs are insufficient
eases and other causes by 2030.36 In some rates among same-age people for both intake of fruits and vegetables, pulses,
low-income countries, NCD deaths already cardiovascular disease and diabetes for nuts, and whole grains and excess intake
outnumber deaths from communicable four representative countries featured in of salt, saturated fat, and trans-fatty acids.
diseases and other causes.37 The case this report. These dietary choices lead to high blood
study on page 35 describes agriculture, pressure, high cholesterol, overweight,
Figures 1 and 2 on page 18 show the and obesity. The WHO estimates that
diet, and health conditions in Bangladesh.
number of deaths among same-age indi- 1.7 million deaths worldwide are associ-
Almost 80 percent of global deaths from viduals due to selected NCDs. Almost ated with a diet low in fruit and vegetable
chronic diseases occur in low- and middle- half of people who die from NCDs in low- intake. Globally, 51 percent of deaths from
income countries.38 At the current rate, and middle-income countries are under stroke and 45 percent of deaths from car-
the World Health Organization (WHO) 70, compared to about one-fourth in diovascular disease are attributed to high
high-income countries, and the disparity blood pressure, which is linked to diets
* According to the World Cancer Research Fund/ widens at younger ages. About 29 per- high in sodium. Cardiovascular disease and
Amercian Institute for Cancer Research, 30%-40% cent of deaths from NCDs in low- and
of cancers are diet-related. strokes are also linked to high cholesterol,
Trends in Agriculture & Health 17Figure 1 :Age-standardized deaths per 100,000 due to cardiovascular diesase, various dates
> 900
733-900
566-733
399-566
< 399
No data
NCD deaths occur at an earlier age in lower-income countries than higher-income countries
Source: World Health Organization.
Figure 2 : Age-standardized deaths per 100,000 from noncommunicable diseases in selected countries
500
Male
Female
400
300
200
100
0
Burkina Faso Bangladesh Brazil U.K.
Source: World Health Organization.
which is associated with diets high in countries and disadvantaged people in contributed to overweight and the chronic
saturated fats. About 44 percent of all dia- other countries have not yet felt the ben- diseases that accompany it. Low- and
betes cases, 23 percent of cardiovascular efits of modern health technologies or middle-income countries are confront-
diseases, and 7 to 14 percent of cancers are improved water and sanitation systems, ing a “dual burden” of rising diet-related
related to overweight or obesity. 40 so they continue to suffer from infec- chronic diseases and persistent infectious
tious diseases at the same time that they and childhood diseases. A related trend
The shift from early death due to com- are experiencing the swift advance of in these countries is the “dual burden of
municable diseases to much longer lives noncommunicable diseases. Changing malnutrition,” in which hunger is com-
and eventual death from chronic, NCDs dietary patterns and lifestyles—spurred monplace, especially among children,
is primarily a story of success: techno- by urbanization, the liberalization of while incidence of overweight, obesity,
logical, social, and economic. The success markets, demographic shifts, and declin- and diet-related NCDs are increasingly
story is incomplete, however. Many poor ing levels of physical activity—have occurring among adults.
18 The Chicago Council on Global AffairsNot only is a nutritious diet crucial to the case study on page 51. Figures 3 and Health facilities in low- and many middle-
good health at each stage of the life cycle, 4 show a range of countries at different income countries lack trained health
but the theory known as “early origins of income levels that have significant preva- workers with knowledge of chronic dis-
health and development” links undernu- lence of both under- and overnutrition in ease treatment and the behavioral and
trition early in life to greater susceptibility their populations. other risk factors that lead to disease. The
to diet-related NCDs later in life. 41 Chronic economic costs of diagnosing, treating,
undernutrition manifests in 180 million Rising Cost of and providing long-term management
children in the world who are short for Noncommunicable for NCDs are potentially overwhelming to
their age, a condition called “stunting.” Diseases Globally low-resource health systems. Although
Stunted children who live in emerg- Chronic diseases present particular data on health expenditures for NCDs are
ing economies appear to be especially challenges to low-income country health limited, research on specific conditions
vulnerable to obesity and later chronic systems that are overburdened with and risk factors provides some indication
disease42 —a situation that is suggested patients needing immediate care for of how much governments are spending.
by the Brazilian example43 described in infectious diseases and acute conditions. In China, direct and indirect costs related
Figure 3 : Over- and Undernutrition in regions of the world, various dates
Southeast
Africa Asia The Americas Eastern Mediterranean Europe Western Pacific
80
Child Stunting (% of children 0-4
years with low height for age)
Overweight and Obese (% of
60 adults with BMI ≥ 25)
40
20
0
LMIC LMIC LMIC High LMIC High LMIC High LMIC High
Income Income Income Income
Low- and middle-income countries experience a dual burden of malnutrition; overnutrition predominates in high-income countries.
Source: World Health Organization.
Figure 4 : Over- and undernutrition in selected countries, various dates
80
Underweight (% of childrento being overweight and obesity are
equivalent to 4 percent of the country’s
What Is a Healthy Diet?
GDP, and by the year 2025 these costs are
There is a wealth of conflicting infor- difficult thing for the poor to attain projected to reach 9 percent. 44 A recent
mation regarding what constitutes in all countries, especially in rural study shows that health spending on
a healthy diet. Consumers in higher- areas of some countries where diets diabetes care alone ranges from 6 percent
income countries encounter “func- are heavy in starchy staples and there of all health expenditures in China to
tional food” that promises health is little consumption of animal prod- 15 percent in Mexico. 45
benefits from reduced cholesterol, ucts, fruits, or vegetables. 49 In urban
better digestive health, enhanced areas, increased consumption of Diet-related NCDs impose significant
brain activity, and increased energy. packaged foods even among the poor economic burdens on health systems and
In lower-income countries, govern- aggravates micronutrient deficien- impede worker productivity, especially in
ments, donors, and industry provide cies. Food availability is not the only low-and middle-income countries where
delivery of minerals and vitamins constraint—these populations also they disproportionately affect working-
through fortified food products. share a lack of awareness about the age people. The WHO estimates that
While affordability and accessibility of benefits of diversifying diets. a country’s economic growth rate falls
adequate food remain a challenge for 0.5 percent for every 10 percent increase
A simple prescription for a healthy
many people, what we know about in prevalence of NCDs. 46 Aggregating eco-
and diverse diet follows as close as
the paths to good nutrition, and thus nomic losses from countries to a global
possible to following 11 simple rules
good health, is relatively simple. The scale, a recent Harvard School of Public
and one piece of advice.50
World Health Organization report on Health study estimates that the “global
Diet, Nutrition and the Prevention decline in productivity due to illness and
of Chronic Disease48 reviewed the deaths from noncommunicable diseases
Emphasize:
evidence on the strength of the links will reach $35 trillion by 2030 … an amount
Fruits
between diet and chronic diseases seven times larger than the current level
Vegetables
and provides an overview of the most of global health spending.”47
Quality Carbohydrates (whole
convincing evidence of the types of grains, fiber) The current and anticipated economic
foods that increase disease risk. High- Nuts costs alone are reason enough to make
calorie foods are linked to weight gain Fish preventing diet-related NCDs a priority for
and obesity, high sodium and trans Healthy Vegetable Oils the international community. Although
fat are linked to cardiovascular dis- Modest Amount of Dairy Products health systems can be improved, health
ease, and saturated fats are linked to
approaches alone cannot solve this prob-
diabetes.
lem. An effective strategy to improve
A key feature of a healthy diet is Limit: health must include a variety of measures
dietary diversity—consuming a vari- Processed Foods
to encourage increased physical activity
ety of foods across and within food Processed Meats
among populations and support good
groups to improve the intake of essen- Sugar-Sweetened Beverages
dietary choices by providing consumers
tial nutrients. Common food groups Industrial Trans Fat and Salt
with nutritious food options at an afford-
include dairy products, meat and able price.
meat alternatives, fruits, vegetables,
and grains. Because dietary patterns
Eating Behavior: Stages of Dietary Transition
Eat at home rather than away from Around the Globe
differ from place to place, the specific
home—food prepared at home is
food items included in food groups Agriculture and the food system play a
generally healthier than take-away
must be established according to significant role in the illness and early
food or other restaurant meals.
the cultural context, the local foods death that arise out of the imbalanced
available, and their nutritional con- diets, empty calories, and overconsump-
tent. Sufficient dietary diversity is a tion that is rampant in high- and middle-
income countries, and increasingly
apparent in the nutrition and epidemio-
logical transitions under way in devel-
oping countries. In order to illustrate in
concrete terms how countries at different
developmental stages experience these
20 The Chicago Council on Global Affairstransitions, Figure 7 presents key agricul- suggest that Burkina Faso should focus and for consumers to demand healthy
ture and food system, dietary, and health on public investment and facilities that food can also be considered.
characteristics for four countries in differ- enhance the ability of its agriculture
sector to deliver a diverse diet, and the The four countries described in this report
ent stages of transition. Specific indicators
health sector should increase preventive are just examples, each with their own
are in the table and longer descriptions
health measures to slow the rise in NCDs. specific circumstances. But they point
of dietary and health conditions in each
Cross-sectoral efforts should be employed toward a global shift in human condi-
of these countries are in boxes elsewhere
wisely to buttress the efficiency of private tions—at different stages but underway
in the report. These country examples—
sector and individual actions.51 around the world—that will only be exac-
from Burkina Faso at stage 1, to the mixed
erbated with rising incomes and changing
transition under way in Bangladesh at
While also a very poor country with a demographics unless concerted action
stage 2, to advanced transition in Brazil at
poverty level near 50 percent, Bangladesh is taken to move the trends in a more
stage 3, and finally to the United Kingdom
is further along in the agricultural and healthy direction.
at stage 4—show how health conditions
health transitions and faces a real dual
are affected by transitions in agriculture To better understand what is driving the
burden of malnutrition. The burden
and food systems. While a 4-stage model rise in malnourishment and diet-related
of disease due to NCDs is 41 percent,
can’t adequately represent all agriculture NCDs in low- and middle-income coun-
while 27 percent of children under 5 are
and health conditions across the globe, it tries, it is important to examine drivers
stunted. Twenty-nine percent of people
does convey a sense of how agriculture of consumer demand and food produc-
in Bangladesh face very high NCD risk.52
and health conditions change as countries tion and the interplay between them. In
Bangladeshi farmers benefit from greater
develop and allows some generalizations the last few decades, global diets have
government investment in agriculture,
about policy options to be made. shifted dramatically to include increased
and the value added per person is much
higher than in Burkina Faso, at $435 per consumption of foods that place people
In general, the indicators show a pre-
year. As a stage 2 country, Bangladesh can at a higher-risk for diet-related NCDs.
dictable relationship between the agri-
usefully target public interventions to This shift is driven by changes in incomes,
culture system and health conditions.
address gaps—such as greater fruit and food prices, and lifestyles. At the same
As countries develop, they urbanize,
vegetable production—and work across time, the agriculture and food systems
and fewer people work in agriculture.
sectors for greater impact. For the first have dramatically changed the types
Simultaneously, their agriculture sys-
time, Bangladesh’s new health sector and amounts of food products avail-
tems modernize and add greater value.
program for 2011–2016 includes an opera- able to consumers. Greater amounts of
Agricultural transition occurs alongside
tional plan for addressing NCDs.53 high-value foods, such as meat, fruits
improvements in diet that become more
and vegetables, and processed foods, are
diverse and protein-filled, which, in turn,
Countries with higher income, such as available to consumers everywhere.
drives the epidemiological transition from
Brazil and the UK, face very different
conditions of undernutrition to overnutri-
agriculture, food, and health conditions. Consumption Trends
tion and NCDs. For instance, as the table
Traditional diseases of poverty have Scattered information is available about
shows, Burkina Faso remains an agrarian
almost disappeared, but NCDs and their what people eat in developing coun-
society with low investment in agriculture
risk factors increasingly affect the poorer tries and how it affects their health.
and therefore there is low value added
segments of the populations. A wide array Food expenditure surveys are sporadic
in that sector. Ninety-two percent of the
of food choices exists, but overconsump- and food composition studies are rare.
population is employed in agriculture,
tion is common. Agriculture is a small Further, food preferences are not immu-
but the agricultural system produces
and/or declining portion of the labor table but are influenced by many fac-
value of only $181 per worker; therefore,
force, but may be important economically tors. People’s eating behavior is strongly
income and productivity remain low. The
for exports, as in Brazil’s case, or for cul- shaped by information from popular
population suffers from high poverty and
tural and environmental values, as in the culture and global information networks.
undernutrition but is beginning to also
UK. In these settings, the government’s For instance, traditional foods in Brazil
experience other health problems, with
role is no longer to spur and guide devel- have been replaced by mass-produced
20 percent of the burden of disease due
opment as such, but to prevent the unin- convenience foods.54 Dietary surveys from
to NCDs in the population. Spending on
tended health consequences of harmful India and China show that consumption
health is high for a country at this low
development. Regulation of both food of animal products, sugar, and fat have
level of income, but most spending on
producers and consumers might be war- risen year after year for more than 20
health comes from people’s personal
ranted, as well as positive incentives for years.55 A closer look at consumption pat-
expenditures, and the performance of the
the private sector to provide healthy food terns in regions and countries is required
health system is poor. These indicators
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