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There is increasing recognition that the nutrition transition sweeping the world’s cities is multifaceted. Urban food and nutrition systems are beginning to share similar features, including an increase in dietary diversity, a convergence toward “Western-style” diets rich in fat and refined carbohydrate and within-country bifurcation of food supplies and dietary conventions. Unequal access to the available dietary diversity, calories, and gastronomically satisfying eating experience leads to nutritional inequalities and diet-related health inequities in rich and poor cities alike. Understanding the determinants of inequalities in food security and nutritional quality is a precondition for developing preventive policy responses. Finding common solutions to under- and overnutrition is required, the first step of which is poverty eradication through creating livelihood strategies. In many cities, thousands of positions of paid employment could be created through the establishment of sustainable and self-sufficient local food systems, including urban agriculture and food processing initiatives, food distribution centers, healthy food market services, and urban planning that provides for multiple modes of transport to food outlets. Greater engagement with the food supply may dispel many of the food anxieties affluent consumers are experiencing.
Half of the world’s population live in large settlements, often on food-producing lands and in political environments where governments have traded off agricultural self-sufficiency for an industrial economy fuelled by the lure of food exports and food import substitution.1 As painfully slow advances are made to reduce the numbers who are underweight, there has been a rapid escalation in the numbers who are overweight and obese, a risk factor for numerous chronic noncommunicable diseases.2 City inhabitants are at particular risk of both under- and overnutrition because of their reliance on a commercial food supply, access to which requires income from wages.
This paper focuses on the dynamics of national food and nutrition systems as they impact on the health inequities present within city populations. We synthesize a broad sweep of literature to develop a theoretical map of the food system determinants of health inequities and nominate seven key determinants of urban nutrition status. To highlight the complex set of relationships that underpin food and nutrition systems in countries at varying stages of industrialization—postindustrial, industrial, and industrializing—we briefly describe the situations of three cities: Melbourne, Bangkok, and Nairobi (see Dixon et al.3 for greater detail—http://www.who.or.jp). Reference to different stages of industrialization reflects more accurately the economic transition underway globally than the terms “developed/developing” countries.
Approximately 800 million people are food-insecure and at risk of undernutrition and underweight. “Of these, 95% are in middle- and low-income countries (and around 60% of these are in Asia.”4 However, since the 1970s, there has been a generalized nutrition transition characterized by greater dietary diversity and a shift toward “Western-style diets” of meat, dairy, less complex carbohydrates, and reduced fruit and vegetable intakes. The amount of energy available for consumption has increased, with the highest levels being in the Middle East, China, Latin America followed by the rest of Asia and Oceania.5 This situation is because of a host of factors, including the global trade in foods and technological revolutions in agriculture and food processing which mean that “[p]eople around the world can purchase more calories today for the same money as Western Europeans could decades ago at a similar gross domestic product level.”6 Relatively easy access to caloric energy is a major contributor to the two billion adults estimated to be overweight and obese.7
Demand side factors include:
Supply side factors include:
Up to a certain stage of socioeconomic development, urban diets are considered to be more nutritious because “urban dwellers consume a more varied diet than their rural counterparts, richer in animal proteins, fats, and processed staple foods.”12 In China, for example, the urban nutrition transition is well-established; per capita meat and fish consumption are significantly higher in urban areas, and urban grain consumption is three times lower than that in rural areas.13
The risk of overconsumption of energy increases with close proximity to markets and food processing sectors,12 whereas many of the urban poor do not benefit from the entire cornucopia because “the shift towards fast and convenience foods is also a shift away from fresh fruits and vegetables, pulses, potatoes and other roots and tubers towards a diet with increasing consumption of sugar, salt and fat in the diet.”9
Hawkes14 argues that analyses of the nutrition transition must acknowledge socioeconomic differentials to dietary changes. She notes that within industrializing countries, the diets of whole populations are converging toward a similar but limited mix of food groups with dietary diversity, or divergence, confined to wealthier and better educated groups. Unequal access to calories and diversity gives rise to inequities in nutrition status, with undernutrition being more common among the poor in industrializing cities, whereas in industrial cities the rising middle classes are at greater risk of overnutrition. The coexistence of under- and overweight individuals in the same household poses difficulties for interventions, with one estimate for China being 10% of households experiencing the double burden of malnutrition.9 Among the very poor, overnutrition can coincide with micronutrient deficiency.14
In the postindustrial country context, unequal access to dietary diversity has been characterized as a slow food–fast food binary. In this scenario, the wealthy consume diverse diets of unprocessed and local foods sourced from specialist providors, city farmers markets, and “wholefood” cafes and restaurants, whereas the majority rely on industrial and processed foods of varying nutritional quality sourced from supermarkets, fast food chains, and cafes that use short-order cooks to heat and serve mass-produced food.15,16
Sonnino and Marsden17 argue that these trends in diets are the result of “the contemporary food sector...bifurcating into two main ‘zones’ of production: standardized, specialized production processes responding to economic standards of efficiency and competitiveness on the one hand; localized, specialized production processes attempting to trade on the basis of environmental, nutritional, or health qualities on the other.” The alternative food “zones” provide distinctive nutritional content and opportunities for food-related satisfaction and satiety.18,19
Driving the food zone based on standardized foods is a relatively small number of transnational corporations, as evidenced by the fact that in 2002, the ten largest food companies controlled 24% of global processed food sales.20 From their numerous country offices, field officers negotiate contracts with farmers and suppliers for highly prescribed quantities and qualities of product, which will enter global commodity chains (see illustrative case studies of African cocoa bean sourcing21 and the global processed tomato industry).22 The global trade in fresh and processed foods is regulated less by governments and producer groups and more by international conventions, such as the Sanitary and Phyto-Sanitary agreement of the WTO, and initiatives such as the European Produce Working Group (comprised of 13 leading food retailers), which has protocols covering supply chain dynamics to ensure food safety. The global harmonization of food standards and retailer consortium domination of standards “reveal tensions between the goals of trade facilitation and the protection of public health,” and can operate in favor of wealthy, urban consumers and against the livelihoods and health status of rural communities.23
In this way, the governance structures that regulate the international food trade alongside the national bifurcation of urban food systems are having significant impacts on health inequities. Given the critical importance of nutrition to early physical and cognitive development, children are especially vulnerable to the inequitable distribution of, and access to, food. Whereas there are significant urban–rural differences, with the prevalence of underweight among urban children less than among rural children, urban areas contain marked disparities, which can be greater than rural differentials. In urban areas of Latin America, the risk of stunting is estimated to be up to 10 times higher among the poorest children than for the wealthiest group.24
On the basis of the foregoing literatures, Figure 1 provides a theoretical schematic of the pathways linking globalization, urbanization, national food system dynamics, and class composition to the differential availability, access, and acceptability of foods at the household level. Factors operating at these different levels codetermine the population’s propensity to consume differential amounts of calories and types of nutrients, leading to inequities in the distribution of diet related diseases.
Issues of food security and malnutrition in rich and poor cities are becoming more complex and differentiated. Because of a lack of comparative data, we illustrate the dynamics of three urban food systems before detailing the major structural determinants of diet-related health inequities.
Australia experiences the full range of nutritional issues, namely:
Food Insecurity Specific nutrient deficiencies are present among indigenous, migrant, and elderly populations.42 The health effects of poor nutrition, including low birth weight, contribute to a life expectancy discrepancy of 20 years between indigenous and nonindigenous populations.43 In car-dominated cities, access to a car and food are related because the cheaper, healthier food outlets are in regional shopping centers. In Melbourne the lack of a car can reduce food access by 50%.44
Ontological Insecurity The decline of traditional culinary cultures based around seasonality, locality, and self-sufficiency has encouraged a state of ontological insecurity among postindustrial eaters.47 There is widespread anxiety among Australian consumers regarding a healthy diet48 and a plethora of competing sources of dietary advice.
Based on a further synthesis of relevant literatures from four fields—nutrition science, development economics, food sociology and public health—we have identified seven major national and household level determinants of urban nutritional inequalities. Each is described in more detail in Dixon et al.3
Determinants 1 to 4 apply to cities at the three stages of industrialization, whereas determinant 5 is most applicable to industrializing cities, determinant 6 to industrializing and postindustrial cities, and determinant 7 applies largely to postindustrial cities. Determinants 1 to 5 result from national government deregulation of financial and commodity markets combined with the activities of global food manufacturing and retailing corporations, within a context of ongoing state regulation of agriculture via producer subsidies by North American and European nations. Determinant 6 is partly a result of mass movements of rural people into cities in search of employment, aggressive lobbying efforts by automobile producers, and fiscal crises of cities leading to underinvestments in active transport infrastructures.51 Determinant 7 is the inevitable consequence and embodiment of the other determinants because they combine to remove consumers physically and culturally from their food supply. Countries that cling to their culinary traditions (France and Japan) exhibit lower levels of overnutrition and have populations who express pleasure in food.52
Any substantial effort to interrupt the pathways depicted in Figure 1 will necessarily involve national governments renegotiating world food production and trade rules. In the meantime, cities can embark upon building and strengthening urban food systems to improve nutrition, increase food sector employment, strengthen food safety for local consumers, and reestablish the sociophysical bonds between people and their food supply. The following initiatives are described in greater detail in Dixon et al.3 Most are partnerships between governments, locally owned small and medium enterprises, and civil society. Some analysts believe that food and agricultural social movements have a pivotal role to play in building socially and environmentally sustainable food and agriculture systems.54
In relation to food production and processing, the Nairobi and Environs Food Security, Agriculture and Livestock Forum has sponsored training courses on urban agriculture and livestock keeping, with gains in the availability and affordability of food, urban farmer incomes, and the cleaning and greening of the city in which it has been piloted. Indigenous people and governments of three South American countries have worked with the Italian-based Slow Food Movement to support the growth of local food economies, and to provide traditional foods of superior nutritional value.
Ninety kilometers north of Bangkok, the city of Sam Chuk has restored its major food and smallgoods market with the assistance of the Community Architects for Shelter and Environment, ensuring the sustainability of trader livelihoods while attracting tourists. Bugurini Market in Dar es Salaam has become an exemplar for WHO’s Healthy Marketplace program, by introducing best practices to prevent and control foodborne hazards, again ensuring the survival of fresh food markets in that city. And in the postindustrial context, the London Development Agency has conducted a feasibility study to establish a sustainable food distribution hub to supply independent food retailers, restaurants, and city-based institutions.
An increasing number of cities are adopting policies to limit car transport and to encourage alternative forms of mobility, but few have developed a comprehensive strategy to make population health a key planning principle. In Melbourne, the National Heart Foundation has developed with the Planning Institute of Australia (Victoria branch) a set of design considerations to promote walking, cycling, and public transport use. Implementation will improve people’s access to healthy food options.
Rather than a single nutrition transition, urban food and nutrition systems are characterized by a complex convergence–divergence in increasing caloric energy and dietary diversity as well as a bifurcation in dietary sources, especially within more affluent cities. These trends are encouraging a maldistribution of global dietary energy and nutrition intake, which is reflected in inequalities in overnutrition, undernutrition, and diet-related health inequities.
Feeding city populations equitably cannot be left to market forces alone, but requires government and civil society-auspiced intersectoral approaches involving agriculture, urban planning, small business, and health sectors. Such approaches must acknowledge complex webs of causation between global and national policies favoring industrialization and private equity, the elimination of food-producing habitats, transformations in food retail, consumer poverty, ignorance, and anxiety.
The WHO Centre for Health Development, Kobe, Japan, supported the research contained in the paper. The material on Thailand results from Dr. Dixon’s chief investigator role on a Project Grant 268055, Wellcome Trust and National Health and Medical Research Council, “The Thai Health Risk Transition.”
Dixon is with the National Centre for Epidemiology and Population Health, Australian National University, Acton, 0200, Australia; Omwega is with the Department of Food Science, Nutrition and Technology, University of Nairobi, P.O. Box 442-00605, Uthiru, Nairobi, Kenya; Friel is with the International Institute for Society and Health, University College London, 1-19 Torrington Place, London, WC1E 6BT, England; Burns is with the School of Public Health, Deakin University, Burnwood, Victoria, Australia; Donate is with the School of Global Studies, Social Science and Planning, Royal Melbourne Institute of Technology University, LaTrobe Street Melbourne, Victoria, Australia; Carlisle is with the Physical Activity, National Heart Foundation of Australia (Victorian Division), 411 King Street, West Melbourne, Victoria 3003, Australia.