Malnutrition is often seen as the problem of undernutrition directly induced by poverty in underdeveloped countries, or the lack of access to food. Yet in recent decades, humans have made considerable progress in terms of food production and delivery – taking a global average, of course – which has been largely in line with demand. Half a century ago, 2 billion people could say they were not hungry, compared to nearly 6 billion today, which is a Dantesque progress on a global scale. Despite these successes, more than 820 million people are still hungry (FAO, IFAD, UNICEF, WFP & WHO, 2017) and at least 2 billion more lack sufficient nutrients (Fanzo et al., 2018). In addition, more than 2 billion people in the world are thought to be overweight or obese (Haddad et al., 2015). This is what was later called the triple burden of malnutrition which has reportedly become for several international organisations the “new normal” (FAO, 1996). So when we talk about nutrition security, it’s not just about food security which is just one of the modalities of the problem.
This was the case for a summit that served as a benchmark in this area for many years: the 1996 World Food Summit. This latter defined food security as a condition “when all people, at all times, have physical, economic and social access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life”. In other words, it was a fight against hunger, focusing almost exclusively on calories. In their 2012 report, the Committee for World Food Security set the benchmark as “when all people, at all times, have physical, social and economic access to food which is safe and consumed in sufficient quantity and quality to meet their dietary needs and food preferences, and is supported by an environment of adequate sanitation, health services and care, allowing for a healthy and active life” (CFS, 2012). It is therefore clear that food, and food security in general, is the sole constituent of the nutrition security. Only recently has a third aspect of malnutrition emerged: overweight and obesity. This is due, mainly, to the over-consumption of energy-dense foods (and especially ‘empty’ calories) but also to other factors, such as insufficient exercise and genetics. Together, these lead to diet-related diseases such as type 2 diabetes and cardiovascular disease (Ingram, 2020). Finally, while noting that nutrition security pertains to the individual, we must recognise that there are multiple factors that influence how we achieve it — and the responsibility for taking action spans jurisdictional levels from the community, to the nations and to the entire world (Cash et al., 2006).
This article will attempt to show that the problem of malnutrition is induced by exogenous economic factors, far from a simple individual responsibility, and that prevention, far from being useless, is not sufficient to address the problem. In a world where eating well is becoming increasingly difficult, all the economic or political actors involved must take their share of responsibility.
Sociodemographic factors of malnutrition
Improving food and nutrition insecurity has become a public health priority in developed and economically rich countries, such as Australia, Europe, the United Kingdom, Canada, and the US (Pollard & Booth, 2019). There are many reasons for this, which differ from country to country, but which have some important similarities. Identifying and understanding them can help to formulate credible responses at an appropriate scale.
Analysis of the 2014 General Social Survey of the Australian population quantified the association between 18 discreet stressful life events and food insecurity. Stressors related to employment and health doubled the likelihood of experiencing food insecurity (Temple, 2018). The occurrence of this nutrition insecurity was also associated with receipt of specific social assistance payments in Australia, suggesting that these families were enduring significant financial stress. This insecurity is growing in Australia among the middle-income groups. Food insecurity after a natural disaster, i.e. resilience to shock-induced insecurity, is also a key factor in developed societies. Examination of the impact of Hurricane Katrina on families five years after the event found that higher income, race, and having a partner were protective factors against food insecurity whereas low social support, poor physical and mental health, and being female were risk factors (Clay et al., 2018). However, faced with the worrying issue of food insecurity, the public authorities have tended to withdraw, leaving the associations, NGOs and food banks alone.
The absence of robust food insecurity monitoring and surveillance systems in the households of Australia, Scotland and Europe has led researchers to undertake a secondary analysis of related surveys in order to determine the nature and prevalence of household food insecurity (Carrillo-Álvarez et al., 2018). Analysis trends in the relation between food affordability at the household level and diet quality in Scotland found that poorer households were less likely to achieve recommended dietary intakes over time. Similar to the concept of rental stress, the innovative geographically based Food Stress Index was developed using the Western Australian Government’s Food Access and Cost Surveys and relevant sociodemographic census data to determine place-based risk of food stress (Landrigan et al., 2018). Furthermore, a tailored Aboriginal and Torres Strait Islander version tested in five remote communities found similar results, with food alarmingly found to not be affordable in either of these areas. The nutritional environment can influence the availability and accessibility of food, which are both components of food insecurity. Nutrition environment measurement tools were applied and they found that in rural and socially disadvantaged communities in Australia, it is harder to access nutritious food at affordable prices (Pollard & Booth, 2019).
Many social and demographic factors are therefore at the root of malnutrition, whether through unequal access to food, the urban/rural gap, or the quality of food acquired, etc. All of these parameters complicate a problem that has long been considered an individual responsibility: we get fat because we eat too much, we don’t do enough exercise, etc. The central point of sociology, research has therefore recently understood that the individual is included in a society and that if he acts on it, it acts on him in return.
The weight of discretionary income and economic factors
The global value of the food trade grew from US$ 224 billion in 1972 to US$ 438 billion in 1998. Food now accounts for 11% of global trade, a proportion higher than that of fuel (Pinstrup-Andersen & Babinard, 2001). This fast-growing market has encouraged the development of companies in the sector, transforming agricultural and food companies into large transnational corporations which have developed global brand names and marketing strategies with adaptation to local tastes. Virtually all aspects of the production and processing of food have been transformed in the last three decades. The overproduction of agricultural produce in developed countries is a perennial problem. For example the food supply in the USA contains 3800 kcal for every adult and child. Moreover, the demand for food is relatively inelastic (Chopra et al., 2002). Sugar and salt are the two most commonly added ingredients, and fats and oils are also added in large amounts. Advantage is thus taken of people’s liking for sweet foods and of the tendency to ignore satiety when sweet and fat foods are consumed (Egger & Swinburn, 1997).
Along with the changes in the food supply, the marketing of food has clearly influenced dietary change. As urbanization proceeds, people’s preferences are clearly being shaped by the introduction of consumers to aggressive marketing techniques and by increased supplies of domestic and imported goods (Evans et al., 2001). Global marketing and the systematic moulding of taste by giant corporations such as Mc Donald’s, Coca Cola or Nestlé is a central feature of the globalization of the food industry (Barnett & Cavanagh, 1994). The food industry in the USA spends over US$ 30 billion each year on direct advertising and promotions — more than any other industry. In South-east Asia, food advertising expenditures increased from US$ 2 billion to US$ 6 billion between 1984 and 1990. Mexicans now drink more Coca Cola than milk (Jacobsen, 2000).
Globalisation has therefore been accompanied by an acceleration in the number of patients. As per capita incomes in developed countries have grown over the past three decades, overnutrition leading to obesity and elevated health risks for cardiovascular disease, diabetes and some forms of cancer has occurred. The prevalence of these forms of malnutrition in populations is highly influenced by the rate of appearance of discretionary income. In developed countries, discretionary (alternatively “disposable”) income refers to funds available after obligate payments (rent, heat, and the cost of getting to work) and payment for necessities (food and clothing) (Karp et al., 2005). With chronic poverty, a process called the “Engel’s Phenomenon” occurs. Food selection narrows to those items providing the most energy at lowest cost. Over time, micronutrients disappear from the diet, and specific nutrient deficiencies follow (Karp & Greene, 1983). For families below the poverty line, increased income results in increased discretionary spending, almost inevitably leaving no room for increasing the nutritional quality of food or caloric intake. Theoretically, at the poverty level, the total income goes to pay the obligate expenses and the cost of necessities – 1/3 for food, 1/3 for housing, and 1/3 for other necessary expenses. Only past poverty incomes does discretionary income appear where discretionary income equals total income minus the cost of obligate expenses and necessities (Citro et al., 1995). At poverty level or below, all income goes for necessities. Increasing the total income has no effect on discretionary income since none accumulates (Karp et al., ibid). The ratio of change in food expenditures to change in income is called the marginal propensity to spend on food (Immink, 1982). The marginal propensity to spend on food in developed countries is high for the poor, and low for the richer. For the affluent, expenditures for food change little with increased or decreased income. Rather, increased income provides an opportunity for choice as new income is available entirely for discretionary spending. This “income of opportunity” is not available to the poor (Karp et al., ibid).
The necessity of a global action
The arguments we have made so far tend to prove the macro dimension of the problem of malnutrition, which is both multiple and difficult to influence. There are limited examples of interventions that are effective in reducing food insecurity in developed countries. For example, monetary incentives to encourage fruit and vegetable purchases in remote Aboriginal communities show limited success due to the multiple challenges related to the operational running of the community stores, but were highly valued by women with children and accepted by the community (Brown et al., 2019).
A majority paradigm until recently emphasised behaviour and individual control to regulate diet and reduce fat and sugar intake. This has emphasized identification of various risks and risky behaviour and, consequently, identification of individuals at greatest risk. Infortunately, this approach ignores the repeated and expensive failures to change diets solely through the improvement of knowledge (Beaglehole, 2001). The trading and global marketing of unhealthy commodities such as tobacco have been recognized as transnational factors that may damage health and globalization is fuelling an epidemic of non communicable diseases through the promotion of certain foodstuffs and diets. In the face of such large-scale global change, individual behaviour appears to be a drop in the ocean, and has so far proved ineffective in solving problems on too large a scale, as in the case of climate change. Multilateral collective strategies, especially the development of international standards, are essential for protecting and promoting public health against the hazards associated with globalization (Taylor et al., 2002).
International trade liberalization has contributed to the world’s growing obesity rate, and the laws that protect and perpetuate such liberalization can, in certain instances, stand at odds with state efforts to address the public health issue. A central component of enhanced multilateral cooperation in support of public health is the expanded use of international instruments. In order to achieve national objectives for the protection and promotion of public health, governments have found it increasingly necessary to cooperate in order to impact the cross-border factors that affect their populations (Taylor, 1996).
It therefore seems necessary to further develop supranational cooperation bodies in this area in order to provide global responses to phenomena that are just as global. Prevention and awareness campaigns at national level are obviously not useless and are a good way to raise awareness at individual level. However, such individual steps are not sufficient and cannot alone solve what is today an urgent global health problem. A global strategy must therefore be established, in close cooperation with the World Health Organization in the field of nutrition, physical activity and health. In addition, there are often related problems of undernourishment. A concerted multisectoral approach, involving political, economic and commercial mechanisms, is necessary to address these issues.
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By Mahmoud Refaat: The European Institute for International Law and International Relations.
