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1. Imbalances in food systems are major drivers of dietary and nutrition inequities. They can restrict access to healthy diets or promote low-quality diets.

2. There is a need for food systems to: go beyond a narrow focus on energy intake; reduce the dominance of cereal production (maize, rice and wheat); and increase the availability of healthy foods such as fruits and vegetables, nuts and whole grains.

3. The food environment, where consumers make decisions about what to eat, is inequitable for many in terms of physical access, affordability, targeting of advertising, and marketing and quality of foods.

4. The interconnected causes of inequities in food systems require an integrated response at global, national and local levels, bringing together the capacity of multiple sectors.

5. An equity-sensitive approach to food systems that delivers healthy diets would seek to reduce inequities, as well as directly address food availability, accessibility and price in local food environments.

6. Addressing inequities within food systems is ultimately about addressing power imbalances: amplifying the voice of those excluded, and holding the powerful to account.

"A food system gathers all the elements (environment, people, inputs, processes, infrastructures, institutions, etc.) and activities that relate to the production, processing, distribution, preparation and consumption of food, and the outputs of these activities, including socioeconomic and environmental outcomes."[1]

Components of the food system include food supply chains, food environments, consumer behaviour and external drivers (Figure 4.1). These components are interdependent and collectively influence diets and broader outcomes including nutrition and health.

With urbanisation, globalisation and trade liberalisation, food systems are changing rapidly. Food environments are globally connected; supply chains are longer and more complex. These changes have a dramatic impact on the nutritional status of populations. The way that people access food, the kinds of food they purchase, the methods of consumption and the culturally conditioned meanings of food and eating are also shaping food systems.

Food environments refer to the physical, economic, political and sociocultural contexts in which consumers engage with the food system to make their decisions about acquiring, preparing and consuming food. Food environments are the connecting link between supply systems and demand systems - they impact food supply chains and their functions, and the choice and quality of individual diets through a variety of factors. They determine: the types of food available at a given time, the physical access to these foods by the consumer, affordability, food promotion, advertising and information, and food quality and safety.

Inequitable processes affect each component of the food system, resulting in unequal outcomes ranging from poor availability and unaffordability to an overabundance of food of low nutritious quality and limited access to healthy foods. Inequities within food environments alone can be substantial for populations, given the crucial role of food environments as underlying determinants of nutrition outcomes (Figure 4.1). Addressing inequities within the food environment could mitigate impact on nutritional outcomes across food systems. The existing inequities in food systems restrict access to healthy diets for some people, leading to unequal nutrition outcomes and malnutrition in all its forms. The food environment, therefore, deserves a special focus. This chapter proposes a focus on inequities across food environments to highlight emerging solutions and propose concrete actions.

Food availability

Spotlight 4.1 shows that virtually all the increase in food energy (calories) from 1970 to 2010 is accounted for by non-staple crops, which are relatively more nutrient-dense. The proportion of calories from sugars and sweeteners has declined since 1970. This positive trend highlights the need for a more balanced policy and research and development focus on non-staple crops, to support producers to diversify. This in turn could improve the diversity of crops contributing to a balanced and healthy dietary composition.

Similarly, natural resources, ecosystems and climate change affect food production, and in turn the quality and quantity of food available to consumers. At the same time, consumer choices and demand influence the type of food produced and therefore potentially increase pressure on ecosystems and can contribute to climate change.

Figure 4.3 shows how animal-sourced foods have a significant impact on greenhouse gases. Production of staple grains (60% of which are used as animal fodder),[5] fruits and vegetables also creates environmental stress, as does intensive use of crop land and fresh water. Additionally, nitrogen and phosphorus fertiliser applications can affect the quality of food. Production and consumption practices affect many people living in low-income countries who do not have the resources to adapt fast enough to environmental changes and are limited in their options[6] for accessing healthy food. Between demand and supply, a well-regulated food environment - with specific attention to environmental impact, ecosystems management and effect on climate change - is an opportunity to ensure more equitable availability and accessibility of food for all, and to reduce inequality of nutrition outcomes.

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FIGURE 4.3 Impacts of different food groups on the environment

The impact of animal products on greenhouse gas emissions is set to double to 145 percent by 2050. The increase of staples on cropland is also set to grow from 43 percent to 66 percent by 2050.

People's physical access to diverse types of food in a given food environment depends on four types of food sources: production-based entitlement (growing food); trade-based entitlement (buying food); own-labour entitlement (working for food); inheritance and transfer entitlement (being given food by others).

Geographic conditions and lack of appropriate infrastructure can limit the availability and distribution of food. This is especially true for perishable foods, in low-income contexts and rural places where built living environments are often inadequate for ensuring healthy and safe food supplies. Critical factors that influence access include: mobility (distance to food entry points and available means of transportation); health; purchasing power and relative food prices; access to land of adequate size and quality, agricultural inputs, technology and services; time, facilities and equipment available for food preparation; knowledge and skills. The inequities in food accessibility for the rural, the poor and the geographically isolated result in limited access to sufficient quantities of healthy food.[13]

Inequitable provision of basic infrastructure such as housing, sanitation, energy and transport increases the vulnerability of populations to malnutrition. Where infrastructure is completely compromised, such as in conflict situations, breakdown of food availability and access can occur. In these contexts, it becomes incredibly difficult not only to access diverse and healthy foods but even to access sufficient quantities to ensure recommended calorie intakes.

Food affordability

For consumers to be able to purchase and consume healthy foods that are available within the food environment, such foods need to be affordable. For the most vulnerable groups of the population, nutrient-rich foods such as animal-source foods, fruits and vegetables are not affordable. Both price levels and volatility affect household purchasing power, welfare and food security, and nutrition.[14]

A healthy diet consists of fresh foods that are more perishable and subsequently require either cold chains or shorter-distance supply chains, as demonstrated in Spotlight 4.2. A lot of cheaply available food tends to be highly processed and unhealthy.[15] The affordability of healthy food is key to ensure a fair food environment for all. Increasing production and consumption of fresh foods locally, through targeted income support, nutritional assistance and agricultural development programmes, which encourage farmers to diversity the crops that they grow and foods that they consume, is a potential route to making healthy diets more affordable and accessible.

Product and vendor properties

Product properties refer to the safety, quality and appeal of food available in the food environment. Vendor properties describe the location and type of a retail outlet. How people access, prepare and consume food is changing rapidly and depends on the food available to consumers. Packaged and processed foods now comprise a significant share of many diets around the world; and most of those foods are not aligned with the World Health Organization (WHO) definition of a healthy diet.[19] As noted in the previous Global Nutrition Report, Europe, North America and Oceania purchase the highest volumes of packaged foods, although sales growth is stagnant or declining. In contrast, Asia and Africa are undergoing significant growth in sales of packaged foods. Spotlight 4.3 shows the sales of processed foods and sugar-sweetened drinks by country-income category. Growth in sales of these foods and drinks is significant in middle- and low-income countries.

Phillip Baker, Priscila Machado, Kate Sievert, Kathryn Backholer, Colin Bell and Mark Lawrence
Processed foods, and especially 'ultra-processed foods' such as savoury snacks, processed meats, sugar-sweetened drinks, confectionery, frozen desserts, breakfast cereals and dairy products, now comprise a significant share of many diets around the world. They are widely available, cheap and intensively marketed. Such foods are often high in added sugars, trans fats and salt, as well as low in fibre and nutrient-density. They are the major contributor to dietary energy in many high-income countries and play an increasing role in the nutrition transition underway in countries undergoing rapid economic and social change.

Yet there is still relatively little data on the role of processed foods and sugary drinks in diets, especially in middle- and low-income countries (MICs and LICs), often because these categories are absent from health and dietary surveys. Instead, industry sales data is often used to shine a light on how purchasing these products is changing worldwide. Euromonitor International sales data reveals patterns in worldwide purchasing, and differences between countries at different stages of economic and social transition. Sales are increasing modestly or declining in many high-income countries (HICs) but growing quickly in upper-middle- and lower-middle-income countries (UMICs and LMICs).

There are notable differences between countries in the types of foods and drinks purchased. In HICs, a wider diversity of processed food types is purchased when compared to other regions. However there are large increases in purchases of processed and convenience foods such as savoury snacks, sweet biscuits, fruit snacks, baked goods, processed meat and meat substitutes. In UMICs, the 'culinary food ingredient' categories (vegetable oils, sauces, dressings and condiments) comprise a much greater share of purchases than in HICs (Figure 4.5).

Fizzy drinks make up the largest category of beverages consumed globally. However, sales in this category are sharply declining or stagnant in many HICs and UMICs, but growing strongly from a low baseline in LMICs and LICs. However, declines in the carbonates category in HICs have been offset by significant growth in non-carbonate categories - for example, sports and energy drinks, and the ready-to-drink coffee and tea categories (Figure 4.6).

Full sources for this spotlight can be found in the notes.[22]

Food marketing and labelling

Information provided about food - and how food is promoted and advertised - influences consumer preferences, purchasing behaviour and consumption patterns, both negatively and positively.[34] Food promotion, for example, has a direct influence on preferences of children, adolescents and adults and their nutrition knowledge, diets and health. Advertising of ultra-processed food is more prevalent in low-income neighbourhoods, and marketing in these communities is increasing.[35] Spotlight 4.5 highlights inequities in food marketing to children by income and ethnic group.

Labelling of foods and the provision of declarations on food packaging are important tools to inform consumers, shape their preferences and influence industry behaviour by encouraging product reformulations. They are also useful for implementing and monitoring more consumer-oriented approaches such as front-of-pack labelling (FOPL), marketing restrictions, taxation/subsidies and school food policies. Yet the "use and understanding of the dominant standard in nutrition labelling - nutrition information panels - is significantly lower among lower income, lower literacy and ethnic minority groups."[47] The use of interpretive FOPL (i.e. nutrition information with recommendations/judgements rather than specific facts) is recommended in addition to the mandatory nutrition declaration, as these can be more easily understood by consumers of different literacy levels.

FOPL can follow a nutrient-specific system (such as Chile's black label) or a summary indicator system (such as the UK's 'traffic lights') but they should signal unhealthiness to guide consumers' choices to more nutritious options.[48] However, while presenting advantages, mandatory labelling can be a barrier for small-scale producers and processors to entering or remaining in markets.

In addition to collecting more and better food-environment data, we need to understand what people are eating and how they make food choices. This is necessary for developing food and nutrition policies, including dietary guidelines. Comprehensive information on diets, food sourcing and costs is needed, therefore, but has been difficult to obtain. Such data is now becoming available, with better use of metrics and surveys that feed into larger databases. Case studies are also providing important insights. Despite these improvements, there are still large gaps in knowledge at the national level, particularly in low-income settings.

Most research on food environments stems from high-income countries and focuses mainly on obesity and non-communicable diseases. Although, as mentioned in the 2018 Global Nutrition Report, initiatives such as INFORMAS[49] are used by some LMICs, there is very little information available - not only on the low-income context but on rural food environments and for those in conflict or protracted-crisis situations. In addition to societal inequities that constrain data collection and analysis, challenges arise from within the research framework, beginning with the lack of consensus on defining the food environment and standardised metrics and tools, as outlined in Spotlight 4.6.

While many societal inequities permeate food systems, there is a unique set of factors concerning power imbalances across food systems. These imbalances arise from the influence of agribusiness, food and drink industries, international development policymakers and donors. Such groups influence how governments structure their food systems and environments, and also affect the poorest marginalised consumers, who are excluded from this process. All these factors shape the types of foods people have access to on a daily basis. There is an "implicit tension between government action to promote food security and economic growth by encouraging investment, and government action to reduce the consumption of highly processed foods to prevent diet-related NCDs".[51]

"In the context of a rights-based approach, those most impacted by inequitable, dysfunctional food systems and unhealthy food environments include low-income consumers, the rural and urban poor, smallholder and subsistence farmers [...] indigenous people",[52] small-scale retailers, processors and distributors.

Addressing dietary and nutrition inequities is about improving the distribution of opportunities to live a healthy and fulfilling life. Governments and other food-system actors generally favour interventions focused on individual-level efforts.[53] While direct action can help, it is important also to consider the underlying unequal distribution of factors that support the opportunity to eat a healthy diet[54] (see Figure 1.1). Unless this oversight is addressed, dietary and nutrition inequities will persist and possibly increase. Food choice is not a simply personal decision: food and diets are shaped by context and driven by deep, often unseen, systemic and social factors. New decision-making and accountability mechanisms are needed to address the uneven power dynamics.

Approaches that require a lower level of personal agency are both more effective and equitable for all.[55] Beyond focusing on a few interventions that adjust small and specific elements of food systems, there is a need to broaden efforts to change system-wide drivers of poor nutrition suggested by recent reports, including: the EAT-Lancet Commission on Food, Planet, Health;[56] The Lancet Commission on The Global Syndemic of Obesity, Undernutrition and Climate Change;[57] and the Double Burden of Malnutrition Lancet Series.[58]

An equity-focused approach to food systems that deliver healthy diets would therefore ideally consider actions that seek to reduce inequities in the immediate conditions in which people are born, live, work and play. It would also directly address food availability, accessibility and price in local food environments.[59]

"Policymakers need to create strong regulatory and fiscal frameworks [free from conflict of interest] that provide guidance to those who produce the diets from our food systems."[60]

"Trade and subsidy policies need to align better with those that promote healthy diets".[61] Voluntary self-regulation efforts by the corporate sector are patchy and inadequate: while some in the food and drink industry are acting in ways that benefit public health, their efforts alone are not enough. Box 4.1 outlines some of the positive actions and collaborations in the food and drink sector to support good health and nutrition. Social movements and civil society organisations can act to rebalance power across the food system, towards healthy systems in the public interest of those whose voices go unheard.

Some emerging solutions

Optimisation of farm subsidies and increased public investment for producing healthier agricultural and food products. For example, one option is increased research spending on biofortified crops and livestock, another is reduced subsidies for staple foods but increased support for healthier vegetables, fruits, nuts and fish.

Support for public transport schemes and shorter supply chains for fresh-food delivery programmes, to improve access to healthy food among disadvantaged groups and reduce inequities in diets.

Development of policies to encourage healthy food outlets and improve physical access to foods, especially in low- and middle-income countries, as these countries urbanise. Such policies need to include actors in the informal food sector.

Cash transfers to increase the affordability of foods and drive food-system change. However, these need to be promoted with complementary policy measures, a well-defined set of policy goals and rigorous evaluation.[66]

Use of fiscal instruments (like taxes on sugar-sweetened beverages and unhealthy foods) and regulatory mechanisms (such as bans) to support healthier diets and hold the food industry accountable. Depending on the type of food system and the national and local context, taxes and subsidies may influence food choices and intakes.

Limiting advertising of ultra-processed food, creating food-based dietary guidelines, improving labelling and regulating health claims on packaged foods to create an equitable food environment where consumers can make informed choices without being misled.

Development of policies and investments to diversify food production away from the staple food cereals and towards more diversified non-staple crop production, and to improve value chains to increase incomes of small-scale farmers.

A range of different strategies and interventions is necessary to shift to healthier, environmentally sustainable and more equitable diets for all. Interventions targeting food environments should be included along with agricultural and food-supply approaches. This will require coordination of global, national and local actions through multiple sectors such as agriculture, health and transport. All stakeholders, including governments, industry, consumers and civil society, must act through different entry points of the food system.

Governments need to create strong regulatory and policy frameworks, and fiscal instruments, to support healthier diets. Governments should also set up adequate monitoring and accountability systems to ensure compliance.

The food and drink industry should comply with international and national codes of conduct, including health and nutrition benefits to society and environmental protection and improvement.

Civil society should actively identify, define and recommend evidence-based policies to promote healthy, sustainable and equitable food systems and should hold the government and the food industry accountable for their actions.

International agencies in collaboration with all stakeholders (including donors) should promote, monitor and track progress to achieve healthy, sustainable and equitable food systems globally.

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Skip to main content Imbalances in food systems are major drivers of dietary and nutrition inequities. They can restrict access to healthy diets or promote low-quality diets. There is a need for food systems to: go beyond a narrow focus on energy intake; reduce the dominance of cereal production (maize, rice and wheat); and increase the availability of healthy foods such as fruits and vegetables, nuts and whole grains.

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This organization seeks to leave no person suffering from hunger.

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You can help save lives during an emergency and give children nutritious meals in school. Please consider making a tax-deductible charitable contribution now: http://bit.ly/37mbwwP

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Food sovereignty, food security and health equity: a meta-narrative mapping exercise

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Food sovereignty, food security and health equity: a meta-narrative mapping exercise

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This article talks about the understanding of where the concepts of food security and food sovereignty are prominent.

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(Book Chapter) Food Security in Australia: Challenges and Prospects for the Future

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(Book Chapter) Food Security in Australia: Challenges and Prospects for the Future

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This book offers information on equity and access to nutritious diets, food production and trade, and the relevance of land use planning for the long-term viability of food production in Australia.

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This article gives insight on food equity in New South Wales.

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The George Institute for Global Health has contributed a submission to the New South Wales Parliament's Legislative Assembly Committee on Environment and Planning Inquiry into Food Production and Supply in NSW.

"We commend the committee on its willingness to investigate the impact climate change and COVID-19 are having on food systems and food security in New South Wales. However, we need to talk about the nutritional quality of food, not just the volume of food that is produced and available," said Damian Maganja, Research Associate and PhD Candidate in the Food Policy Division at The George Institute for Global Health.

"When we consider changes to the food system, it is important to recognise that a person can be in a state of food insecurity but not necessarily hungry," said Maganja. "While hunger is still a major problem in NSW, many people are also struggling to access healthy foods and follow healthy dietary patterns amidst systems and environments that prioritise unhealthy products. The healthiness of the foods produced, made available and consumed, must be considered throughout this Inquiry".

The George Institute's submission also conveys the urgent need to collaborate with First Nations peoples to address issues of food security, production and supply in a way that integrates First Nations peoples' lived experiences of food and water systems and ensures better health.

"First Nations Elders and local Aboriginal Community Controlled Organisations are best placed to lead the development of culturally appropriate, sustainable solutions that empower and strengthen their communities," said Dr Julieann Coombes, Co-Lead of the Aboriginal and Torres Strait Islander Health Program at The George Institute.

"The gradual damage to strong connection between First Nations peoples and Country - where Country includes the complex food and water systems that embody the social, emotional, cultural, spiritual and physical aspects of First Nations Health and well-being - has had enormous impact on the nutrition, health and well-being of remote communities."

"An equitable food system means genuine engagement with First Nations communities, and we call upon the NSW Government to act," she added.

Please read our full submission here

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aboriginal and torres strait islander health

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George Institute calls for reform of the food system in NSW inquiry

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The George Institute for Global Health has contributed a submission to the New South Wales Parliament's Legislative Assembly Committee on Environment and Planning Inquiry into Food Production and Supply in NSW. "We commend the committee on its willingness to investigate the impact climate change and COVID-19 are having on food systems and food security in New South Wales.

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(Video) Partnership for a Healthier America

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(Video) Partnership for a Healthier America

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"We’re working with partners across the country to ensure every family in every zip code has access to affordable, good food."

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Introduction to the US Food System : Public Health, Environment, and Equity (Book)

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Introduction to the US Food System : Public Health, Environment, and Equity (Book)

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The introduction focuses on the food system's interrelationships with public health, the environment, equity, and society.

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This organization strives to insure that all people have access to healthy food options.

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Even though the US produces an ample supply of high-quality produce and plant-based products, tens of millions of Americans live in communities where access to fresh fruits and vegetables is either severely limited or non-existent.

Rising rates of obesity in America's children and young adults are fueling increases in diabetes, heart disease, and other chronic conditions. This health crisis undermines academic performance, workplace productivity, military readiness, and diminished quality of life.

In 2020, we witnessed how the lack of affordable access to healthy food has led many to die from the ravages of COVID-19, and that this inequity falls along racial and economic lines. Black, Native, and Hispanic populations are 5x likelier to be hospitalized from COVID-19, and are dying at higher rates than white Americans.

Meanwhile, companies are grappling with competing demands to produce better food for the globe's growing population and to do so sustainably.

Our vision: All children, families, and adults - especially those disproportionately affected - will live healthier lives free from diet-related diseases, such as obesity, diabetes, heart disease, and other chronic conditions.

Our mission: To leverage the power of the private sector to transform the food landscape in pursuit of health equity.

Our work: PHA employs its vast convening power, diverse network, and thought leadership to develop and spotlight the top programs and practices with the greatest potential to create positive change in the U.S. food landscape. PHA works with organizations across the supply chain - food producers, manufacturers, distributors and retailers - to improve the nutritional profile of foods and beverages wherever consumers are - resulting in a greater volume of healthier options for all. We also collaborate with other non-profit organizations, including food banks, who understand the importance of, not just providing any food to communities in need, but providing the right food to children and families who suffer the most from health disparities caused by lack of access to healthier food options.

Our impact: Thanks to the work of PHA and our partners, American consumers are regaining control of their health. More than 8.5 million people now live in areas with new or renovated grocery stores, a direct result of our partner commitments that resulted in more than 800 new or renovated stores offering fresh fruits and vegetables and other nutritious food. In the process, our partners created more than 42,000 new jobs in neighborhoods that needed them.

PHA convenience store partners have over 2,500 locations across 39 states, 75 percent of which are located in food-scarce neighborhoods. PHA also reaches over 77,000 convenience stores through its six (6) distributor partnerships.

In addition, by 2017, PHA's Drink Up campaign, which sunset in 2019, helped to make water the most consumed bottled beverage in America.

PHA's work spans diverse communities across the country and touches every sector involved in getting food in the mouths of Americans.

Learn more about PHA's impact in the most recent Progress Report.

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Even though the US produces an ample supply of high-quality produce and plant-based products, tens of millions of Americans live in communities where access to fresh fruits and vegetables is either severely limited or non-existent. Rising rates of obesity in America's children and young adults are fueling increases in diabetes, heart disease, and other chronic conditions.

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Provides an explanation of what food equity is and how it affects the health of all people.

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What is Food Equity?

Food equity is the expansive concept that all people have the ability and opportunity to grow and to consume healthful, affordable, and culturally significant foods. In an equitable food system, all community members are able to grow, procure, barter, trade, sell, dispose and understand the sources of food in a manner that prioritizes culture, equitable access to land, fair and equitable prices and wages, human health, and ecological sustainability. Food equity requires that food systems be democratically controlled and community stakeholders determine the policies that influence their food system.

What is a Community Food System?

A community food system is the soil-to-soil system that enables the production, processing, distribution, acquisition, and consumption of food, and management of food waste. A CFS depends on natural resources, technologies, cultural norms, governance structures, policies and laws that shape and influence how food moves from farm to plate. An equitable CFS enhances the environmental, economic, social, and health equity of a place and its inhabitants. In the Global South, where hunger and malnutrition remain a pressing problem, community food systems are rapidly changing, creating both challenges and opportunities. Because of its complexity and breadth, community food systems are ripe for transdisciplinary scrutiny and innovation.

In cities across the United States and in countries around the world, communities lack the ability and opportunity to access healthful, affordable, and culturally significant foods. In particular, food inequity leads to broken food systems that heighten undernourishment and hunger in low- and middle-income countries.

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Despite producing 70% of the world’s food, small-scale farmers remain undernourished, as do their neighbors throughout the Global South. Improving food security cannot be done by increasing agricultural production alone; a systems approach is needed to advance access to nutritious, culturally meaningful food.

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How food equity affects communities