“Serving Sustainable and Healthy Food to Consumers and Decision Makers”: From Commitments to Action
Although most countries have a nutrition policy, sustainability is rarely incorporated into dietary guidelines or paid serious attention to in food and nutrition policies. There is lack of coherence in politics, and powerful corporate, political and other interests tend to impede the process. Moreover, consumers are confused and have difficulties understanding what constitutes a healthy and sustainable diet. This chapter presents some past failures, current progress, and future options. It describes some potentially useful measures such as public procurement, fiscal policies, and choice architecture to promote healthy and sustainable diets. There is a need to move sustainability and nutrition higher up the agenda of both consumers and decision makers. Promotion of healthy and sustainable diets need to be part of all government policies.
KeywordsFood policy Nutrition policy Procurement Fiscal tools Agriculture Education Commitments Sustainable and healthy diets
4.1 Struggling for Sustainable Diets
Bringing sustainability into food and nutrition policy and implementing it is not easy. The first attempts to promote sustainable diets among nutrition educators were met with criticism as questions were raised about the feasibility, objectivity, and advocacy of doing so. Even the term “sustainable diets” was reportedly confusing and even threatening (Gussow 1999).
Sustainable diets are still a difficult concept to promote. The importance of improving the sustainability of diets and food systems is recognized, and many NGOs and other activists are pushing the agenda forward, but the political response from governmental bodies and representatives has so far been inadequate. Challenges include understanding complex multidisciplinary research and a lack of knowledge about good policy practices that are effective (Sedlacko et al. 2013). Powerful actors in the for-profit private sector and elsewhere have hampered the process. Putting health and sustainability onto the agenda of decision makers ranging from consumers to political leaders requires not only the will to do so and an understanding of their importance but also multisectoral cooperation, policy coherence, and practical tools for policy implementation. It also requires courage to say that some foods are better than others, although in small quantities all foods can be part of a healthy sustainable diet. This is clearly not an easy task.
There are also many obstacles, not least from powerful corporate and political interests that have the potential to impede progress. Such challenges have existed for many decades. For example, in January 1977 when government authorities in the USA first published the dietary goal of reducing people’s meat intake, the food industry protested heavily at the guidance. Under intense pressure the authorities published a revised version later that year in which the statement “reduce consumption of meat” was replaced by “choose meat, poultry, and fish which will reduce saturated fat intake” (Nestlé 2007).
More recently, problems occurred when the US Department of Agriculture Dietary Advisory Committee (2015) proposed the inclusion of sustainability into Dietary Guidelines for Americans; it was accused of overstepping its statutory rights. Political and other pressures were brought to bear as well because the food and beverage industry did not want individual foods disparaged, while the inclusion of sustainability would have required current policies to be changed (Merrigan et al. 2015). Ultimately the proposal was rejected. US Department of Agriculture Secretary Tom Vilsack and Secretary of Health and Human Services Sylvia Burwel wrote in a joint statement that the Dietary Guidelines for Americans would remain within the scope of the mandate in the 1990 National Nutrition Monitoring and Related Research Act, which is to provide “nutritional and dietary information and guidelines”. They stated that the 2015 Dietary Guidelines were not the appropriate vehicle for a policy conversation about sustainability (Vilsack and Burwel 2015). Yet one legal analysis (Simon 2015) argues that nothing in the mandate or Act precludes the inclusion of sustainability in the Dietary Guidelines.
In Australia, statements about the importance of ecological sustainable development were made as part of food and nutrition policy back in 1992. But its implementation received little support because agricultural interests dominated state food policy initiatives. In 2010 a fresh commitment to develop a new integrated National Food Plan was initiated, but during the process of consultation and stakeholder involvement powerful food industry groups managed to effectively sideline nutrition and sustainability (Carey et al. 2015). Despite some 65% stakeholders supporting the inclusion of environmental sustainability, the final plan positioned sustainability only in the context of maximizing food production efficiency for economic sustainability with limited attention to either consumption or equity (Ridgway et al. 2015).
eating less meat and choosing locally produced meat, beef and lamb, preferably from animals that had grazed on natural grassland;
choosing locally grown vegetables, potatoes, fruit and berries;
choosing sustainable fish;
avoiding bottled water and palm oil;
consuming pesticide-free or organic products; and
limiting rice consumption (Livsmedelsverket 2009).
The guidelines were subsequently withdrawn, however, when the Commission determined that recommendations to eat more locally produced food contravened free trade rules (Dahlback 2010).
Although including sustainability within dietary guidelines is still rare, some countries have managed to do so (see Chap. 3). Ministries of health tend to play a key role in developing guidelines with other ministries becoming involved when the guidelines impact on their policies or activities. Although processes differ widely, an overall commitment from government seems crucial, especially to withstand opposition from the food industry and other interest groups (Fisher and Garnett 2016).
Opposition from industry is understandable because many of the recommended changes threaten parts of the agricultural and food processing industry. Cost-benefit analysis from the LiveWell project shows that if recommended dietary habits were to be adopted, agricultural revenues related to the production of vegetables, eggs, and pulses would significantly increase, but not sufficiently to compensate for losses in the meat and dairy industry, while the total income earned by the agriculture and food processing industry overall would decrease. Nevertheless, such financial losses could be outweighed by the environmental and health benefits that would follow including a reduced prevalence of obesity and less greenhouse gases (Alleweldt et al. 2014).
Including sustainability within dietary guidelines has a clear potential to move dietary guidance more towards individual foods and to shift it from giving advice on food groups to making choices about individual foods within food groups (Merrigan et al. 2015). This could favor some parts of the food industry over the others and offer new market opportunities.
4.2 Current Commitments and Policies
Calls to include sustainability into food and nutrition policies have been increasing in recent years. Different actors have made commitments to promote sustainable food systems and healthy sustainable diets at global, regional and local levels.
On 19 November 2014 the UN Food and Agriculture Organization’s Second International Conference on Nutrition (ICN2) endorsed the Rome Declaration on Nutrition and its accompanying Framework for Action to guide implementation. More than 2200 participants from 162 member states and many stakeholders from civil society attended the Conference. The Rome Declaration highlights that current food systems are increasingly challenged by climate change, resource scarcity, and unsustainable production and consumption patterns, and that difficulties in providing healthy, safe, and nutrient rich food for all are increasing. Those endorsing the Declaration made a commitment to “enhance sustainable food systems by developing coherent public policies from production to consumption and across relevant sectors to provide year-round access to food that meets peoples’ nutrition needs and promote safe and diversified healthy diets”.
But although sustainability is mentioned in the ICN2 documents several times, there are very few concrete proposals to align sustainability with health. Several statements and positions made during the meeting reveal tensions including those from the food industry emphasizing the important role that meat and animal products play in nutrition (Report of the Joint FAO/WHO Secretariat 2014). These tensions were also present during very difficult negotiations before the ICN2 Conference itself on outcome documents. Some countries like Finland made proposals to have stronger wording about sustainability and healthy diets in the final commitments but were attacked by food industry lobbyists and received little support from other countries. After lengthy negotiations about the Rome Declaration, the Framework for Action was finalized without proper discussion among all participants. Brinsden and Lang (2015) have stated that ICN2 can be regarded as a missed opportunity to have a more ecological approach to diet and nutrition.
More positively, the process is not over yet. The Rome Declaration proposed that the United Nations General Assembly consider declaring a Decade of Nutrition Action from 2016 until the year 2025 with existing structures and resources, a proposal to which United Nations General Assembly (2016) agreed. It also calls on FAO and WHO to lead implementation of the UN Decade of Nutrition Action and develop a work program based on the Rome Declaration and its Framework for Action. This work programme (2017) includes developing sustainable resilient food systems for healthy diets as one of the six action areas that refer both to sustainable consumption and production as well as developing commitments and establishing action networks. More than 90 countries have already adopted improved practices in their food systems, 27 countries have activities to reduce food waste, 146 have intersectoral coordination mechanisms, and a growing number of countries are considering including sustainability in their food-based dietary guidelines (WHA 2017).
In addition to these global commitments, regional and local commitments have been made by various actors and stakeholders. For example, 133 city mayors and representatives of local governments from all over the world signed the Milan Urban Food Policy Pact (2015) committing themselves to work towards developing sustainable food systems that are inclusive, safe, resilient, and diverse, that provide healthy and affordable food for all people within a human-rights-based framework, and that minimize waste and conserve biodiversity while adapting to and mitigating the impacts of climate change. The Pact calls for cross-sectoral collaboration and policy coherence, and contains a voluntary framework for action with 37 specific areas.
Other similar initiatives within city regions or local areas have been launched such as the C40 Food Systems Network of the world’s megacities committed to addressing climate change, the Nordic cities EAT initiative, WHO’s Healthy Cities Network, the network of Sustainable Cities in Argentina, and (Mason and Lang 2017) and across Latin America. Sustainable and safe food policies are also one of the ten priority action areas mentioned in the Shanghai Consensus on Healthy Cities (2016).
Food business operators, especially those in the meat and dairy industries, have historically been active in resisting regulations and guidelines on health and sustainability. Today, however, views and action taken by the private, for-profit sector vary widely. More and more companies are making commitments as they identify market opportunities in health and sustainability. Big food companies like Unilever, Nestlé, and Danone set up their own Sustainable Agriculture Initiative in 2002 which has 80 members worldwide. Italian food giant Barilla has funded academics to create guidelines for sustainable and healthy diets, and is actively pushing the sustainability agenda forward. While some of the proliferating corporate actions on food and sustainability can be described as “greenwashing” (Mason and Lang 2017), they do show that the private sector is aware of pressures for change.
In addition many non-governmental organizations and stakeholders such as health professionals have made commitments or statements on sustainability. NGOs focusing on environmental topics are addressing nutrition and health, while those working in public health are taking up environmental, food, and sustainability perspectives. For example, the Worldwide Fund for Nature (WWF) has produced guidelines for healthy and sustainable diets, while Greenpeace, US Sierra Club, and Friends of the Earth focus on food within their existing lobbying as a vector to redefine policy towards sustainability (Mason and Lang 2017).
A decade ago, the American Public Health Association (2007) made a statement, “Towards a healthy sustainable food system”, covering the improper use of antibiotics, biodiversity, and many other topics. More recently, the European Public Health Association (Birt et al. 2017) has published a paper calling for strategies and action to promote healthy and sustainable diets in European countries including a statutory Sustainable Nutrition Task force, reform of agricultural policies, and development of sustainable dietary guidelines and accountability systems. The US Academy of Nutrition and Dietetics (2016) states in a position paper that appropriately planned vegetarian and vegan diets are healthful, nutritionally adequate, and may provide health benefits in treating certain diseases such as ischemic heart disease, type 2 diabetes, hypertension, certain types of cancer, and obesity. These diets are also more environmentally sustainable than diets rich in animal products because they use fewer natural resources and are associated with much less environmental damage.
4.3 Implementing Commitments and Policies
Implementing commitments made towards healthy and sustainable diets is a complex task that requires many tools. Multiple approaches are potentially useful ranging from improving production efficiencies and creating a more equitable balance of power to changing eating patterns and reducing food waste along the whole supply chain. There are many potential interventions that could influence and change the way we eat, including regulation and legislation, fiscal measures, changing the choice architecture, education, providing information, and raising awareness (Garnett 2014). To get the maximum benefit results, both the production and the consumption of foods need to be influenced.
4.3.1 Investing in Healthier and More Sustainable Production
Reshaping food production and food systems is crucial for the health of the planet and for people’s health. Food systems need to become more adaptive and resilient to future changing circumstances, provide nutritious and healthy food for all, act within planetary boundaries, and support livelihoods and the well-being of people working within them. This all requires coherent policy measures.
Food production needs to be progressively shifted towards lower-impact, less-resource-intensive foods that have good nutritional quality. Agricultural practices need to be improved, and investment put into developing new sustainable agricultural and aquaculture techniques. These changes would benefit from a holistic strategy and good governance that fundamentally acknowledges the critical role that individuals and societies play in the proper functioning of food systems (Gladek et al. 2016).
There are many potential ways that food production can be geared more towards healthy and sustainable food production, including making better use of health impact and environmental impact assessment methods in decision-making processes (see Snowdon et al. 2010). A powerful tool to influence food production would be adopting a fiscal policy that promoted sustainability and health. Most developed countries currently provide substantial subsidies to their agricultural sector but sustainability is not taken seriously as part of their allocation.
The European Union’s Common Agricultural Policy (CAP) is responsible for around 40% of the EU’s budget. More than half of CAP spending goes on meat, dairy, and animal foods; subsidies for fruit and vegetables are far less than those for wine, tobacco, olive oil, and sugar. Moreover, the production within the EU of fruit and vegetables has been slowly decreasing, a worrying trend that requires action (EPHA 2016). The current CAP does not give nutrition much attention. Within the EU, trade, agriculture, and public health experts hold conflicting opinions on nutrition . There is also a lack of clarity on the EU mandate to address nutrition-related health concerns and a lack of understanding about healthy diets (Walls et al. 2016).
It has been suggested that public health and sustainability should become a stronger part of the CAP by means of fiscal tools that would shift support towards more sustainable and healthy options. Concrete proposals include reducing support for the livestock sector and re-allocating subsidies towards rural development programs ; using nutrient profiling as criteria for school milk subsidies; and ending preferential treatment for the wine sector including promotional measures. Consumption of fruit and vegetables could be boosted by policy actions while fiscal tools could be deployed to promote both the production and consumption of fruits and vegetables (EPHA 2016).
In the USA agricultural policies have been similarly counterproductive for public health; it is often asserted that the US food system is unhealthy, inequitable, and unsustainable. Antimicrobials are used in raising animals to prevent diseases but in such high doses that they can also serve to promote animal growth. Federal farm bills have favored big companies and supported the growth of cheap oils, grains, meat, and processed foods over the production of fruit and vegetables. Minor amendments to the 2014 Farm Bill did support more diverse and sustainable forms of production, including increased funding for research on fruit, vegetables, and organic crops; federally subsidized crop insurance for farmers growing fruit and vegetables; and insurance payouts for organic producers, but more action is still needed. This could include prohibiting the use of antimicrobials in animal rearing when there are no diseases present, removing distortions in agricultural markets that disincentive fruit and vegetable production, using nutritional standards as criteria for support, discontinuing incentives for the use of corn and soy as biofuels, and providing support for farmers using agro-ecological methods (Shannon et al. 2015).
Globally, investing in agriculture that supports small-holders and acts so as to eradicate hunger and support healthy and sustainable food habits is essential. Most of the 800 million people who go hungry in the world work in agriculture themselves. Government spending on agriculture is generally low and has been decreasing with a negative impact on many poor farmers. Nevertheless, there are also new funding mechanisms and cooperation initiatives such as community cooperatives that have successfully developed alternative financial investment schemes for small-scale producers in Africa and Latin America (Hilmi and Nærstand 2017).
4.3.2 Education and Information
Education is an essential part of the action that needs to be taken to bring about healthier and more sustainable diets. Ideally it should start as early as possible in children’s lives and include not just reliable and attractive information but also practical skills and support to behavior change. Education should include future parents and families with children and continue through educational settings, supported by health care systems and institutions providing consumer information.
To help consumers make informed choices and to orient production and consumption patterns towards more sustainability, it is essential to make available adequate information about sustainable dietary patterns and characteristics of products as well as other relevant information such as guidelines for recycling and waste management . Moreover, education has a more powerful effect if it can be combined with practical skills such as cooking and food handling, and illustrated by models of behavior that can influence lifestyles.
For example, providing healthy and sustainable school meals together with teaching about health, nutrition, cooking skills, and sustainability is a useful tool in promoting healthy and sustainable food habits. School meals are more than food: they can also be part of an educational system that supports learning capacity, healthy lifestyles (Sarlio-Lähteenkorva and Manninen 2010) and a sustainable future. Unfortunately this potential is rarely utilized.
A survey assessing school food in Vancouver’s state schools by Black et al. (2015) illustrates some of the challenges. None of the schools in the study were fully supporting the initiative of integrating healthy and environmentally sustainable food in the curriculum. Schools scored highest in the areas of school gardening, compost systems , and integration of food-related teaching and learning activities, but in promoting the availability of healthy and sustainable food were taking only initial steps. Likewise, a study from the UK by Fairchild and Collins (2011) shows that the average school meal among secondary school students fails to meet nutritional standards and guidelines but still has an ecological footprint more than twice that of a typical resident. Most commonly purchased products were soft drinks and more than half the ecological footprint came from meat and dairy. The authors call for attention to be paid to changing pupils’ purchasing behavior.
There are also many challenges in providing information and education outside the school setting. At present, various messages are circulated through diverse channels but all with very different objectives. The substantial commercial marketing of unhealthy foods counters and attacks information on healthy diets. It has been estimated that for every dollar the World Health Organization spends on preventing diseases caused by unhealthy Western diets, the food industry spends more than 500 dollars promoting those same diets. Industry marketing of unhealthy foods high in salt, fat, and sugar content to vulnerable groups such as children has increased in recent years but the promotion of healthier alternatives has not kept pace with it. Yet there has been progress in food labeling in the USA and EU while an increasing number of countries are introducing mandatory nutrition labeling (Mason and Lang 2017).
Communicating sustainability by means of food labels is more complicated. There is a multiplicity of signs and labels for different dimensions of sustainability such as the Fairtrade certificate indicating that farmers and workers obtain good prices and have decent working conditions in developing countries, organic labels for specific production methods, and carbon footprints indicating the environmental impact of a product. Overall, at least 148 different labeling schemes for sustainability have been identified globally (Neto et al. 2016), most of them directly addressing only some dimensions of sustainability. Paradoxically labels that cover broad dimensions of sustainability are more difficult to communicate whereas simple messages such as “dolphin friendly” on tins of fish have proved to be very effective. Moreover, sustainability concerns are intertwined with other food quality attributes in consumers’ attitudes towards foods. The most commonly stated motive for buying organic food , for instance, is concerns about personal health, although health is not a criterion for a product to be certified organic. Unsurprisingly many consumers are very confused about sustainability and have difficulty even in understanding terms such as green, organic, natural, and environmentally friendly (Meybeck and Gitz 2014).
Moreover, changing food-related behavior is not easy – it is often easier to change non-food behavior. Social, cultural, and personal values associated with foods need to be addressed. For example, consumers may not be willing to reduce their intake of foods they value highly like meat, or may not be aware of the association between food consumption and climate change or skeptical of its scientific evidence (Macdiarmid et al. 2016). Motivational factors also vary. Consumers who avoid red and processed meat are motivated mostly by animal welfare and human health concerns, less by those of environmental sustainability (Clonan et al. 2015).
In general, consumer awareness of the environmental impact their diets have is very low. People underestimate the environmental impact of meat consumption itself compared with other behaviors such as using less packaging or eating locally grown produce. Only a minority are ready to reduce their meat consumption for ecological reasons, women being somewhat more likely to do so than men. People also have a low acceptability threshold for unfamiliar foods like insects or for foods they perceive to be unnatural such as cultured meat. Consumer information about the environmental impacts of various food choices certainly helps in encouraging people to adopt new behaviors but other strategies such as nudging, improving taste, and increasing the familiarity of alternatives are equally important (Hartmann and Siegrist 2017).
Even a consumer trying to eat a healthy and sustainable diet can find choices and options difficult. Providing information is important but is not enough. Gjerris et al. (2016) point out that many consumers are confused as to how they should act responsibly given the many approaches and trade-offs entailed in different notions of sustainability. Moreover, buying products labeled as sustainable do not have a direct and personal impact on a consumer unlike those described as healthy. It can also be argued that consumers should not be pressured to make their decisions based on sustainability criteria given that they are far from being the most powerful stakeholders in the food value chain; sustainability decisions should be made much earlier in a food system. New modes of governance could engage the general public in their capacity as citizens rather than as consumers.
4.3.3 Choice Architecture and Nudging
The immediate environment strongly influences the choices that people make. We buy what is easily available and we usually like what we are used to eating. To promote healthy and sustainable diets, the choice architecture of our food environment can be altered. Choice architecture refers to both the informational and physical structure of an environment that influences the ways in which people make choices. The changes made in this choice architecture such that individuals make more desirable choices almost automatically are called nudges.
A review by Lehner et al. (2016) shows that different types of nudges can be effective. For example, reducing plate diameter or portion size significantly reduces food waste and calorie intake. Having a milk dispenser or water pitcher close to a dining area results in an increased intake of water. Providing simplified information and visual markers such as carbon footprints have proved to influence purchases. Relying on people’s adherence to social norms by providing information on ideal types of behavior works particularly well if a behavior is publicly visible and there is general uncertainty as to what appropriate behavior is. The best results have been achieved where nudging is applied without the counteracting effects of commercial marketing. Individuals also need to have positive attitudes and an understanding of the recommended behavior for nudging to be effective. If individuals are nudged to less meat but do not have an internal conviction that doing so is desirable, compliance tends to be low. Nudging should therefore be preceded by information and education aimed at people understanding the underlying policy and rationale.
Incorporating choice architecture into food service guidelines may include using default options (for instance, serving salad instead of chips), payment strategies (such as cookies being purchased only with cash), and placement organization (for example, making recommended food the most accessible or locating only healthy and sustainable options near the checkout lines). Comprehensive approaches using multi-component strategies have proved to be the most successful (Kimmons et al. 2012). Potentially effective options could also include adjusting canteen and store layouts, designing attractive branding, and marketing vegetarian foods or vegetarian meal deals (Garnett 2014).
sell compelling benefit;
maximize awareness; and
evolve social norms.
As any change in taste, look, texture, packaging or even in-store location can be a major barrier to changing consumers’ food behavior, minimizing disruption for consumers refers to strategies such as replicating familiar characteristics – making meat substitutes look and behave like meat, for instance – or disguising the changes, such as gradually replacing some of the meat with vegetables. Selling the compelling benefit involves marketing a product by emphasizing an attribute known to motivate consumption such as animal health, healthiness, or lower price. Maximizing awareness can include improving the visibility or memorability of recommended choices while constraining those for undesired foods. As social norms influence all of us, making certain foods or behaviors socially desirable or socially unacceptable can change behaviors. When celebrities such as UK chef Jamie Oliver spoke out in favor of free-range eggs, sales of such eggs increased while campaigns against eating shark fins challenged the social acceptability of doing so (Ranganathan et al. 2016).
Despite these positive indicators, evidence also suggests that nudging may not be enough to bring about significant behavioral shifts. Bigger changes in choice architecture are essential, requiring shoves more than nudges (Mason and Lang 2017).
4.3.4 Public Procurement for Healthy and Sustainable Meal Services
Public procurement refers to goods and services purchased with public money by governments and state-owned institutions. Public sector procurement represents about 13–20% of Gross Domestic Product (GDP) in OECD countries while estimates for developing countries are significantly higher (Smith et al. 2015). Food services are an important part of public procurement. Changing institutional food services is a promising strategy to shift dietary patterns towards more healthy and sustainable diets. The overall purchasing power of public institutions can potentially have large-scale impacts at individual, community, and national levels. Indeed, procurement of healthy food could reduce food insecurity and diet-related diseases (Freudenberg 2016). The US federal government has developed guidelines to make sure that healthy and sustainable foods are available at federal workplaces (Kimmons et al. 2012).
Guidelines for institutional food services with health and sustainability criteria have also been developed and implemented at universities, cities, counties, states, and federal agencies. A basic approach to determining dietary standards is to adapt or adopt a set of scientifically based guidelines. Sustainability guidelines include standards on local or regional purchasing and on production methods such as organic or other sustainability certification. Changing food service practice requires comprehensive analysis, engagement, and education of all relevant stakeholders ranging from institutional management through to individual customers (Kimmons et al. 2012). A study by Mikkelsen and Sylvest (2012) shows that implementing changes in food services such as using organic foods involves not only instituting new routines in the purchase and preparation of foods but also organizational changes including in documentation and capacity building while implementing strategies to overcome problems such as insufficiency of supply and price premiums. Interestingly, the introduction of organic foods in Denmark led to the menus being reformulated with less meat and more of a focus on health.
To promote healthier food choices, it is useful to have clear nutrition criteria and standards establishing which foods and beverages are eligible to be purchased and served for use in policies, bids, and contracts for food services. These criteria could include nutrients to avoid as well as foods and beverages to be encouraged. Gardner et al. (2014) have analyzed food procurement standards for worksites in the USA developed by stakeholders ranging from non-governmental organizations and government agencies to the food industry. Standards focus on nutritional quality but also include topics like product placement, pricing, nutrition education or some elements of sustainability. Most of these standards are based on evidence-based recommendations of nutrients that should be avoided in excess such as salt, saturated fats, transfats , sugar, and energy. Standards set by different stakeholders are broadly similar but those drawn up by the private sector tend to be less strict. There are also standards promoting vegetarian options and environmental sustainability by increasing organic, local, seasonal, and sustainable food as well as of meat from grass-fed animals. The authors point out that some standards have a more established history and are more evidence-based than others; they recommend relying on evidence-based approaches in future standard-setting.
Niebylski et al. (2014) reviewed 34 studies of various healthy food procurement programs implemented mostly in schools and worksites but also in hospitals, care homes, correctional facilities, government institutions, and other miscellaneous settings. The programs varied greatly from promoting foods like fruit and vegetables to specific food-based standards. Nearly all programs were effective at increasing the availability of healthier food and increasing the intake of healthier foods such as fruit and vegetables while lowering that of food high in fat, sodium, and sugar. Most policies included other components as well such as education, supporting price policies, and health interventions, which may be critical factors for success.
Green Public Procurement (GPP) – the public purchasing of products and services that are less environmentally damaging – is increasingly being used to achieve environmental protection policy objectives. The OECD and European Commission have produced general guidelines and recommendations on GPP. The reviews and market analysis of the public procurement of food and catering services in the EU carried out by Neto et al. (2016) show a multitude of approaches in different member states. These include setting criteria on production methods such as organic production or not using genetically modified organisms (GMOs), quality labels, reduction of ingredients like red meat, management of waste and energy, animal welfare, and packaging. Some states used innovative approaches to buying local food by using criteria such as freshness or avoiding air transport.
Unfortunately these GPP criteria do not mention health or nutritional quality. Indeed, green procurement tends to focus on selected areas of environmental concern only. It has been suggested that sustainable procurement should encompass all pillars of sustainability, integrating social and health priorities as well but this rarely happens. A study using the expertise and case studies from the European Commission-funded Foodlinks project reveals that some communities have nutritional quality as a part of their public procurement policy but environmental criteria, including eating less meat and more organic and seasonal food, seems to be the dominant approach in sustainable public procurement. There is a scarcity of data about approaches that have both nutrition and health as a part of their procurement criteria (Smith et al. 2015).
Unfortunately procurement policies that include different dimensions of both sustainability and nutrition are rare. Moreover, most guidelines are voluntary and focus on improving access to better options without limiting the availability of other options. There is clearly room for stronger, evidence-based and -informed policies with transparent processes , effective implementation, and proper monitoring so that public bodies can provide healthy sustainable meals in future.
4.3.5 Fiscal Tools
Consumer choice of food items is mostly influenced by price, followed by people’s habits and taste preferences (Meybeck and Gitz 2014). Therefore, fiscal policies such as taxes and subsidies have a great potential for shifting consumer behavior towards sustainable and healthy diets. Taxing products that are potentially harmful for the environment or consumers’ health is a way of internalizing these costs to the companies that make profits from selling them. Otherwise these costs fall on those who suffer the damages such as society and communities or individuals that have to face an increased burden of disease or a despoiled environment. As cheap food does not reflect the true costs of producing or consuming it, fiscal policies can redress the balance to a degree.
But data on fiscal measures is still limited. Different approaches need to be investigated and implemented such as environment-linked production and consumption incentives and disincentives (for instance, taxes and subsidies), personal carbon budgets and a livestock headage tax (Garnett 2014).
Existing studies on heath-based fiscal measures on food and drink show promising results. A systematic review by Niebylski et al. (2015) showed consistent evidence that taxing unhealthy foods like soft-drinks and subsidizing healthy foods such as fruit and vegetables influences dietary behavior. To maximize success and effects, the authors suggest that food taxes and subsidies should be set at a minimum of 10–15% and preferably used in tandem.
Some other studies have estimated both the environmental and health impacts of fiscal measures. Spingmann et al. (2016), for instance, estimated the climate change mitigation potential and the health impacts of levying taxes on food commodities based on their greenhouse gas emissions. Data from 150 world regions and 62 agricultural commodities was analyzed. Taxes varied by region and different model scenarios were tested. The results show that levying taxes based on greenhouse gas emissions could be both a health-promoting and climate-friendly policy in all high-income countries, and in most middle- and low-income countries. A regionally optimized tax scenario with maximum health benefits reduced mortality by about 510,000 avoidable deaths and led also to a 8.6% reduction in global food-related greenhouse gas emissions, about two-thirds of which were due to reduced consumption of beef, and one-quarter to reduced milk consumption. To optimize health benefits, part of the tax revenues could be used to subsidize consumption of recommended foods like fruit and vegetables.
Special attention is needed, however, to make sure that low-income countries and vulnerable groups do not experience negative health consequences. Indeed, people from lower socioeconomic groups obviously have lower incomes, tend to buy cheaper foods, and spend a larger portion of their food budget on meat and dairy products. A greenhouse gas emission-based tax is therefore regressive in that its burden falls disproportionately on households with a lower socioeconomic status. Taxing foods on their emissions only could result in low emission foods such as candy or soft drinks becoming more tempting for consumers. There could also be unintended health consequences if such a tax fails to take into account high-emission foods that are beneficial for health like milk (Kehlbachen et al. 2016).
A modeling study by Abadie et al. (2016) calculated the optimum combination of taxes and subsidies for 16 foods in Norway so as to obtain a diet with both reduced emissions and better nutritional quality than the country’s current one. Their results show that different emission targets ranging from a 2.5% reduction to 10% reduction lead to a different combination of foods. Reducing emissions by 7.5% seemed to lead to the lowest level of sugar and saturated fat in a diet, which contained less red meat, cheese, soft drinks, and eggs than the present one but more poultry, fish, and milk. The envisaged 7.5% reduction in greenhouse gas emissions was obtained by imposing an 18–40% tax on meat from ruminant animals, coffee, tea, soft drinks, candy and sugar and providing 15–40% subsidies on eggs, milk, poultry, and fish.
Caillavet et al. (2016) studied the potential effect that taxes on specific animal-based foods could have on emissions of three gases: the greenhouse gas carbon dioxide (CO2), sulphur dioxide (SO2) which is implicated in air acidification, and nitrogen dioxide (N) which is directly related to the eutrophication of water. They also studied the effect of such taxes on the diet quality of different socioeconomic groups. Their modeling scenario, which included both nutritional quality and environmental benefits, showed that a 20% increase in the price of beef, cooked meats, animal foods high in fat, cheese, and prepared meals resulted in a 7% reduction in CO2, 13.2% reduction in SO2 and 6.6% reduction in N while improving diet quality because of less salt and saturated fat and more vitamins and minerals. The highest environmental impact was seen in low-income families with the youngest children. Modelling indicated an especially improved diet among older groups of people while nutritional inequalities between different groups slightly narrowed.
Cleary any fiscal policy should be carefully designed. A WHO (2016) technical report highlights how important are a proper situation analysis using all relevant information, appropriate objective setting, an implementation plan that includes advocacy for political buy-in, monitoring, and evaluation. Issues that need attention include price elasticity, substitution effects, regressive outcomes, and tools to identify and define products to be included.
4.4 Towards Ensuring a Healthy Sustainable Diet Is a Goal of All Public Policies
To this end, sustainable and healthy diets need to be on the agendas of decision makers in all sectors of society, both private and public, in areas ranging from environment, health, and agriculture to tax, subsidies, and trade. Policies need to be multisectoral and multidisciplinary operating on multiple levels from local and national to regional and global. As this requires raising awareness, education, media, and communication of research are of paramount importance. Permanent institutional structures ensuring that the healthiness and sustainability of diets is addressed whenever decisions are made on food systems and the food environment are essential.
International commitments have certainly been made, including setting Sustainable Development Goals to be achieved by the year 2030 under the auspices of the United Nations General Assembly (2015), but such commitments are of little value if world leaders and others fail to recognize environmental and health threats and do not implement appropriate measures. Given the many competing approaches, it is crucial that different food-related agendas and values – human health, planetary health, animal welfare, cultural dimensions – are reconciled with each other better than they are at present, especially given that there are many potential synergies in the promotion of healthy food and of sustainability. But a study by Risku-Norja et al. (2014) of national level policy documents in Finland showed that, despite adopting and promoting a Health in all Policies (HiaP) approach, potential synergy advantages between human and environmental well-being were poorly made use of.
Good governance, leadership, and cooperation are indispensable if sustainability is to be achieved. In the field of human health it is well known that people’s health is largely produced by factors and influences outside the health sectors per se, and the benefits of multisectoral action are recognized. Multisectoral actions can be carried out in different ways, as reviewed by Bowen and Ebi (2015), but all require systems-based approaches, enabling structures, resources, and leadership. A Health in all Policies approach incorporates health impacts into the policy development processes of other sectors, while a One Health approach uses collaborative networks to address zoonotic infectious diseases that originate at the animal-human-ecosystem interface. There are also important lessons to be learnt from disaster and risk management and from WHO’s Commission on the Social Determinants of Health that places equity at the center of all planning, policy, and decision-making. In the future we need approaches that integrate and combine all these elements together.
Given that the issues are complex and that sector-driven strategies have failed, increased inter-linkages between sectors require new integrative approaches. Integration could be achieved by bringing different sectors together to work out joint modeling approaches or joint action plans on topics such as food, water, and energy – the water, energy, and food nexus is currently popular in environmental management (Al-Saidi and Elagib 2017) – or by cross-linking different sectors or assimilating them under one roof.
identifying problem policies and gaps that contribute to an unhealthy food environment;
identifying potential policy solutions; and
assessing solutions to identify a shortlist of those most recommended for implementation.
Potential health impacts in different population groups were identified followed by a qualitative estimate of their likelihood and size of effect. A feasibility assessment encompassed technical feasibility, cost, political acceptability, cultural acceptability, and trade-related legality. Stakeholders were then invited to give their views on the relative importance of these issues and, guided by the available evidence and data, to assess the potential effectiveness of different options. This participatory process included identifying potential negative and positive side effects, and those potentially affected, followed by estimating the probability, severity, and evidence for the negative effects and suggesting possible actions to counteract them. The successful process provides a systematic way of appraising and understanding those policy interventions that show the most promise (Snowdon et al. 2010). A similar participatory process covering environmental effects and pathways as well could be useful in drawing up policies to promote healthy and sustainable diets. In countries that already have guidelines for sustainable and healthy diets, the starting point could even be identifying potential policy options to implement the guidelines.
Public health nutrition and sustainability are “fiendish” policy problems: they are complex in themselves and their causes and solutions are unclear and contested. Food policies and environmental policies are linked and have flow-on effects on other sectors and systems. Lawrence et al. (2015) present a change schema for food systems to describe the potential of three types or stages of change: adjust, reform, and transform. In the adjustment model, the focus and solutions can be found within the systems themselves, examples being technical innovations to improve resilience within existing structures. The reform model addresses structural and operational shortcomings across sectors, bringing relevant stakeholders together to solve the problems by reforming both structure and operation. In the transform model, the function of a food system is reoriented towards integrating all the relevant departments while promoting empowerment and social inclusion. A combination of all three orders of change may be needed to redesign food systems towards healthy sustainable diets.
Data and research to support policies aiming at healthy and sustainable diets are also essential, as is selecting the best possible tools to collect data and carry out research. In particular, we need to gain more knowledge about sustainable healthy eating patterns and about the health and sustainability implications of current dietary habits in different socioeconomic and demographic groups. Learning more about the social, economic, and policy influences that shape our dietary habits and how to bring about the change needed to shift towards more sustainable and healthy diets is essential. Also fundamental are measuring, monitoring, and accountability mechanisms in place.
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