Opportunities and challenges for financing women's, children's and adolescents' health in the context of climate change.

Women, children and adolescents (WCA), especially in low-income and middle-income countries (LMICs), will bear the worst consequences of climate change during their lifetimes, despite contributing the least to global greenhouse gas emissions. Investing in WCA can address these inequities in climate risk, as well as generating large health, economic, social and environmental gains. However, women's, children's and adolescents' health (WCAH) is currently not mainstreamed in climate policies and financing. There is also a need to consider new and innovative financing arrangements that support WCAH alongside climate goals.We provide an overview of the threats climate change represents for WCA, including the most vulnerable communities, and where health and climate investments should focus. We draw on evidence to explore the opportunities and challenges for health financing, climate finance and co-financing schemes to enhance equity and protect WCAH while supporting climate goals.WCA face threats from the rising burden of ill-health and healthcare demand, coupled with constraints to healthcare provision, impacting access to essential WCAH services and rising out-of-pocket payments for healthcare. Climate change also impacts on the economic context and livelihoods of WCA, increasing the risk of displacement and migration. These impacts require additional resources to support WCAH service delivery, to ensure continuity of care and protect households from the costs of care and enhance resilience. We identify a range of financing solutions, including leveraging climate finance for WCAH, adaptive social protection for health and adaptations to purchasing to promote climate action and support WCAH care needs.

Policy vs Business: Well-Designed Health-Related Food Policy Should Not Let Industry Marketing Undermine its Intended Effects Comment on "Understanding Marketing Responses to a Tax on Sugary Drinks: A Qualitative Interview Study in the United Kingdom, 2019".

Health-related food policies, such as taxes on unhealthy food and drink, can act as catalysts for food industry to take action which may or may not align with the policy goal of improving population health. This commentary discusses the framework proposed by Forde et al in analysing the food industry marketing responses to the Soft Drink Industry Levy (SDIL), implemented in the United Kingdom in 2018. We suggest and discuss ways which may help broaden the use of the framework to other relevant policies. This includes widening the framework to cover strategies that may have not come up within the SDIL context but have been studied in other contexts. It would also be important to consider interactions between the strategies and with external factors influencing company decisions. Going forward, comprehensive evaluations of health-related policies should consider likely interactions with industry marketing strategies to fully understand potential impacts.

Growing health: global linkages between patterns of food supply, sustainability, and vulnerability to climate change.

Global food systems are developing rapidly, and have resulted in a large burden of disease and a high proportion of environmental resource use. We combined global data sources on food supply and trade, environmental footprints, burdens of disease, and vulnerability to climate change to explore patterns from 1990 to 2017. Four distinct patterns of food supply (animal sources and sugar, vegetables and nuts, starchy roots and fruits, and seafood and oils) were matched to health and environmental risks. The animal sources and sugar pattern was found to have the greatest environmental footprint and to be associated with a greater burden of chronic disease than any other pattern, although it was also associated with lower undernutrition. This pattern is globally predominant, but has begun to decrease in higher income countries. Countries where this pattern is predominant are generally among the least susceptible to climate change, whereas more susceptible countries tend to have more sustainable patterns of food supply. More countries that are susceptible to climate change are increasingly exporting a larger proportion than before of their cereals, fruit, and vegetables globally, which will lead to increased risks in global food security. To increase resilience to future shocks, dietary change towards more sustainable patterns should accelerate in high-income countries, and the food systems of the most susceptible countries should be protected.

A food systems approach and qualitative system dynamics model to reveal policy issues within the commercial broiler chicken system in South Africa.

Global broiler production and consumption levels continue to rise. South Africa's broiler system is dominated by commercial production and formal retail trade, with competition from cheap imports. Local broiler policies have narrow, production-driven, short-term aims for industry growth and national food security. However, these have unintended consequences that undermine the system's future sustainability. Using a food systems approach, this study developed a qualitative system dynamics model of the South African commercial broiler system and used it to engage stakeholders in policy discussions within the boundaries of health, nutrition, and environmental sustainability. A problem statement and key system elements were drawn from a previously published qualitative study and were validated by 15 stakeholders via an online questionnaire. From this, a seed model was developed, expanded into a larger model, and shared in a modular format with stakeholders in virtual meetings, on an individual or institutional basis, for feedback and validation, and for discussion of areas for policy consideration. Refinements were incorporated into the modules, policy considerations were summarised, and crosscutting issues were identified. The model demonstrated the system's complexity, interlinkages, feedbacks, reinforcing and balancing loops, and behaviour archetypes. The modular presentation format created a suitable platform for stakeholder engagement. Current policies focus on local commercial production, formal markets, and affordability without cognisance of the broader system represented by the model. Inequality pervades throughout the system. Commercial producers, linked to large supermarkets and fast-food chains, dominate the system, presenting barriers to entry. Affordability is unintentionally traded off against non-communicable disease risks through brining of most frozen products, and ultra-processing of fast-food items. Foodborne disease control is critical, given the proportion of vulnerable individuals, and greater coherence of food safety policy is urgently needed. The environmental footprint of broilers, whilst less than that of ruminants, deserves closer scrutiny based on its dependence on intensive cereal production for feed. This study's food systems approach provides a system-wide perspective and a foundation for policymakers to develop more integrated and transformative policies.

Escaping the Red Queen: Health as a corporate food marketing strategy.

Public health advocates highlight the role of corporate actors and food marketing in shaping diets and health. This study analyses insider-oriented communications in food industry magazines in the UK to analyse actions and narratives related to health and nutrition, providing insights into relatively overlooked areas of marketing strategy including inter-firm dynamics. From a sample of four specialized food industry magazines covering the main industry segments we identified 319 articles (published 2007-2018) mentioning health or nutrition together with industry actions affecting the food environment. We identified health-related actions and analysed underlying strategies through content and thematic analyses. Health and nutrition have a rapidly growing role in food marketing strategy. Content analysis revealed a focus on ultra-processed foods, as well as product and nutrient-specific trends including increased health-based marketing of snacks and "protein rich" products. Health-related actions predominantly relied on consumer agency rather than invoking structural food environment changes. Thematic analysis identified proactive and defensive marketing strategies. Proactive approaches included large investments in health-related promotion of ultra-processed foods which are made highly visible to competitors, and the reliance on a "credence goods" differentiation strategies. Defensive strategies included a 'Red Queen' effect, whereby firms take health-related actions to keep up with competitors. These competitive strategies can create challenges, as well as some opportunities, for public health promotion. Challenges can include undermining efforts to support product comparison and healthier choice, and limiting firms' engagement in specific health improving actions. Systematic analysis of health-oriented marketing strategies could support more effective public health intervention.

A Qualitative Analysis of the Commercial Broiler System, and the Links to Consumers' Nutrition and Health, and to Environmental Sustainability: A South African Case Study.

Food systems face growing challenges to meet targets of Zero Hunger (SDG 2), and South Africa is no exception given its triple burden of malnutrition, foodborne disease outbreaks, and threats of climate change to food production. Broiler meat is South Africa's most affordable meat option, supporting household food and nutrition security. Although considered healthier and less environmentally harmful than ruminant meat, it is not without food safety risks and environmental impacts. This research aimed to present the foremost commercial broiler system narratives in South Africa, around targets of SDG 2, and to discuss key considerations for policymakers. Twenty-nine key informants and stakeholders, purposively selected to cover a wide range of opinions, participated in semi-structured interviews. Transcripts underwent a qualitative framework analysis. Results showed a highly efficient system, dominated by a small number of interlinked large-scale actors, vulnerable to competition from cheaper imports, yet pressurized to maintain high food safety and environmental impact standards, with a price-sensitive consumer base. Existing policies lack integration and enforcement capacity, and are undermined by siloed government departments, and mistrust and power struggles between public and private sectors. We propose removal of silo walls, and trust building through participatory policy development, with collaborative and transformative public-private partnerships that are designed to build capacity to deliver sustainable solutions.

Trading water: virtual water flows through interstate cereal trade in India.

Cereals are an important component of the Indian diet, providing 47% of the daily dietary energy intake. Dwindling groundwater reserves in India especially in major cereal-growing regions are an increasing challenge to national food supply. An improved understanding of interstate cereal trade can help to identify potential risks to national food security. Here, we quantify the trade between Indian states of five major cereals and the associated trade in virtual (or embedded) water. To do this, we modelled interstate trade of cereals using Indian government data on supply and demand; calculated virtual water use of domestic cereal production using state- and product-specific water footprints and state-level data on irrigation source; and incorporated virtual water used in the production of internationally-imported cereals using country-specific water footprints. We estimate that 40% (94 million tonnes) of total cereal food supply was traded between Indian states in 2011-12, corresponding to a trade of 54.0 km3 of embedded blue water, and 99.4 km3 of embedded green water. Of the cereals traded within India, 41% were produced in states with over-exploited groundwater reserves (defined according to the Central Ground Water Board) and a further 21% in states with critically depleting groundwater reserves. Our analysis indicates a high dependency of Indian cereal consumption on production in states with stressed groundwater reserves. Substantial changes in agricultural practices and land use may be required to secure future production, trade and availability of cereals in India. Diversifying production systems could increase the resilience of India's food system.

International trade, dietary change, and cardiovascular disease health outcomes: Import tariff reform using an integrated macroeconomic, environmental and health modelling framework for Thailand.

United Nations (UN) member states have, since 2011, worked to address the emerging global NCD crisis, but progress has, so far, been insufficient. Food trade policy is recognised to have the potential to impact certain major diet-related health and environmental outcomes. We study the potential for using import tariff protection as a health and environmental policy instrument. Specifically, we apply a rigorous and consistent Macroeconomic-Environmental-Demographic-health (MED-health) simulation model framework to study fiscal food policy import tariffs and dietary change in Thailand over the future 20 year period 2016-2035. We find that the existing Thai tariff structure, by lowering imports, lowers agricultural Land Use Change (LUC)-related GHG emissions and protects against cholesterol-related cardiovascular disease (CVD). This confirms previous evidence that food trade, measured by import shares of food expenditures and caloric intakes, is correlated with unhealthy eating and adverse health outcomes among importing country populations. A continued drive towards tariff liberalization and economic efficiency in Thailand may therefore come at the expense of reduced health and environmental sustainability of food consumption and production systems. Due to large efficiency losses, the existing tariff structure is, however, not cost-effective as an environmental or health policy instrument. However, additional simulations confirm that stylized 30% food sector import tariffs generally improve nutritional, clinical health, demographic, and environmental indicators across the board. We also find that diet-related health improvements can go hand-in-hand with increased Saturated Fatty Acid (SFA) intakes. Despite limited cost-effectiveness, policy makers from Thailand and abroad, including WHO, would therefore be well advised to consider targeted fiscal food policy tariffs as a potential intervention to maintain combined health and environmental sustainability, and to reconsider the specification of WHO dietary guidelines with their focus on SFA intake (rather than composition of fatty acid intake) targets.

Analysing the policy space for the promotion of healthy, sustainable edible oil consumption in India.

OBJECTIVE: To identify opportunities and challenges for the promotion of healthy, sustainable oil consumption in India. DESIGN: We use a framework for policy space analysis which distinguishes between policy context, process and characteristics. SETTING: We focus on the Indian edible oils sector and on factors shaping the policy space at a national level. PARTICIPANTS: The study is based on the analysis of policy documents and semi-structured interviews with key experts and stakeholders in the edible oils sector. RESULTS: We find opportunities associated with the emergence of multisectoral policy frameworks for climate adaptation and non-communicable disease (NCD) prevention at a national level which explicitly include the oils sector, the existence of structures for sectoral policy coordination, some supportive factors for the translation of nutrition evidence into practice, and the possibility of integrating nutrition-sensitive approaches within current state-led agricultural interventions. However, the trade-offs perceived across sustainability, NCD prevention and food security objectives in the vegetable oils sector are considered a barrier for policy influence and implementation. Sustainability and nutrition advocates tend to focus on different segments of the value chain, missing potential synergies. Moreover, policy priorities are dominated by historical concerns for food security, understood as energy provision, as well as economic and strategic priorities. CONCLUSIONS: Systematic efforts towards identifying synergistic approaches, from agricultural production to distribution of edible oils, as well as increased involvement of nutrition advocates with upstream policies in the oils sector, could increase policy influence for advocates of both nutrition and sustainability.

Evidence on the magnitude of the economic, health and population effects of palm cooking oil consumption: an integrated modelling approach with Thailand as a case study.

BACKGROUND: Palm oil's high yields, consequent low cost and highly versatile properties as a cooking oil and food ingredient have resulted in its thorough infiltration of the food sector in some countries. Longitudinal studies have associated palm oil's high saturated fatty acid content with non-communicable disease, but neither the economic or disease burdens have been assessed previously. METHODS: This novel palm oil-focussed disease burden assessment employs a fully integrated health, macroeconomic and demographic Computable General Equilibrium Model for Thailand with nine regional (urban/rural) households. Nutritional changes from food consumption are endogenously translated into health (myocardial infarction (MI) and stroke) and population outcomes and are fed back into the macroeconomic model as health and caregiver-related productive labour supply effects and healthcare costs to generate holistic 2016-2035 burden estimates. Model scenarios mirror the replacement of palm cooking oil with other dietary oils and are compared with simulated total Thai health and macroeconomic burdens for MI and stroke. RESULTS: Replacing consumption of palm cooking oil with other dietary oils could reduce MI/stroke incident cases by 8280/2639 and cumulative deaths by 4683/894 over 20 years, removing approximately 0.5% of the total Thai burden of MI/stroke. This palm cooking oil replacement would reduce consumption shares of saturated/monounsaturated fatty acids in Thai household consumption by 6.5%/3% and increase polyunsaturated fatty acid consumption shares by 14%, yielding a 1.74% decrease in the population-wide total-to-HDL cholesterol ratio after 20 years. The macroeconomic burden that would be removed is US$308mn, approximately 0.44% of the total burden of MI/stroke on Thailand's economy or 0.003% of cumulative 20-year GDP. Bangkok and Central region households benefit most from removal of disease burdens. CONCLUSIONS: Simulations indicate that consumption of palm cooking oil, rather than other dietary oils, imposes a negative health burden (MI and stroke) and associated economic burden on a high consuming country, such as Thailand. Integrated sectoral model frameworks to assess these burdens are possible, and burden estimates from our simulated direct replacement of palm cooking oil indicate that using these frameworks both for broader analyses of dietary palm oil use and total burden analyses of other diseases may also be beneficial.

Palm oil and dietary change: Application of an integrated macroeconomic, environmental, demographic, and health modelling framework for Thailand.

Palm oil is a cooking oil and food ingredient in widespread use in the global food system. However, as a highly saturated fat, palm oil consumption has been associated with negative effects on cardiovascular health, while large scale oil palm production has been linked to deforestation. We construct an innovative fully integrated Macroeconomic-Environmental-Demographic-health (MED-health) model to undertake integrated health, environmental, and economic analyses of palm oil consumption and oil palm production in Thailand over the coming 20 years (2016-2035). In order to put a health and fiscal food policy perspective on policy priorities of future palm oil consumption growth, we model the implications of a 54% product-specific sales tax to achieve a halving of future energy intakes from palm cooking oil consumption. Total patient incidence and premature mortality from myocardial infarction and stroke decline by 0.03-0.16% and rural-urban equity in health and welfare improves in most regions. However, contrary to accepted wisdom, reduced oil palm production would not be environmentally beneficial in the Thailand case, since, once established, oil palms have favourable carbon sequestration characteristics compared to alternative uses of Thai cropland. The increased sales tax also provokes mixed economic impacts: While real GDP increases in a second-best Thai tax policy environment, relative consumption-to-investment price changes may reduce household welfare over extended periods unless accompanied by non-distortionary government compensation payments. Overall, our holistic approach demonstrates that product-specific fiscal food policy taxes may involve important trade-offs between nutrition, health, the economy, and the environment.

Integrated mixed methods policy analysis for sustainable food systems: trends, challenges and future research.

Agriculture is a major contributor to greenhouse gas emissions, an important part of which is associated to deforestation and indirect land use change. Appropriate and coherent food policies can play an important role in aligning health, economic and environmental goals. From the point of view of policy analysis, however, this requires multi-sectoral, interdisciplinary approaches which can be highly complex. Important methodological advances in the area are not exempted from limitations and criticism. We argue that there is scope for further developments in integrated quantitative and qualitative policy analysis combining existing methods, including mathematical modelling and stakeholder analysis. We outline methodological trends in the field, briefly characterise integrated mixed methods policy analysis and identify contributions, challenges and opportunities for future research. In particular, this type of approach can help address issues of uncertainty and context-specific validity, incorporate multiple perspectives and help advance meaningful interdisciplinary collaboration in the field. Substantial challenges remain, however, such as the integration of key issues related to non-communicable disease, or the incorporation of a broader range of qualitative approaches that can address important cultural and ethical dimensions of food.