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The Importance of Food Reformulation in Developing Countries

  • Heethaka K. S. De Zoysa
  • Viduranga Y. Waisundara
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Abstract

Noncommunicable diseases (NCDs) are on the rise around the world, while this phenomenon is comparatively more prevalent in developing countries. It has been identified that this situation arose in developing countries owing to nutrition transitions and adaptation of a sedentary lifestyle, both of which are consequences of urbanization. While priority actions have been documented by various groups to curb this condition, dietary change has become the common implementation across all these recommendations for developing countries, in particular, reducing the occurrence of salt, sugar, and trans-fatty acids (TFAs) in processed food products. These components are readily available in ultraprocessed food products, which are high in calories and nutrient-dense and cause a variety of NCDs. Salt reduction has been identified to be one of the major factors that may help reduce the burden of cardiovascular diseases (CVDs) and strokes. In addition, there is an association between the consumption of free sugars and increased risk of obesity, diabetes, and CVD, which is mediated through the energy intake and the metabolism of sugars. Dietary TFAs have adverse effects on blood lipoprotein profiles, CVD, and chronic heart disease (CHD) risk, impacting individuals and populations. Efforts on reformulation of food products to reduce these adverse components require policy changes, government and industry tie-ins, and maintenance of food composition databases. In addition, for a successful implementation of reformulation objectives in developing countries, “silent” reformulation has been recommended in order to prevent consumers from perceiving an allowance to compensate for the reduced contents by increasing the consumption of other products with these substances. Also, awareness on reformulated food products and healthier choices should start at a young age, especially among school children, in order to influence their food preferences. Recurrent exposure of children to the same food environment can lead to routine or habitual behavior, leading to preferences in maintaining health and wellness.

Keywords

Africa China Developing Countries India Food Reformulation Salt Sugar Trans Fatty Acids 

1 Current Landscape of Health, Wellness, and Dietary Transition in Developing Countries

The spread of noncommunicable diseases (NCDs) presents a global crisis in almost all countries. In particular, in many of the developing countries, rapid urbanization is prevalent among certain districts, although substantial gains have been achieved in economic growth, health, and living standards in these areas. However, this progress is now threatened by factors such as food security and NCDs, primarily in the forms of heart disease, stroke, diabetes, cancers, and chronic respiratory disease. The main risk factors for NCDs for individuals are well known and are similar in all countries, regardless of whether they are developing or developed (Popkin et al. 2012). The Lancet NCD Action Group and the NCD Alliance had proposed five priority interventions, which are illustrated in Fig. 1, to reduce the incidence of NCDs (Beaglehole et al. 2011). Two out of the five priority actions are based on food and diet, and thus, it is implied that an emphasis is placed on nutrition and production of healthy food.
Fig. 1

Priority actions identified by the Lancet NCD Action Group and the NCD Alliance to prevent the global crisis and increasing prevalence of NCDs (Beaglehole et al. 2011)

In the recent past, many low- and middle-income countries have undergone a drastic transition in diets, physical activity levels, and burden of disease (Lozano et al. 2012; Popkin 2014). In South Africa, for instance, despite continuing high levels of underweight and nutritional deficiencies, overweight and obesity among both adults and children is a rapidly growing public health problem (Department of Health 2007; Reddy et al. 2010; Armstrong et al. 2011; Kruger et al. 2011). India, as another example, had 65 million people who were malnourished in 1995, and one in five adults is now overweight (Doak et al. 2005; Stein et al. 2005; Stuckler and Nestle 2012). Although the coexistence of food insecurity and obesity may seem like a paradox, over- and undernutrition is in essence a reflection of two facets of malnutrition. Underlying both these nutrition statuses is a common factor, which has a significant impact on developing nations above all; that is, food systems are unable to deliver optimal human diets but, essentially, are targeted toward maximizing profits. For countries living in poverty or with impoverished populations, this means either exclusion from development leading to food insecurity or eating low-cost, highly processed foods, which are inevitably lacking in nutrition, resulting in the two major consequences of overweight and obesity. Having said these, although the food industry has been criticized for contributing to the rise of these adverse health effects, the former WHO Director General, Gro Harlem Brundtland, categorically stated that solutions to the overweight and obesity problem depend in part on the innovation and efficiency of the food industry (WHO 2004). In actual fact, this statement implied that in the immediate future, food reformulation must be implemented, the food-labeling system must be improved, and awareness of food reformulation initiatives must be further increased through educational campaigns.

Widespread changes in diets all around the world include a decrease in consumption of coarse grains, staple cereals, and pulses, an increase in the consumption of animal foods, sugar, salt, fats and oils, refined grains, and processed foods, and either an increase or decrease in consumption of fruits and vegetables (Hawkes et al. 2017). These changes are occurring at different rates in different regions and populations, although it can be stated in isolation that the most rapid change is taking place in developing countries (Hawkes et al. 2017). The nutrition transition, which is quite visibly seen in almost all of the developing countries, is a shift from consuming traditional diets to a more “western” one; this dietary change constitutes a high consumption of processed foods and animal products, eventually resulting in an increased risk of NCDs (Lozano et al. 2012; Popkin 2014). Most of the early work on the nutrition transition in developing countries showed that the shift toward greater availability of fats and sugars and reductions in reliance on starchy carbohydrates as dietary staples was occurring faster in cities, which have accelerated economic growth, than in rural areas (Hawkes et al. 2017). Urban populations tend to consume more calories, while a lesser proportion of these calories come from cereals or carbohydrates (Hawkes et al. 2017).

Apart from the transition from consuming traditional food items to processed products, having meals outside of households; in particular, in restaurants; the availability of ready-to-cook and ready-to-eat products in supermarkets; and preference/dependence on street food have further contributed to the dietary transition in developing countries (Chandon and Wansink 2007). These habits are seen to facilitate access to unhealthy diets, although they may also improve access to nutritious foods for people who can afford them (Hawkes et al. 2017). Even for the urban poor in developing countries, the most easily available and affordable diets are often unhealthy (Hawkes et al. 2017). An estimated 20–25% percent of household food expenditure in low- and middle-income countries is on food prepared outside the home, and some segments of urban populations in these countries appear to depend entirely on street food (Hawkes et al. 2017). At the same time, the habit of consuming food that is not domestically prepared appears to be comparatively overlooked as an area requiring intervention for the purpose of maintaining health and wellness in developing countries. The void is clearly seen through the comparative lack of systematic data and intervention strategies in the ready-to-cook and ready-to-eat food product manufacturing, restaurant, and street vendor sectors.

2 Food Product Reformulation for the Developing World

Food processing comprises of primary processing and secondary processing and in itself is not necessarily unhealthy – it is the nature, extent, and purpose of processing that results in the consequence of being unhealthy (Monteiro 2010). The term “ultraprocessing ” has been coined to describe foods that have undergone extensive processing, and these foods tend to be high in sugar, salt, and fat (particularly saturated fats and TFAs), while being energy-dense with little nutritive value (Monteiro 2010). These ultraprocessed food products have become ubiquitous in the food supply of high-income countries and more recently in many low- and middle-income countries (Stuckler et al. 2012; Moodie et al. 2013). As market growth in developed countries has slowed down, the food industry has begun focusing on emerging economies to restore growth in sales (Stuckler et al. 2012). As a result, nearly all growth in processed food sales are now generated from low- and middle-income countries (Stuckler et al. 2012; Moodie et al. 2013). Given the high quantities of salt, sugar, and fat (including TFAs) in many of these foods, the influx of processed food in low- and middle-income countries is problematic (Downs et al. 2014). Age-specific NCD death rates are nearly two-times higher in low-income and middle-income countries than in high-income countries, where they often cause slow and painful deaths after prolonged periods of disability.

Food product reformulation is seen as one among several tools to promote healthier eating in the developing world. By reformulating the recipe of a processed food, for example, reducing the fat, sugar, or salt content of the foods, or increasing the content of whole-grains, food manufacturers can help consumers maintain a healthier life style, sometimes, even without changing their dietary behavior (Jensen and Sommer 2017). According to Vlassopoulos et al. (2017), “improving the nutrient density of food products through reformulation is one approach to improve diet quality and to reduce the prevalence of non-communicable diseases (NCDs).” Food reformulation could be considered as either mandatory or voluntary, although it has been regularly identified as one of the most relevant and cost-effective public health nutrition strategies in many health-promotion platforms. The World Health Organization (WHO) and the World Health Assembly have identified the need for the food industry to reduce the amounts of saturated fats and TFAs, free sugars, and salt where this especially applies to the food supplies produced and coming into developing countries (WHO 2011). However, for developing countries, consumer information is seen as an absolute necessity and the most effective means in order for such industrial mechanisms to be effective.

Overall exports from countries and regions with plenty of agricultural land are forecast to increase; however, according to the Organization for Economic Cooperation and Development – Food and Agriculture Organization of the United Nations (OECD-FAO) Agricultural Outlook 2018–2027, there needs to be an enabling trade policy environment between developed and developing countries. This is because agricultural trade plays an important role in ensuring food security in developing countries. According to the Agricultural Outlook, undernourishment is concentrated in conflict-ridden and politically unstable countries – with the Middle East and North Africa (MENA) facing simultaneous challenges in food insecurity, rising malnutrition, and managing limited natural resources. According to these reports, poorer countries are forecasted to be increasingly dependent on the developed nations for imported food products. Thus, although perceived as an exclusive initiative for the developing nations, developing countries also need to partake in the exercise of food reformulation, especially the exports that are sent out to the developing countries. Bearing this in mind, the next few sections of this chapter will look closely into the prospects of reducing salt, sugar, and TFAs in food products for the purpose of promoting health and wellness and assuring nutrient security. There are several other food ingredients that are deemed as requiring food reformulation strategies, for instance, the use of synthetic colorings, artificial flavors, and preservatives. These are not discussed herein since most of the information presently available on these aspects about developing countries appears to be vague, incomplete, or conflicting. This does, however, highlight the need for proper monitoring strategies to be in place on the reformulation of these food ingredients, which are commonly used in the production of processed food in developing countries.

2.1 Salt Reduction

Salt reduction has been shown to be one of the most cost-effective ways of reducing the growing burden of NCDs, primarily through reducing the incidence of cardiovascular diseases (CVD) and strokes (Webster et al. 2014). The actual physiological requirement for salt is less than 1 gr per day although most populations appear to consume between 9 and 12 gr per day (He and MacGregor 2010; Webster et al. 2014). The WHO’s global action plan for the prevention and control of NCDs identifies a 25% reduction in premature mortality from cardiovascular disease, a 25% reduction in raised blood pressure, and a 30% reduction in mean population salt intake as targets for 2025 (WHO 2012, 2013). In addition, the WHO recommends a maximum dietary salt intake of 5 gr/day for adults (WHO 2013). According to Beaglehole et al. (2011), in the longer run, a reduction in salt consumption through reformulated food products will have a greater effect, since it will attenuate the age-associated rise in blood pressure. Although the incorporation of iodine to the diet is tied together through its addition to table salt, which is used in households on a daily basis, any small risk of iodine deficiency can be addressed by other means and should not be a reason for concern by sacrificing the more important cause of preventing CVD and coronary heart disease (CHD). As the consumption of processed foods rises in many countries, a change in the food industry to reduce the addition of salt to their product line will have immense and important benefits in the future.

There are many salt-reduction initiatives adapted around the world, some of which greatly differ between developing and developed nations. According to Trieu et al. (2015), national salt-reduction strategies in the form of reformulating food, which have been previously identified in large-scale (Webster et al. 2011), were limited to 25 high-income and 7 upper middle-income countries. However, according to Trieu et al. (2015), strategies now exist in 41 high-income countries, 21 upper middle-income countries, 11 lower middle-income countries, and 1 low-income country. This was a noteworthy finding given the influx of food products coming from the developed countries to the developing countries, which have salt in their list of ingredients. Having said that, Trieu et al. (2015) also noted that the large and increasing number of countries with salt reduction strategies remains to be limited to the low- and middle-income regions, where reduction of salt added to retail food products remains a high priority.

The approach to industry engagement is one of the key differentiating factors in this aspect of salt reduction with most developed countries establishing mandatory targets, while developing countries choose voluntary agreements and negotiated commitments through meetings (Webster et al. 2014). It is the belief of many public health experts that regulation is a much stronger driver for industry reformulation than voluntary agreements, which are followed by developing countries, as sanctions usually carry a penalty for noncompliance (Webster 2009; Monteiro et al. 2010). For many of the developing countries, laws are difficult to introduce, taking a considerable amount of time to move through numerous layers of bureaucracy. Once laws are established, they may also be less flexible and difficult to change. It may be for this reason that many developing countries prefer to adopt voluntary approaches by establishing partnerships with the food industry to negotiate agreements, and ensure adequate monitoring mechanisms are in place to hold the food industry accountable for any pertinent misdemeanors (Webster et al. 2014). Regardless of whether or not the approach taken for salt reduction is voluntary or legislative, one of the key decisions for developing countries to make is for which foods the salt level targets need to be set. In this instance, ready-to-cook or ready-to-eat products could be a starting point. The contribution of processed foods to salt intake varies considerably throughout the world owing to a multitude of factors, and national strategies to reduce salt need to take this aspect into account (Webster 2009; Webster et al. 2014).

There have been a few noteworthy initiatives taken from some of the African countries to reduce the salt intake to meet WHO guidelines. South Africa, in particular, documented its national salt reduction initiatives in 2013, and this was published as a case study (Hofman and Lee 2013; Sookram et al. 2015). This paper documents the measures taken by the Government of South Africa to reduce salt content of commonly consumed processed foods such as bread, breakfast cereals, cured and raw processed meat, savory snacks, butter, and margarine. Based on this strategy, South Africa passed a new mandatory regulation more recently, limiting the quantity of sodium in processed foods, which came into effect in 2016. At the same time, Mauritius carried out a survey on population salt intake in 2012 to establish intake levels among adults (Pauvaday et al. 2012). The study found that the daily salt intake among adults of the country was 7.9 g. These findings were used to initiate measures to reduce salt intake to WHO recommended levels in Mauritius. There have been several other initiatives in other African nations and developing countries in other continents. However, these two appear to stand out from the rest in terms of being systematic as well as the success rate.

2.2 Reduction of Sugar

Free sugars, that is, sugars that have been removed from their naturally occurring sources, are often found in food that are both energy-dense and nutrient-poor, in particular, fast foods snacks, sweets, juices, and other discretionary foods (Ambrosini 2014; Bernstein et al. 2017). When isolated from their naturally occurring sources, free sugars become readily available to be incorporated into food and beverages, and to consume in greater quantities compared with the still intact intrinsic sugars, typically found in abundance in a healthy, balanced diet (Sigman-Grant and Morita 2003). The association between the consumption of free sugars and increased risk of obesity, diabetes, and cardiovascular disease is thought to be mediated through energy intake and the metabolism of sugars (Malik et al. 2010; Te Morenga et al. 2013, 2014; Yang et al. 2014). When it comes to research on these disease conditions, diabetes research in particular has mainly focused on people living in developed countries as a disease caused by obesity (Waisundara and Shiomi 2018). However, the prevalence rate of diabetes has been increasing also in many developing and newly industrialized nations. Data extracted from the International Diabetes Federation (2014) on South Asia alone, which was estimated by a statistical investigation of the relevant populations primarily 20–79 years of age, is shown in Table 1. The prevalence of diabetes and estimated diabetes numbers among adults aged 20–79 years for the years 2011 and 2030 in some of the most populous countries of South Asia, in comparison with South Africa and South America, are shown in Table 2. These numbers raise attention to the alarming diet-related consequences on health, especially since much industrialization and economic growth is observed in South Asia.
Table 1

Prevalence of diabetes in South Asia in 2014 and its estimated prevalence in 2035 (International Diabetes Federation 2014)

Countries

Total adult population (20–79 years) in 2014

Diabetes prevalence per total adult population in 2014 (%)

Number of deaths by the disease related to diabetes in 2014

Mean diabetes-related expenditure per person in 2014

Estimation of total adult population in 2035

Diabetes prevalence per total adult population in 2035 (%)

Afghanistan

13,086.9

6.15

18,514

102

27,768.7

6.63

Bangladesh

94,378.5

6.34

111,371

43

133,493.5

8.18

Bhutan

474.0

4.94

124

150

656.9

6.90

India

774,920.8

8.63

1,039,980

95

1042,007.9

10.46

Maldives

214.0

7.97

109

870

332.9

5.94

Nepal

15,307.4

4.58

14,778

60

23,032.1

5.44

Pakistan

102,124.6

6.80

87,548

56

158,355.1

8.08

Sri Lanka

14,155.4

8.32

16,384

123

16,398.4

9.47

Table 2

Prevalence of diabetes and estimated diabetes numbers among adults aged 20–79 years for the years 2011 and 2030 in some of the most populous countries in Africa, South America, and Asia

 

Prevalence (%) adjusted to

Number of adults with diabetes (000 s)

Mean annual increment (000 s)

World population

National population

2011

2030

2011

2030

2011

2030

Africa

Angola

2.9

3.4

2.2

2.4

185

383

10

Burkina Faso

3.0

3.6

2.4

2.7

175

371

10

Cameroon

6.1

7.1

5.2

5.9

501

913

22

Cote d’Ivoire

4.9

6.1

4.2

5.0

406

813

21

Democratic Republic of Congo

3.1

3.7

2.5

2.7

731

1422

36

Ethiopia

3.4

3.7

3.5

3.8

1377

2629

66

Ghana

5.0

6.2

4.1

5.0

517

1036

27

Kenya

5.1

6.3

4.0

5.0

769

1683

48

Madagascar

4.7

5.1

4.4

4.5

428

831

21

Malawi

5.6

6.5

5.4

6.1

352

747

21

Mali

1.9

2.4

1.5

1.8

100

217

6

Mozambique

3.1

3.9

2.7

3.2

295

581

15

Niger

4.2

4.3

4.4

4.7

284

620

18

Nigeria

4.8

6.0

4.0

4.8

3055

6113

161

South Africa

7.0

7.9

6.5

7.2

1947

2548

32

Uganda

2.8

3.5

2.2

2.5

308

690

20

United Republic of Tanzania

2.8

3.8

2.3

3.0

473

1107

33

South America

Argentina

5.5

6.4

5.8

6.5

1532

2078

29

Brazil

10.1

11.9

9.7

12.3

12,440

19,605

377

Chile

9.5

11.1

10.2

12.3

1190

1730

28

Columbia

9.7

11.5

9.1

11.4

2609

4412

95

Cuba

9.4

11.4

11.4

15.3

939

1293

19

Ecuador

6.6

7.8

6.0

7.5

524

890

19

Guatemala

9.3

10.9

7.7

8.4

533

1037

27

Peru

6.0

6.8

5.4

6.4

942

1523

31

Venezuela

10.2

12.0

9.4

11.4

1675

2835

61

South Asia

Bangladesh

10.5

13.7

9.6

13.3

8406

16,837

444

India

9.0

10.6

8.3

9.9

61,258

101,203

2102

Nepal

3.6

5.4

3.0

4.5

488

1171

36

Sri Lanka

7.5

8.7

7.8

9.1

1080

1467

20

According to the OECD-FAO Agricultural Outlook 2018–2027, increases in global sugar consumption over the next ten years are expected to come mainly from the developing countries who are expected to account for 94% of the additional demand. The global caloric consumption and world trade projections on sugar imports according to this report is shown in Tables 3 and 4, respectively. The largest contributions to additional demand will occur in Asia and Africa at 60% and 25%, respectively. According to this data , in Asia, it is expected that India, followed by China, Indonesia, and Pakistan, will experience the largest increases in sugar consumption. Despite these statistics, slowing population growth, dietary changes based on increased health consciousness, and nutritional commitments taken by many in the food sector are expected to continue to impact the saturated sugar markets around the world, especially in Asia and Africa. The extrapolations clearly demonstrate the need to reduce sugar intake through product reformulation in developing countries, especially in continents such as Asia and Africa.
Table 3

Global caloric sweetener consumption – sweeteners include sugar and high fructose corn syrup (OECD Agriculture statistics database 2018)

 

2027 (kt)

2015–17 (kt)

Asia (except India and China)

50.3

42.3

India

31.1

24.7

China

22.7

18.0

Africa

27.1

19.4

Other Europe

 8.9

 8.6

European Union

19.8

19.3

Latin America and Caribbean

32.2

28.7

North America

19.4

17.9

Table 4

World trade projections on sugar imports (OECD Agriculture statistics database 2018)

Sugar

Average 2015–17

2018 (kt)

2019 (kt)

2020 (kt)

2021 (kt)

2022 (kt)

2023 (kt)

2024 (kt)

2025 (kt)

2026 (kt)

2027 (kt)

World Trade

54,721

52,526

53,311

54,101

55,447

56,151

56,941

57,803

58,702

59,751

60,797

OECD

11,205

10,440

10,400

10,448

10,568

10,672

10,799

10,905

11,020

11,151

11,268

Developing Countries

42,911

41,960

42,856

43,637

44,838

45,453

46,133

46,908

47,717

48,664

49,621

Least Developed Countries

7073

6540

6947

7151

7376

7516

7684

7843

8019

8220

8430

Reformulating food products in the consumer market of developing countries to be low in free sugars requires interventions; this initiative may also aim at reducing the overall calorie contents of the food products, whenever possible (Guidelines for Industry 2017). Removing free sugars, especially in solid foods, often requires replacement with other ingredients to preserve properties such as bulk, texture, and other functional attributes that contribute to the overall appearance and coherence of the product (Goldfein and Slavin 2015). This additional complexity of maintaining sensory properties means reductions in free sugar levels may not always result in a reduction in calories (Hashem et al. 2016). Thus, it is imperative that more effective replacements for sugar should be discovered through research, since organoleptic properties are a key determinant influencing consumer choices. Some developing countries, including Mexico, Chile, Thailand, and Saudi Arabia, have introduced a sugar tax on soft drinks in an attempt to reduce overconsumption of sugar (OECD-FAO Agricultural Outlook 2018–2027). These taxes have prompted the food industry and manufacturers to adapt through product reformulation or the use of alternative sweeteners.

2.3 Trans-Fatty Acids

In 2003, the joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Disease confirmed that dietary TFAs have adverse effects on blood lipoprotein profiles and CHD risk, impacting individuals and populations (Nishida et al. 2004; Uauay et al. 2009). The adverse effects on CHD are mediated by increases in plasma concentrations of low-density lipoprotein cholesterol (LDL) and lipoprotein(a) [Lp(a)], and reductions in high-density lipoprotein cholesterol (HDL); other than these, promotion of inflammation and endothelial dysfunction, and possible effects on coagulation, insulin resistance, and displacement of essential fatty acids from membranes may also affect prostanoid- and other membrane-related functions (Mozaffarian and Willett 2007; Mozaffarian and Clarke 2009; Mozaffarian et al. 2009). The current body of evidence further indicates that TFA enhances multiple cardiovascular risk factors and leads to a surge in CHD-related events (Mozaffarian and Willett 2007; Mozaffarian and Clarke 2009; Mozaffarian et al. 2009).

Attention should be given to possible health effects of TFAs created during industrial processes, such as light deodorization of marine oils and prolonged deep-frying (Uauay et al. 2009). According to Uauay et al. (2009) and Mozaffarian and Clarke (2009), “removal of partially hydrogenated vegetable oil (PHVO), which is a main source of TFAs in processed foods, would result in substantial health benefits , with the greatest advantage obtained when TFAs are replaced by oils rich in polyunsaturated fatty acids (PUFAs) and/or monounsaturated fatty acids (MUFAs).” This is an important aspect considering the increased vegetable oil consumption in developing countries. According to Table 5, which displays data from the OECD-FAO Agricultural Outlook 2018–2027, rising per-capita income is expected to lead to a 1.0% per annum increase in per-capita vegetable oil consumed as food in developing economies, which is considerably less than the 2.7% per annum increase observed during 2008–17. This slowdown reflects the saturation in per-capita uptake in many emerging economies. However, in most emerging markets, per-capita vegetable oil food availability is set to reach levels comparable to those of developed countries (OECD-FAO Agricultural Outlook 2018–2027). Substitution of vegetable oils with no or low TFA and high cis-unsaturated fatty acid can replace PHVOs. Thus, there is a clear need to raise awareness among oil seed producers and agriculturists of the requirement for an increased supply of substitute oils. This also represents an opportunity to expand or develop new oil seed varieties.
Table 5

Projections of vegetable oil consumption and growth in selected African and Asian countries, developing countries, developed countries, and least developed countries (OECD Agriculture statistics database 2018)

 

Consumption (kt)

Growth (%)

Average 2015–17

2027

2008–17

2018–27

World

191,590

234,515

4.48

1.65

Africa

15,896

21,665

4.94

2.90

Egypt

2296

3049

4.50

2.45

Ethiopia

534

989

26.22

5.63

Nigeria

3145

4326

4.82

3.19

South Africa

1344

1598

4.81

1.60

Asia

107,489

140,269

5.27

2.19

China

35,611

40,957

4.53

1.00

India

23,868

36,782

5.16

3.93

Indonesia

12,246

15,777

9.14

2.16

Iran

1698

2261

2.81

1.90

Japan

2404

2454

0.85

−0.02

Kazakhstan

290

423

1.30

2.34

Korea

1237

1260

4.01

−0.57

Malaysia

4730

6008

3.72

1.45

Pakistan

4993

6806

4.88

2.27

Philippines

1955

2866

6.24

3.01

Saudi Arabia

730

1029

13.54

2.77

Thailand

3171

4105

9.16

1.95

Turkey

2801

3234

6.07

1.10

Viet Nam

1363

2122

8.08

3.97

Developed Countries

53,747

55,029

2.67

0.27

Developing Countries

137,843

179,486

5.26

2.11

Least Developed Countries

8623

12,628

5.87

3.33

Efforts to reformulate foods to reduce TFAs can have substantial effects on health and require reformulations of health policies themselves. Public campaigns and policy measures inadvertently motivate food manufacturers to replace TFAs with alternative fats (Mozaffarian et al. 2006; Mozaffarian et al. 2010). Following attempts to reduce or remove TFA from the food supply in industrialized and developing countries, experts have considered a number of successful public health initiatives adopted by government agencies and public health organizations, which in some cases were done in collaboration with the food industry. According to L’Abbé et al. (2009) and Uauay et al. (2009), these include “nutrition recommendations about TFAs and the selection of healthy fats, awareness programs through nutrition and health claims on the adverse effects of TFAs, voluntary or mandatory labeling of the trans content of foods, voluntary or legislated programs to encourage industry to reformulate food products in an effort to remove TFA , promoting the reduction of TFAs through health and agricultural policies that also support the production of healthy alternatives, and mandatory regulation of food standards to remove or reduce TFA content.” To date, no exhaustive national database exists in developing countries about product-specific changes in TFAs and also saturated fat over time. This void indicates, nevertheless, that there is room for improvement in some reformulation strategies, especially for supermarket foods – which require labeling, and restaurant foods  – which do not require specific labeling.

3 Strategies for Food Reformulation in Developing Countries

There are several strategies that can be or are currently being adapted by developing countries associated with food reformulation. Those which have been successfully implemented or have the potential to be successful are discussed in the next few sections.

3.1 Nutrient Profiling of Fast Food for Improving the Nutritional Profiles

This is a timely topic that requires urgent attention since in developed countries, and increasingly in developing countries , most consumers appear to purchase large numbers of meals outside the home (Paeratakul et al. 2003; Rangan et al. 2009; The Food Monitoring Group 2012). This surmises that retail food is contributing substantially to population intakes of energy, fat, sugar, and salt. The portion sizes of many fast foods and restaurants in particular have doubled over the past 50 years, thus raising the importance of monitoring changes in the nutritional content of these products (Young and Nestle 2003; The Food Monitoring Group 2012).

Various nutrient profiling systems exist, and they have been developed for different purposes such as claims eligibility, advertising, signposting, and food reformulation (Rayner et al. 2005a, b; Garsetti et al. 2007; Nijman et al. 2007); however, a single standard method has not been developed and identified as yet. The methods that have been developed to date, which are targeted toward evaluating the nutrient profiles, are aimed at determining whether the foods are categorized as “healthy” or “not healthy” (Roodenburg et al. 2011). This categorization alone may be insufficient when it comes to nutrient profiling of food products in developing countries. Given this dichotomous categorization, which resides in all methods of nutrient profiling, a possible alternative approach is to estimate whether the food products are suitable for their purpose, for example, their potential to influence daily nutrient intakes (Roodenburg et al. 2011). Overall, any nutrient profiling method should stimulate changes in nutrient intakes through nutrient profiles as reformulation targets, and this is very much so when it comes to fast food available in the current consumer markets of developing countries.

Most governments and food regulatory authorities have been reluctant to impose additional sanctions on food manufacturers to improve the nutritional profile of their products (UK Food Standards Agency 2018a, b). Instead they have been made to rely on self-regulation or voluntary codes of practice. The same reluctance from relevant authorities exists when nutrient profiling of fast food products is sanctioned, and the outcome appears to be no different (Popkin et al. 2012). It is no surprise that these unenthusiastic approaches have delivered progress and compliance in food reformulation only in a few countries that do not require significant directives in the first place (i.e., most of them being developed countries with high levels of consumer awareness on making healthier choices in the retail market) (Puska 1992). Nevertheless, it is obvious that authoritative monitoring of food product formulation in both developed and developing countries could provide additional support toward efforts to drive change in the composition of fast foods through nutrient profiling. Also, validation of nutrient profiling systems is of highest research importance prior to imposing sanctions in the fast food industry, so that the nutrient intakes can be improved in the direction of the recommendations such as the WHO’s Global Strategy on Diet, Physical Activity and Health, which is strongly recommended to the private sector (Waxman 2004).

3.2 Influencing Food Preferences of Children

The success of food reformulation strategies hinges on the effectiveness of awareness campaigns. In this regard, a good starting point to influence food preferences toward a healthier choice is during childhood. A number of papers have concluded that food promotion has an influence on children’s food preferences, purchasing requests, and consumption (Drewnowski and Hann 1999; Brug et al. 2008; McClain et al. 2009). According to Hawkes et al. (2015), food preferences are well established as important determinants of food intake, although in psychological terms, the phrase is narrowly used to refer to liking for a food, or more specifically for a taste. Some preferences for food are innate, for example, infants have an inclination for liking things that are sweet (Ventura and Mennella 2011; Hawkes et al. 2015). Nevertheless, most aspects of food preferences are learned over time, and this flexibility indicates an evolved capacity to learn which food products provide adequate energy and are nontoxic, or do not cause adverse health effects (Birch 1998; Wardle and Cooke 2008). Other than children themselves, parents and caregivers potentially exert a key influence on their children’s food preferences, which may be conducive to, or hinder, the development of healthy eating patterns (Savage et al. 2007; Kral and Faith 2009). Recurrent exposure to the same food environment can lead to routine or habitual behavior, leading to preferences for some actions and choices. The more often an action is taken under stable circumstances, the more a behavior is determined by the habit.

Schools are an ideal and influential setting for young children in developing countries to be influenced in their food preferences and, thus, be encouraged to consume food products that are low in sugar, salt, and TFAs. Actions in schools can be expected to work through different mechanisms, depending on the specific policy action taken and the characteristics of the population. Specific actions to improve diets in school settings have already been carried out with noticeable success, such as the provision of fruits and vegetables, food-based and nutrient-based standards on the foods and meals available in schools, changes to presentation and financial incentives for food choices at point-of-purchase, and nutrition education (Hawkes et al. 2015). Evidence is also available that school food policies can work by encouraging children to reassess their preferences at the point of purchase. Changes to the order of foods presented in buffets in public and private institutional settings that are labeled as a healthier choice and void of excess sugar, salt, and TFAs have been shown to encourage a shift toward healthier consumption patterns (Hanks et al. 2012; Wansink and Hanks 2013). Randomized controlled trials in different countries show that well-designed education-only interventions can effectively improve knowledge, and shift consumption of a range of foods in children across various socioeconomic ranges – an outcome and remedy that could clearly be applied to enlighten children on reformulated food products that are healthier alternatives (Amaro et al. 2006; Sichieri et al. 2009; Francis et al. 2010; Waters et al. 2011; Lerner-Geva et al. 2014).

Advertisements have a direct effect on food preferences by creating positive associations. Children who habitually watch more television display changes to their food preferences after exposure to food advertising (Boyland and Halford 2013). Awareness through media by celebrities would have a significant impact aimed at mobilizing, enhancing, and sometimes even creating food preferences. For instance, preferences toward snack foods and confectionery, which are typically formulated to exploit innate preferences for sweetness and energy density, could be tactically diminished through campaigns by characters such as movie stars and sports personalities – personnel who have a noteworthy presence in media in most of the developing countries (Robinson et al. 2007; Letona et al. 2014). Sustained behavioral change in children could be regarded as the ultimate goal of effective nutrition education at an early age. For this to occur, it is imperative that those involved in nutrition education narrow the gap between the mere provision of nutrition information, and the enhancement of nutrition knowledge and promotion of actual dietary practice (Love et al. 2008). A number of countries have adopted some form of voluntary or statutory regulation of food advertising to children; however, none of them appear to be developing countries (Hawkes 2004). In the countries where such strategies have been implemented, the advertisements tend to focus on ensuring truthful claims, and avoiding the promotion of overconsumption, rather than on exclusion of advertisements for particular foods. Countries and regions such as Norway, Sweden, and Quebec, Canada have imposed scheduling restrictions (or total bans) on all advertisements aimed at children, rather than food advertisements in particular (Hawkes 2004).

Some middle-income countries – Brazil being the best example – regulate food available in schools, including through mandatory or voluntary guidelines for school meals and, less commonly, by restricting other foods available for purchase, such as in vending machines (Hawkes et al. 2017). A small number of countries, including Mexico, the Republic of Korea, and Taiwan, China, implemented specific restrictions on unhealthy food marketing to children. It is well established that while changes to food environments are critical to shaping healthier choices and preferences, they are likely to be more successful if reinforced by behavior change communication. Programs in schools that take this type of multilevel approach, for example, the ACTIVITAL program in urban Ecuador, have been found to be successful in improving diets and reducing overweight. A dual approach was used in the ACTIVAL program as follows: (1) An individual classroom-based strategy comprising an interactive toolkit to assist teaching on healthy eating and healthy physical activity, (2) an environmental strategy that included participatory workshops with parents and food-shop staff along with social events such as the preparation of healthy breakfasts, motivational talks by famous local athletes, and the development of walking trails for the schools. Nevertheless, despite these examples, overall action in terms of food reformulation aimed at children has been minimal in many of the low- and lower-middle-income countries, even in those where the nutrition transition is most rapid.

3.3 The “Silent” Reformulation Approach of Retail Food Products

In developing countries, it is possible that food reformulation for reducing fat, sugar, or salt content might induce compensation effects, where the consumers perceive an allowance to compensate for the reduced contents by increasing their consumption of other products with these substances (Jensen and Sommer 2017). Product reformulation might be expected to change the perceived quality of the products, and thereby, affect the comparison between the reformulated product and its substitutes. This may occur primarily because the reformulated product is considered by consumers to be “unnatural” or a “diet” product. To the extent that consumers respond to such perceived quality changes, these responses may enhance or undermine the success of the effort of reformulation itself.

A recently recommended product reformulation strategy is to make it “silent,” as in, to not announce the reformulation explicitly to the consumers – except may be on standard nutrition labels. This strategy has been developed in such a manner to remove the potential competitive advantage of appealing to health-oriented consumers for the individual product (Jensen and Sommer 2017). The reason behind a manufacturer’s or retailer’s motivation to undertake such “silent” reformulation could also be to enhance the health profile of its corporate brand by considering reformulation as part of its strategy of Corporate Social Responsibility. This type of reformulation strategy seems to have attracted little interest in developing countries, but may well be successful if properly implemented (Popkin et al. 2012).

The “silent” reformulation approach has been successfully exercised by one of the major retail chains in Denmark (Jensen and Sommer 2017). Although a developed country where many initiatives of this nature have taken place, its strategy to successfully impart a behavioral change in consumers can be adapted by developing countries as well. In this instance, modest changes to the food composition only had an impact on the nutrient content, but not on the price and the sensory quality of the products. Only the nutrition information labels on the products were updated as a result of the reformulation. This is based on the premise that, if consumers have not noticed changes on the nutrition facts label or the sensory characteristics, their product choices are thought to be unaffected by the reformulation. On the opposite end of the spectrum, if consumers perceive a change in sensory or nutritional, their choices could be affected. However, it was observed in the instance of Denmark that the direct effect of “silent” product reformulation resulted in a reduction in the sale of calories from the respective product categories. This may well be a good strategy for many of the developing countries, which look into an effective sales pitch to increase trading of reformulated food products, especially the ready-to-cook and ready-to-eat food categories.

3.4 Policy Options of Food Reformulation

In 2015, over 100 countries signed the Milan Urban Food Policy Pact, which calls for actions around the world to “address non-communicable diseases associated with poor diets and obesity, giving specific attention where appropriate to reducing intake of sugar, salt, trans fats, meat and dairy products and increasing consumption of fruits and vegetables and non-processed foods” (Milan Urban Food Policy Pact 2015). Examples of city-level action to date based on this strategy include Medellín, Colombia, and Belo Horizonte and Curitiba in Brazil, which all introduced lower-cost “popular” restaurants to increase access to healthier food. Quito, Ecuador, and Nairobi, Kenya, introduced urban agriculture programs, while in Dakar, Senegal, microgardens were initiated. While research evidence is inadequate to show if there is a direct cause-and-effect relationship, some positive signs are emerging. For instance, the prevalence of obesity among children has started to decline in Curitiba (Hawkes et al. 2017).

Policies at the national level to change food environments are particularly relevant to city environments. Governments around the world have implemented approaches to improve food environments in six main areas highlighted in the “NOURISHING” framework (World Cancer Research Fund International 2004), which is as follows:

  • Nutrition label standards and regulations on the use of claims and implied claims on food.

  • Offer healthy food and set standards in public institutions and other specific settings.

  • Use economic tools to address food affordability and purchase incentives.

  • Restrict food advertising and other forms of commercial promotion.

  • Improve nutritional quality of the whole food supply.

  • Set incentives and rules to create a healthy retail and food service environment.

  • Harness food supply chain and actions across sectors to ensure coherence with health.

  • Inform people about food and nutrition through public awareness.

  • Nutrition advice and counseling in healthcare settings.

  • Give nutrition education and skills.

One approach under this scheme is nutrition labeling for packaged foods. Chile, for example, introduced new “warning” labels on packaged foods high in fats, sugars, and salt in 2016, and Ecuador has a system of stoplight labels, with red indicating high levels of fats, sugars, and salt. Economic incentives provide another option – a growing number of middle-income countries (including Mexico and some Caribbean and Pacific island nations) have taxed certain foods, particularly sugary drinks and, less commonly, confectionery and fats.

3.5 Maintenance of Food Composition Databases

Food Composition Databases (FCDBs) contain nutrient composition, energy, and/or other bioactive components of foods largely consumed by a given population (Marconi et al. 2018). To date, none of the developing countries appear to have comprehensive FCDBs in place, which contain systematically collected information on food products. With proper FCDBs in place, these could be used to make a series of decisions and interventions in the developing countries in terms of food reformulation strategies, including assessing the dietary intake of individuals or groups, carrying out epidemiological studies and clinical research, formulating diets at the individual and/or population level, formulating agri-food policy in relation to public health and educational-information, and supporting food manufacturers for their products’ nutrition labeling. The level of certain nutrients in some food products available worldwide may vary nevertheless between countries, because of differing cultivars, soils, climates, agricultural practices, processing procedures, and analytical methods. However, the increasing consumer attention in many of the urban populations of developing countries about food products and mandatory nutrition labeling has increased the need to produce more complete composition data.

4 Conclusions

Throughout the developing nations, traditional food systems and dietary patterns, which have been intrinsic to social, cultural, and economic life, and to personal, community, and national identity, are undergoing significant transitions. While these long-established dietary patterns are linked with low rates of obesity and chronic diseases, and can be readily improved by modifications that respect the underlying tradition and culture, many consumers in the developing world tend to select ultraprocessed food products from retail stores and fast food outlets owing to changes in mindset, lifestyle, and improved incomes. The ongoing processes of globalization, privatization, and deregulation of food products may have relatively little impact on public health in developed countries whose dietary patterns are already fully commercialized. However, it is the displacement of traditional food systems in Africa, Asia, and even Latin America by the sugary, salty, and fatty products, which has been increasing rapidly, and have the potential to undermine public health by increasing the incidence of NCDs. It is high time that governments and other authorities, and also research and public health institutions, examine the possibility of reformulating these novel ultraprocessed food and subsequently monitor their impact on improving public health. The impact of food reformulation on competition, particularly its impact on small and medium enterprises (SMEs), is another concern of some governments. However, this would not be a problem as long as technological and expertise assistance is provided. Trade associations could be considered as a potential source for offering advice, especially to retailers, to meet target nutrient levels. It has to be borne in mind that such work must not inhibit the implementation of policies and actions that are presently in need, and most importantly, once enacted, the impression of these essential policies and actions needs to be also carefully monitored.

In the general context of food manufacturing, reformulation may simply appear to refer to changing the chemical or nutritional composition of processed foods. Manufacturers might reformulate a product to make it look or taste better because of requirements related to the food’s ingredients, manufacture, storage, or transportation or to keep up with consumer trends and demands. However, in developing countries, reformulation would evidently mean changing the composition of processed food to achieve public health policy goals. Unfortunately, for many developing countries, such policies appear to be virtually nonexistent, and any self-directed initiative taken as such from food manufacturers for the purpose of maintaining consumer health and wellness seems to go unreported. There also appears to be very little information available on food reformulation strategies initiated in restaurants in developing countries, and it is not surprising that development of policies in this regard seems to be virtually absent as well. While it is obvious that such gaps need to be addressed, proper procedures for monitoring the reformulation initiatives need to be put in place to objectively evaluate the success of such strategies.

Notes

Conflicts of Interest

The authors have no conflicts of interest to declare, financial or otherwise.

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Heethaka K. S. De Zoysa
    • 1
  • Viduranga Y. Waisundara
    • 2
  1. 1.Department of Bioprocess Technology, Faculty of TechnologyRajarata University of Sri LankaMihintaleSri Lanka
  2. 2.Australian College of Business & Technology – Kandy CampusKandySri Lanka

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