What are the greatest nutritional challenges facing the world today?
GLOBALLY, WE FACE A DOUBLE BURDEN OF MALNUTRITION – some populations have high prevalences of overweight and obesity, while other populations are undernourished, and both conditions present significant health outcomes and challenges.
In the Global North, with so many high-income countries, we see a lot of activity around overnutrition and the chronic diseases that result from it. But actually, there are more people in the world burdened with undernutrition, which produces health outcomes such as stunting and wasting, which devastate nations and economies for generations to come by decreasing human capital.
To complicate matters, there’s evidence that undernutrition early in life can predispose people to overweight and other diet-related chronic diseases later in life. Some people even refer to the triple burden of malnutrition, which refers to overnutrition, undernutrition, and micronutrient deficiencies.
The challenges are diverse, but the solution is the same for all burdens, as all these conditions are rooted in poverty. By reducing poverty globally, we increase health, human capital, wellbeing and life expectancy.
Developing Sustainable Diets
Patrick Webb is the Alexander MacFarlane Professor at the Friedman School of Nutrition at Tufts University. He serves as Technical Adviser to the Glopan Panel on Agriculture and Food Systems for Nutrition and is director of the Feed the Future Innovation Lab for Nutrition.
Patrick also served until recently on the Science Council of the Consultative Group on International Agriculture Research (CGIAR), and was for several years Chief of Nutrition for the United Nations’ World Food Programme.
Yes. National and local governments hold a special responsibility in facilitating and protecting public health. That means ensuring that public systems and institutions are not harmed or overwhelmed by health challenges. The world’s greatest single (non-infectious disease) health challenge today is poor quality diets. These are diets that do not secure minimal nutrient needs for all people around the globe; they are diets that contribute to a growing burden of diet-related chronic diseases; and they are diets underpinned by unsustainable production and processing practices that damage planetary resources as well as the climate. While the private sector is largely responsible for the current nature of food system, it is up to governments to inform, incentivize and require the system-wide changes that can support appropriate food choices in future. Healthy and sustainable dietary patterns will deliver improved nutrition, while also significantly reducing the economic and social costs associated with dysfunctional food systems. Those are costs that are borne by the public purse. That’s why governments have to take responsibility for transformative change and improve dietary habits.
Dr. Shenggen Fan is currently Senior Chair Professor at the College of Economics and Management at China Agricultural University (CAU). He is known not only as an author of widely cited journal articles and books, but also as a global leader in agricultural economics and food policies. His research covers a wide range of issues, such as public investment, agricultural and rural development, food systems, transition economies, poverty, and food security and nutrition.
Prior to joining CAU, Dr. Fan served as director general of the International Food Policy Research Institute (IFPRI) from 2009 to 2019. Dr. Fan joined IFPRI in 1995 as a research fellow. He led IFPRI’s program on public investment before becoming the director of the Institute’s Development Strategy and Governance Division in 2005.
He was a member, vice chair and chair of food and nutrition council of the World Economic Forum. He serves as a member of the Lead Group for the Scaling Up Nutrition (SUN) Movement appointed by former UN Secretary General Ban Ki Moon. He also serves as advisor to many national governments on agriculture, food security and nutrition.
In 2014, Dr. Fan received the Hunger Hero Award from the World Food Programme in recognition of his commitment to and leadership in fighting hunger worldwide.
In 2017, Dr. Fan received the 2017 Fudan Management Excellence Award. The award is referred to in China as the “Nobel Prize for Management.” This highly prestigious award recognizes individuals who have made outstanding contributions to the field of management.
Dr. Fan received a PhD in applied economics from the University of Minnesota and bachelor’s and master’s degrees from Nanjing Agricultural University in China.
Yes, they are drawing connections, but they need to work with others like the private sector, all actors in food value chains to implement policies, practices, and technologies to find solutions for both human and planetary health.
Actors in the value chains or food systems include smallholder farmers, traders, processers, retailers, wholesalers, and consumers, Woman and youth are particularly important to be empowered and reached, so they can benefit from the system.
Policy environment will also be critical. Public investment and public spending must be reprioritized for achieving both human and planetary health. Market and trade must also work to achieve both goals.
I am a global food system expert and advisor, with specialist knowledge in sustainable diets, food and nutrition security and agricultural diversity. I am an expert public speaker and have spoken at universities, festivals and to the EU parliment and the FAO, I have appeared on radio and TV and on podcasts and have contributed to various books and blogs. I am a founder and a Director at Eating Better. Currently I am participating in the Global Alliance for the Future of Food (GAFF) Salzburg process on food systems. I am on the advisory body for the DiverIMPACTS project, which focuses on crop diversification through crop rotation with multiple actors across Europe. This built on my work at WWF UK on agricultural diversity, which partially led to their partnership with Knorr and the Future 50 report. I am on the steering group for foodSIVI – the impact valuation of Food System program looking at the true cost of food, run by Oxford University. I am on the advisory group for the Food and Climate Research Network and the Food Bites project. I have participated in various Food Systems Dialogues, led by David Nabarro. I have been on steering groups and advisory bodies for Forum for the Future’s Protein 2040, and the Food Foundation’s Peas Please and Veg Power programs. I was one of only 2 Civil society experts invited to join the steering group that negotiated the format of the One Planet Network’s Sustainable Food Systems Program, previously under the UN’s 10YR Sustainable Consumption and Production banner. Until April 2020 I was the Global Head of Policy and Research at Compassion with the goal of helping to create a global agreement for sustainable food systems. Whilst WWF UK I led the work food systems, diets, nutrition security, agricultural diversity and behaviour change. I developed and delivered the on-going Livewell project, which demonstrates that a healthy diet can be sustainable. I ran WWF International’s area of collective action on sustainable diets for the food practice and on the steering group for the SDG post 2015 agenda.
Joined up, agricultural and health policies are the cornerstone of a sustainable food system. We need to produce the right food to ensure people have access to healthy, nutritious food in a way which benefits nature, soil and livelihoods, all while we face global malnutrition and climate crises.
Our food system must be underpinned by diversity – agricultural, bio, cultural and economic – all providing us with good health. Diverse diets can reduce micronutrient deficiencies by providing a rich source of nutrients all year round and it can also result in increased income sources for farmers. Yet national food systems are supplying less diverse food. This is reflected in diets that are monotonous and based on a few staple crops, especially in low-income communities where access to nutrient-rich sources of food, such as animal source foods and fruits and vegetables is a challenge.
There is a huge disconnect between agricultural policy and our nutritional reality. Current agricultural policies are focusing on producing the wrong sort of foods, with a biased towards calorie crops. Three crops – rice, wheat and maize – provide more than 50% of the world’s plant-derived calories. At the same time, malnutrition has been rising, as agricultural policy has been focused on productivity not on nutritional outcomes, and we produce more than enough food to feed over 10 billion people, but this growth in calories has not resulted in better health for all.
One area that shows how different polices can be mutually beneficial is sustainable diets. Almost 10 years ago both WWF’s Livewell and the Barilla Foundation’s food pyramids demonstrated the linkage between nutrition and the environment and since then a growing group of leading organisations, including the Lancet and Eat Foundation, have called for joined up policy making to deliver win win outcomes.
A good, working food system should produce healthy, sustainable food that is affordable and accessible to all. Health and nutritional outcomes should underpin all agricultural and food production policies from what we grow to subsidies.
Isabela Sattamini is a Brazilian nutrition researcher who holds a PhD in Public Health Nutrition from the University of São Paulo. Her expertise is focused on dietary diversity and ultra-processed foods consumption. Isabela was involved in the multi-country study on “Ultra processed food consumption, nutritional profile of diet and obesity ” and the “Nutrinet Brazil Cohort project: Food and Chronic Non-Communicable Diseases”. She coordinated the advocacy project for advancing trans-fat restriction laws in Brazil, that later culminated in the national ban law approval in December 2019. Currently, Isabela is a consultant at the Nutrition and Food Systems Division (ESN) in the Food and Agriculture Organization of the United Nations (FAO), dedicated to the Minimum Dietary Diversity for Women of reproductive age indicator (MDD-W) project, based in Rome, Italy.
National dietary guidelines are developed by the Ministry of Health and usually coordinated by a technical-scientific team of experts. Dietary Guidelines are evidence-based recommendations that take into account a country’s nutrition problems, diet patterns, food environments and food-systems, in addition to globally established diet-health relationships. They provide recommendations about food consumption, but can also include physical activity and sustainability aspects. In the Dietary Guidelines construction, there should be participation and consultation of social movements such as those of farmers, consumers, parents, educators, and all those who eat, and therefore, everybody in the society. There should not be a chance for financial interests to determine what the Guidelines will recommend, as these should be based on science and in the social food habits of the concerned population.
Liv Elin Torheim is professor of Public Health Nutrition at OsloMet – Oslo Metropolitan University in Norway. She has more than 20 years’ experience in food and nutrition research from various African and Asian countries as well as from Norway. Her research interests include maternal and child nutrition, dietary assessment, food and nutrition policy and nutrition as a human right. At OsloMet she is head of the research group Public Health Nutrition. Liv has been chair of the Norwegian National Nutrition Council for four years, and is currently vice chair. The nutrition council consists of independent experts advising the Norwegian health authorities on nutrition related issues.
National dietary guidelines tell what foods to eat and what to stay away from in order to stay healthy. Dietary guidelines are usually based on research on the association between intake of foods or dietary pattern and health. Sustainability aspects of food production is increasingly included in national dietary guidelines. Dietary guidelines offer guidance to both individuals, policy makers, researchers and the food industry.
Dietary guidelines are often shaped into messages/advices/recommendations communicated to the general population to help people make the right food choices. Dietary guidelines also provide a way for monitoring the healthiness of the food intake of the population. If, for instance, the guidelines recommend eating 5 portions of fruits and vegetables per day, one can assess the proportion of the population with a lower intake and see how this vary between population groups. Over time, one can monitor how the situation changes. This information will form the basis for national food and nutrition policies. If the population’s intake deviates from the recommended intake, one can plan strategies and programs to improve the situation and target the most vulnerable groups. National dietary guidelines are also used by the food industry to guide them in making and promoting healthier food products.
Angie Tagtow is the Founder and Chief Strategist of Äkta Strategies, a consulting firm that designs authentic solutions for systems change. She has more than 25 years of experience working at local, state, federal, and international levels in agriculture, food, and nutrition policy; public health; and food and water systems. In 2014, she was appointed by President Barack Obama to serve as the Executive Director for the USDA Center for Nutrition Policy and Promotion in which she co-led the development and launch of the 2015-2020 Dietary Guidelines for Americans. Angie is a registered dietitian and served as a Senior Fellow and Endowed Chair at the Minnesota Institute for Sustainable Agriculture, University of Minnesota College of Food, Agricultural and Natural Resource Sciences, and as a Food and Society Policy Fellow with the Institute for Agriculture and Trade Policy. She was the founder and CEO of a successful consulting firm that provided program and policy development, strategic planning, capacity building, communication, and education services to diverse clients that worked toward advancing sustainable, resilient, and healthy food and water systems. She co-founded a non-profit focused on health and food systems in addition to forming a statewide community of practice that promoted evidence-based strategies to increase access to healthful food. Angie has served in professional leadership positions within the Academy of Nutrition and Dietetics, Iowa Academy of Nutrition and Dietetics, Society for Nutrition Education and Behavior, and the American Public Health Association. In addition to launching the Journal of Hunger & Environmental Nutrition in 2005 in which she served as the managing editor for 11 years, she has published numerous peer-reviewed articles, book chapters, and reports. Angie has been honored by many organizations for her leadership and professional contributions to nutrition, public health, and food systems. Angie is currently a doctoral candidate at the University of Illinois at Chicago School of Public Health. She is a graduate of the University of Northern Iowa and Iowa State University and resides on a reconstructed tallgrass prairie in central Iowa.
Food-based dietary guidance systems are essential for countries to set consistent guidelines for promoting and improving the nutritional health of a population. In the United States. The Dietary Guidelines for Americans are important for establishing consistent evidence-based recommendations for healthy diets for all Federal food and nutrition programs as outlined in the 1990 National Nutrition Monitoring and Related Research Act. Furthermore, they are used to inform policies and nutrition education interventions that promote health and reduce the risk of diet-related chronic diseases. Dietary patterns that are aligned with the Dietary Guidelines for Americans promote human and planetary health.
Dr. Lee co-ordinates FAO’s nutrition and food systems policy, programmes and research in the Asia and Pacific region. He has recently moved to join the FAO Regional Office in Bangkok from the FAO headquarters in Rome. While at FAO headquarters, Dr. Lee headed the Nutrition Assessment and Scientific Advice Team at the Nutrition and Food Systems Division. He coordinated programmes on nutrition assessment, human nutrient requirements, Codex scientific advice on nutrition, and the impact of food losses and waste on malnutrition. He was responsible for developing dietary assessment tools and nutrition indicators, and building country’s capacity to collect dietary information and indicators for informed policy.
Before joining FAO, Dr. Lee has served as faculty member at universities and health care institutions in Australia, Hong Kong, and the U.K. He has pioneered research in calcium and vitamin D requirements, bone growth and calcium bioavailability using the stable isotopic techniques. He has also coordinated clinical and community-based projects on growth and nutrition of infants, children and adolescents; bone growth and osteoporosis, and research into the patho-etiology of adolescent idiopathic scoliosis. Dr. Lee has served at executive and scientific committees of food and nutrition related organizations. He has been the President of the Hong Kong Nutrition Association (1994-95, 1996-97, 2002-03) and council member of the Asian Federation of Dietetic Associations (1994-99). Dr. Lee has published over 56 scientific papers in peer reviewed journals, 12 scientific reports and guidelines, 8 book and book chapters and over 170 conference papers.
Dr, Lee holds a BSc in Human Nutrition & Dietetics from Trinity College, Dublin, Ireland and a PhD from The Chinese University of Hong Kong. He is also a practicing Registered Dietitian and Registered Nutritionist (Public Health), U.K.
National dietary guidelines, also called Food-based dietary guidelines (FBDGs) advise the public to consume food groups or a variety of foods on a daily basis that contribute to healthy diets and minimize the risks of malnutrition. FBDGs also suggest types of foods high in fats, sugars and/or salt foods to be consumed in small quantities in order to reduce the risks of overweight and obesity as well as diet-related non-communicable diseases. FBDGs are also used as a reference to formulate national agriculture, food and nutrition policies for producing sufficient foods to nourish people.
The success of establishing national dietary guidelines often relies on political commitment and leadership that recognizes raising people’s nutritional status is an integral part of the country’s investment. Smooth operation of FBDGs development and implementation requires adequate resources allocation; hence, securing political commitment would facilitate such a process.
FBDGs development is a science-based process that requires a team of experts with appropriate technical capacity in human nutrient requirements, food consumption survey, food composition data, food science, public health, agriculture, economy and creative designs and communications. Furthermore, the availability of national data or up-to-date national data on nutrition, diet-related health and diseases, food consumption (including food habits, culture and taboos), cost of diets and food price, incomes, food production and food supply, etc. is critically important as a base on which to develop a set of ‘fit for purpose’ FBDGs. In addition, to appoint a team leader with relevant experience in nutritional guidelines development would be conducive in coordinating the process. Otherwise, to set up an advisory committee with relevant external experts may also help steer the process of guidelines development. Upon completion of the dietary guidelines development, it would be effective to designate a responsible ministry or a public institution to promote or reinforce the use of the up-to-date FBDGs for food and nutrition policies and programming implementation, nutrition education and communication, as well as agricultural food product developments and food trade, etc. Documentation of the FBDGs implementation process and a collection of feedback from the public and stakeholders would be useful for future revision and improvement of the FBDGs when new data emerge.
Shauna Downs, PhD, MS (FOOD SYSTEMS RESEARCHER) is an Assistant Professor in the Department of Urban-Global Public Health at Rutgers School of Public Health. Her research focuses on two main areas: 1) the role of policies and interventions to reorient the food system towards the sustainable production and consumption of nutritious foods and 2) the implementation of food policies.
A country’s national dietary guidelines can be a powerful tool for influencing the food choices of its citizens. Although most people don’t follow nutrition guidelines closely when making their own individual food choices, these guidelines feed into national policies that have a far reach (e.g., over 30 million children participate in the United States National School Lunch Program). There has been much debate and political push back regarding the inclusion of sustainability considerations in national dietary guidelines, but these are not motivated by science nor what’s in the public’s best interest. What we eat has serious implications for our health as well as that of our planet. Food production contributes to approximately a third of greenhouse gas emissions, 70% of freshwater use and is the largest contributor to biodiversity loss globally. In order to reduce the pressure that’s being placed on the planet’s resources, we need to make changes to the foods we eat. Given the interconnectedness of food choices and sustainability, countries have an opportunity through their national dietary guidelines and associated policies to make strong dietary recommendations that align with planetary health providing their citizens with the guidance to better support a sustainable future for themselves and generations to come. A handful of countries around the world have already incorporated sustainability into their dietary guidelines and it’s time that this practice moves beyond being the exception and becomes the norm.
A diet that complies with food-based dietary guidelines, in terms of including a diversity of foods from different categories, to ensure that nutrient needs (protein, healthy fats, vitamins, minerals) and health needs (low sugar, low salt, good amount of fibre etc) are met. Furthermore, the quantities of the different foods should together provide the amount of energy that an individual needs (maintain body weight, or for children grow in length and weight as per growth curve); intake of empty calorie foods (i.e. high in sugar and/or fat and not a good source of vitamins or minerals) should be low; and the main fluids consumed should be water (and unsweetened tea or coffee). The total free sugar intake should be less than 10% of energy. For example, for an adult who consumes 2400 kcal/d, that means no more than 60 g of sugar, which is equivalent to e.g. 1 can of sugar sweetened beverage or fruit juice and a sweet yoghurt or slice of cake.
Santiago Mazo Echeverri
Nutritionist and Dietitian from Colombia – South America.
MSc in Epidemiology
Pediatric Nutrition Specialist
Food Security and Nutrition Advisor at FAO
My best advice would be:
Erik Oberholtzer is the co-founder of Tender Greens, a pioneering fine casual brand founded in Los Angeles, CA in 2006 with a mission to democratize good food. A vision of the future he continues to drive as a Food Forever Champion on global biodiversity for the Crop Trust with whom he cooks globally alongside the world’s leading chefs. He joined the Rodale Institute’s board in 2019 to help drive awareness around soil health, regenerative organic agriculture and food as medicine. In 2009, he founded The Sustainable Life Program, a six month paid culinary internship program with a mission to provide a path forward for foster youth. Many of the students now hold leadership positions at Tender Greens, serving as beacons of success and inspiration to those at the edge of society. In 2019, Erik joined Cohere as an advisor to founders of conscious brands as they navigate the headwinds of scale. With the success of Tender Greens, he provides a founder-centered roadmap to growth with emphasis on culture, supply chain integrity and long term strategic planning. Currently he is advising brands that are putting the health of people and the planet first, such as The Butcher’s Daughter in NYC/LA, Pocono Organic’s regenerative farm and Mulberry & Vine in NYC. Prior to founding Tender Greens Erik worked as a chef in many of California’s best restaurants. This chef identity informs his intense dedication to ingredient providence, technique and deliciousness without compromise. A daily practice of meditation, fitness and good food helps Erik show up with a calm demeanor in a dynamic world. Erik is based in Brooklyn, NY and a small farm in Pennsylvania where he and his family grow organic hemp, native flowers and heirloom crops.
A balanced meal usually means a combination of fresh fruits and vegetables, complex grains and some animal protein. The specific blend of balance is often debated between stakeholders causing public confusion. For me, Michael Pollan defines it best – “Eat good food, whole food, real food, mostly plants, not too much”. Eating as Pollan suggests supports more than sound nutrition. It supports ingredient diversity important to soil health and ecosystems resilience. Meals built around diverse ingredients deepen our connections to various food cultures and support micro economies around the world. Meals centered on organic heirloom varieties alleviate the pressure on the environment from industrialized food production. As a chef, meals built on fundamentals of fresh, clean, pure flavor simply taste better.
Daphene joined the Center for a Livable Future in 2019 as a Program Officer with the Food Communities & Public Health Program, following a year-long dietetic internship that led to her becoming a registered dietitian/nutritionist (RDN). Before that, she was an epidemiologist and lead evaluator at the Maryland Department of Health and Mental Hygiene, Oral Health Department. While there, she performed all data collection, analysis and reporting activities, and served as the chief evaluator for the HRSA workforce grant and CDC’s Cooperative Agreements oral health grant. She developed and implemented a five-year evaluation plan for Maryland’s oral health program and evaluated legislation to determine effectiveness and impact.
At the Center, Daphene uses her expertise and experience as a nutritionist to support the Meatless Monday campaign. She’s especially interested in reaching young people with wellness messages through school programs and community outreach to effect generational change. “Get them started early,” is one of her guiding principles.
As the granddaughter of long-lived Haitians who “ate what they grew and what they raised on the land,” Daphene learned first-hand about the benefits of eating fresh, organic, whole, locally-grown foods. “They taught me the importance of family, wholesome eating and how to live simply,” she says about her grandparents, who lived into their late 80s and 90s. She feels that her work at the Center and with the Monday Campaign is an opportunity to apply her experience in public health epidemiology to issues she feels passionately about—public health and sustainability.
Willett WC, Koplan JP, Nugent R, et al. Prevention of Chronic Disease by Means of Diet and Lifestyle Changes. In: Jamison DT, Breman JG, Measham AR, et al., editors. Disease Control Priorities in Developing Countries. 2nd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006. Chapter 44.
Finding the right balance and making the right food choices have the potential to prevent and, in some cases, reverse the progression of diseases like type 2 diabetes, heart disease, stroke, certain cancers and obesity. Of the top ten leading causes of death in the United States, seven of them are diet related. Diets high in red and processed meats are associated with a higher risk of cardiovascular diseases, type 2 diabetes and some cancers. However, a balanced diet, with whole grains, legumes, vegetables, fruits, nuts, seeds and lower in salt is not only salient for optimal health, but necessary for the prevention of chronic illnesses and maintaining a healthy weight. Additionally, foods that are high in omega 3 fatty acids (salmon, nuts and seeds), low in saturated and trans-fat, and high in fiber (fruits and vegetables) are good choices for decreasing your risk of those chronic conditions.
With an MSc in biochemistry (1973) and a PhD in microbiology (1977), Harry Aiking worked as a research associate at Indiana University in Bloomington, USA, 1978-79. Subsequently, he became a KWF (Royal Dutch Cancer Fund) Fellow at the Central Blood Bank Laboratory in Amsterdam before joining VU University in Amsterdam in 1980. There he has been leading dozens of multidisciplinary projects on the interface of natural and social sciences. He has been Advisor to the Dutch Attorney General in cases of industrial soil pollution 1987-2014 and a European Registered Toxicologist (ERT) 1997-2018. During 1999-2005, he led the NWO programme PROFETAS (Protein Foods, Environment, Technology And Society). He authored over 400 publications. After his formal retirement in 2014, he was rehired by the Institute for Environmental Studies (IVM-VU) in 2017. Thus, he remains affiliated there, continuing to supervise PhD students, lecture and publish.
Many people think that sustainability is cast in stone. However, it is a highly dynamic issue, since ambient conditions determine what can be sustained for prolonged periods of time. Trends such as increasing global levels of population, income and urbanization (all leading to changing diets) are currently threatening several planetary boundaries. In fact, the rates of biodiversity loss and nitrogen cycle acceleration both exceed carbon cycle acceleration (leading to climate change). Moreover, these three boundaries are strongly interlinked1-2 by the way we produce animal protein in intensive systems (such as CAFOs).
We need protein primarily because it supplies our metabolism with nitrogen as a macronutrient. Our bodies contain 3-5% nitrogen, which is indispensable as a constituent of DNA, for example. Protein consists of 20 amino acids, some of which must be in our food as such, because our metabolism cannot synthesize them. Different foods contain varying levels of these “essential” amino acids. Therefore, strictly vegan diets require some more effort for a balanced intake than vegetarian or flexitarian diets. However, balanced diets are healthy irrespective of the proportion of plant proteins and animal proteins.
Unfortunately, few people are eating according to national dietary guidelines. This leads to unnecessary pressure on public and environmental health. Reducing our overall intake of protein, particularly from animal foods, would benefit our health as well as sustainability. The latter derives from the fact that intensive animal systems are wasting precious resources such as land, water and energy, because 6 kg of plant protein is required to yield 1 kg of animal protein, on average. Replacing feed crops with food crops can sustain about 1 billion more people. And how about wildlife? Are you aware that currently two thirds of all terrestrial invertebrates are livestock? Merely 5% are living in the wild, which may drop to 1% by 2050, if we don’t return to more plant-based diets soon. Back to the future!
Food insecurity restricts people’s access to food, i.e. the availability of food may be limited or its affordability may be the problem. Often, people still have access to basic foods, but the availability and variety of fresh foods is more limited, and their prices are relatively high. This restricts the choice options people have. People prioritize the foods that provide them energy such as maize porridge, rice, bread or potatoes. Especially when people do not know whether they will be able to prepare a second meal that day, they will try to make the one meal as filling as possible.