Healthy Diets Depend on Equity and Justice: Understanding the Context in Brazil, South Africa, the UK, and Vietnam

Summary The purpose of this paper is to outline a new intellectual and research agenda for future work taken forward by the Food Equity Centre on the theme of Healthy Diets. We outline our initial conceptual approach and summarise current thinking and action on dietary equity through four country case studies, then propose a number of research gaps that we will address in future research and publications together.

Who is malnourished, why some people have access to diverse and healthy diets while others do not, and the lifelong and intergenerational consequences of these situations are questions that are central to why we care about food equity (Nisbett et al. 2022).Yet equity issues related to malnutrition and diets have seldom been understood beyond important but basic notions of gender and income inequality (Harris et al. 2021).The human right to food has two inseparable dimensions: being free from hunger by having access to adequate food (De Schutter 2014).It is the second dimension that is often overlooked in discussions on food justice and rights, but understanding and addressing dietary inequalities and their roots in inequity are central to ensuring this dimension of the right to food.A focus on dietary inequities has not been well served by research and policy that focuses in a narrow and medicalised way on different forms of malnutrition and on who gets which individual nutrients (Scrinis 2008).A more holistic understanding of how inequities are shaped through diets, food, livelihoods, and the wider and important cultures of cooking, eating and culinary knowledges are less often researched or brought into policy and practice debates.
The purpose of this paper is to outline a new intellectual and research agenda for future work taken forward by the Food Equity Centre on the theme of Healthy Diets.We outline our initial conceptual approach and summarise current thinking and action on dietary equity through four country case studies, then propose a number of research gaps that we will address in future research and publications together.

Framing inequality and inequity
Our approach is interdisciplinary and draws on food systems and wider systems thinking (HLPE 2020) as well as political histories of power in food regimes (McMichael 2021) and sociological and geographical theory on how people's bodily conditions come into being because of the wider structural injustices they face both contemporaneously and historically (Fumey, Jackson and Raffard 2013;Nisbett 2019).Our understanding of food and diet goes beyond interpretation for solely medicalised and/or commodified perspectives (Mennell, Murcott and Van Otterloo 1992), considering food in broader interdisciplinary dietary, cultural, political-economic, and life-course perspectives.This wider focus is due to our understanding that the food environment impacts upon on the development of dietary and food practices and habits, and health outcomes (Holsten 2009, Caspi et al. 2012).To further investigate the contemporary and historic intersections of diet and the food environment we use the lenses of family (Jackson 2009) and generational change, allowing us to map diet influences across time and space.These are important theoretical and methodological distinctions, as single discipline economics or nutrition investigations into diet, wellbeing, and equity are typically narrower and medicalised -our wider approach and conceptualisation will provide a stronger evidence base, theories of change, and impact pathway with which to produce change.
We draw on and expand the thinking on nutrition equity that went into the Global Nutrition Report (Development Initiatives 2020), now published as the Nutrition Equity Framework (NEF) (Nisbett et al. 2022) (Figure 2.1), and update it with theory and perspectives from Brazil, South Africa, the UK, and Vietnam on how researchers and activists are involved in the struggle for healthier, just, and more sustainable diets.The NEF illustrates how forms of capital and micro and macro socio-political processes structure the food, health, and care environments most important to nutrition, as well as structuring different people's experiences of inequity through their daily living conditions, behaviours, and practices.Central to the framework are processes of unfairness, injustice, and exclusion as the engine of inequity across place, time and generations, ultimately influencing a social distribution of nutritional status.We consider inequalities as differences in outcomes between socially relevant groups at different parts of the framework; and inequities as the socio-political reasons why this uneven distribution exists and accrues systematically to certain social groups.
This framework was designed to aid understanding of the social distribution of malnutrition, but this paper -and the related theme of the Food Equity Centreis about healthy diets and nutrition.This slightly different emphasis is important, as diets are a key input into nutrition, but are 'upstream' of nutrition conceptually, and have a different sub-set of determinants that are more clearly rooted in food systems than in health systems -though the deeper structural determinants of inequity are likely to be similar.We discuss at the end of the paper any insights gained on applying the framework for this newer purpose through four country case studies.We suggest that considering all forms of malnutrition caused by inadequate diets (from hunger to obesity, from insufficient healthy food to the high availability of unhealthy products, and from nutritional composition to chemical or microbiological contamination) will reveal a diverse set of inequalities, often sharing similar drivers through inequity.In this section, we use the NEF to guide assessment of the diet and nutrition equity contexts of Brazil, South Africa, the UK, and Vietnam.Specifically, we use existing literature combined with new analysis of secondary data where possible to say something about each area of the framework, and to identify gaps where research is so far silent on certain aspects of equity in those contexts.
Thereafter, we draw out similarities and differences across country experiences, applying our framework for both mutual learning and the beginnings of comparative study.

Background
The UK has amongst the worst dietary, nutritional, and food insecurity outcomes in Europe, with an adult obesity rate higher than the European average and faring worse than comparable larger and wealthier countries such as France and Germany (OECD 2022).Childhood obesity figures are similarly poor.Inequities across all population groups in terms of diet and food insecurity are increasing after a decade of public service cuts, and some commentators also link this to broader trends in trade policy, the UK's exit from the European Union (EU), and changes to consumer culture (Lang 2020).Public service cuts have fallen heavily on health, education, social welfare, and local authority funding, including for public health and early years provision (Marmot et al. 2020).The economic fallout of the Covid-19 pandemic, combined with school closures, contributed further to an increase in food insecurity and dietary deprivation.Personal and public finances are now being further stretched by high food price inflation and some of the highest fuel price inflation in Europe (Cooban 2022).
Food is an active source of public and media discussion and while the overall picture is poor, there are pockets of innovation in and amongst the different UK nations and in various towns, cities, and regions.The UK's first food strategy, although largely ignored by the current government and deemed too weak by some commentators, continues to be a useful focal point for relating diet to wider systemic considerations including sustainability and equity, and this national conversation is well supported by groups such as the Food Foundation and Nourish Scotland.There is an active though highly politicised debate on the systemic racism faced by the UK's marginalised communities, as well as broader inequities faced by deprived areas and communities throughout the country.The idea of a right to food is not shared as a widespread conception or objective, despite the UK being signatory to the International Covenant on Economic, Social and Cultural Rights, but has had more resonance at a national level in Scotland and in some local instances, such as Brent Council in London and in work led by the Human Rights Centre at the University of Essex, which has examined food poverty alongside other poverty and rights issues (Barker and Casla 2022).

Dietary context
The UK's poor dietary outcomes start in the early years and in childhood, and for many indicators or population groups are worsening.Breastfeeding, which has a preventative role for poor health and obesity later in life as well as during childhood, appeared to be improving from historically low levels in the last UKwide infant feeding survey in 2010. 1 The UK government has so far resisted calls to continue surveying this important indicator, despite encouragement by international agencies such as the United Nations Children's Fund (UNICEF).Unpacking the complexity of food choice and eating behaviours of those experiencing food insecurity sheds light on the challenges of navigating daily food acquisition.Puddephatt et al. (2020) highlight practices of food rationing, skipping meals, reducing portion sizes, and prioritising children's food intake as coping strategies among food bank clients in Liverpool.Food practices for many are linked with the welfare system, affected by payments coming late or punitive sanctions for actions as simple as missing an official appointment, resulting in periods of acute food insecurity.Moreover, the ability to budget, shop, and prepare food was found to be linked to pre-existing physical and mental health status.These intersecting inequities can result in less ability to source or prepare healthy food options.

Equity/marginalisation context
The roots of these dietary inequalities can be found both in the broader equity context and the wider history of the UK food system (next section). of domestic labour and the care burden, as well as broader inequalities in labour market opportunities and pay.

Roots in the wider food system
The UK's food system has undergone a number of significant implications for dietary and food equity.The first transformation occurred over centuries, but culminating in the 1801 General Enclosure Act, with the seizure of land held in common by rural populations, much of which had been used for common grazing or kitchen garden production and the incorporation of this land into the estates of large owners (Burnett 1989; Sutton 2016).A related transformation was the dispersal of many of these rural workers to cities, either to take up industrial employment or to eke out a living in relative destitution now that rural livelihoods linked to the land were no longer viable.While at first the UK maintained a relatively closed, mercantilist economy, benefitting the large landed estates and supported by large tariff barriers on inputs from abroad, pressure from urban populations and politicians eventually led to a reversal of this process and adoption of the early liberal market system which favoured cheap calories for a growing industrial and urban population.Workers no longer went hungry, but suffered from poor diets.This was supported by imports at favourable/ exploitative rates from the UK's growing colonies, where flows of trade to and for the benefit of the UK were prioritised over the welfare of local populations, effectively exporting famine and food shortage away from the metropole to the colonies (as famously charted by Amartya Sen in Bengal, but also shown by the plight of Irish populations in the nineteenth century famines there under British rule).
Industrialisation of food production continued at pace during the First and Second World Wars, with local food production declining in deference to national production, particularly of staples such as bread and sugared processed products such as biscuits, which were increasingly produced in large factories.Food shortages during the Second World War led to a rationing system which led, ironically, to better nutritional outcomes in the population as a whole, though with a 'persistence of class differentials' (Zweiniger-Bargielowska 2020: 139).This was not abandoned until 1954.Despite the nutritional thought that had gone into the rationed diet, Britain's post-war policy continued to prioritise cheap calories and domestic production of grain, meat and dairy, and many of the food support mechanisms that had been put in place to support consumers were removed once the crisis rescinded.On Britain's accession to the European Community in 1973, food and agricultural policy were largely incorporated into the Common Agricultural Policy (CAP), which via a combination of production subsidies and high external tariff barriers, continued to prioritise grain and dairy over broader dietary diversity.While this may have made more sense in the immediate post-war period, with many European countries suffering from food shortage and population-wide hunger, by the 1980s this had led to the famous wastage represented by mountains of grain and lakes of milk and butter.The environmental legacies of this system are still being felt.Horticulture was never directly supported by the CAP, but the UK's major source of fruit and vegetables, around 40 per cent (House of Lords European Union Committee 2018; Lang 2020), remains imported from the EU, particularly from the largest producers such as Spain and Holland.
These class, industrial, colonial, and post-war developments have all had significant impacts on UK diets.Most UK food purchases are from supermarkets and, despite the re-introduction of high-end farmers markets, the UK generally lacks direct connections between rural production and urban consumption in the form of city markets that still exist in countries such as France.Because of their purchasing power, supermarkets have an outsized influence on food production and food standards, as well as the ability to set consumer prices.The UK's food and drink sector is the largest manufacturing sector in the UK, and fourth largest in the world, accounting for 6 per cent of gross added value (£116bn) (DEFRA 2023).When it comes to food and drink retailing, the four largest retailers -Tesco, Sainsburys, Asda, and Aldi -accounted for 64.9 per cent of market share in 2022 (ibid.).This huge proportion of the economy and consolidated retailing environment gives the food industry enormous power to influence food choice in terms of advertising, marketing, and public policymaking.Together, these factors might explain why consumption of ultra-processed foods, which have strong associations with obesity and some cancers, are the highest or among the highest in Europe (Rauber et al. 2018).

The current policy context
A national food strategy -the UK's first for 75 years -was the government's response to an independent review commissioned in June 2019 and which reported in two parts, in July 2020 and July 2021.The review covered a broad range of equity, health, sustainability, and production aspects of the food system.Views on the report itself were mixed, with some seeing it as a useful and, in some places, hard hitting view of the current failings of the food system, while others finding it lacking in radical and transformative vision.Views on the government's response in the form of this strategy were that it has been a disappointing and missed opportunity for reform, largely inadequate in the face of food system-based health and sustainability crises and with much backtracking and missed promises thought to have been influenced by industry lobbying, for example to ground proposals to restrict advertising and marketing of unhealthy foods in the form of multi-buy deals, or attempts to influence product development via a tax on salt and sugar content.The independent report's chair, Henry Dimbleby, has himself bemoaned the fact that only half his recommendations were taken forward.As the report highlighted, the environmental costs of the UK's diet remain high and although the UK's post-CAP agricultural policy is intended to tip the balance further towards environmental benefits, neither farmers nor environmentalists are happy with the new system.The system, covered by separate policy developments such as the Environmental Land Management scheme, still fails to balance environmental, production and business/income support goals sustainably and is unlikely to have a strong focus on balanced and sustainable diets.

Conclusion
Food and diets are a source of much public debate in the British media, but this public interest is not matched by government policy that is sufficiently focused on the dietary inequities outlined here and the wider steps necessary to transform a broken food system to something more sustainable and equitable.The widespread failure of the national food strategy to address urgent issues in the food system is disappointing, but there are strong coalitions of stakeholders now pushing for reform whether from the perspective of environmental justice or broader social justice, the latter in the face of the persistent crises following government austerity policies, the pandemic, and recent significant inflation in food and fuel.The broader roots of dietary inequity in the UK can be traced both through the country's internal politics and its wider geopolitical position as a colonial power, a European nation, and its confused place in the global system as it untangles itself from EU policy.While the food and fuel price crises underline the pressures governments have felt since the industrial revolution to keep populations well fed, the focus on cheap calories has come at a great cost, with dietary-related disease now one of the biggest drains on the nation's health sector.It is timely to be studying dietary inequities in the UK and to discover what can be learnt mutually from the other countries in this project suffering from similar problems with different historical roots.

Inequality and dietary context
Vietnam has achieved significant progress in reducing undernutrition over the past several decades and is held up as a regional example of what can be accomplished through sustained commitment to coherent policy across economic and social development, including nutrition.Between 2000 and 2014, levels of child stunting fell from 37 per cent to 25 per cent (Development Initiatives 2018).These national figures mask significant inequalities in outcomes, however: among high-income households, stunting fell from 21 per cent to 6 per cent, while among low-income households the decline was from 52 per cent to 41 per cent (ibid.In Vietnam, the poorest households tend to be ethnic minority households: of the 10 per cent of the population still living below the poverty line, 65 per cent belong to ethnic minority groups (Tung and Trang 2012).Vietnam has 54 recognised ethnic groups, and the primary beneficiaries of higher living standards have been the Kinh majority, along with the ethnic Chinese Hoa.Expenditure levels of Khmer and Cham groups, largely in the southeast, have increased to around the national average; but the remaining minorities were doing between 33 per cent and 25 per cent worse than the national average 15 years ago, when data was last analysed (Nguyen and Baulch 2007).Ethnic minorities, and in particular smaller ethnic groups in the central and northern highland regions, have fallen significantly behind in Vietnam's rush to middle-income status, and a large proportion of the remaining burden of undernutrition, and the poorest diets, therefore falls in ethnic minority communities.
In an analysis of the drivers of stunting change in Vietnam (Harris et al. 2021), stunting reductions nationally are explained by increased household wealth (explaining 61 per cent of change), improved access to specific health services (16 per cent), and changes in level of maternal education (12 per cent).It would be useful to undertake a similar exercise to look for determinants of dietary change, and to look explicitly at ethnic minority experiences of these, but at present no national quantitative data exists to enable such a study.Instead, looking across multiple data sources and combining them narratively, a second paper (Harris et al. 2020)  communities (Minority Rights Group n.d.) -the census may do, but national nutrition data does not, or at least is not released.Given that we know (above) that a majority of the poorest households are ethnic minority households in Vietnam, extrapolations can be made, but these are large assumptions and having properly disaggregated data will be necessary to look at inequality in more depth.

Equity and marginalisation
Beyond disaggregating data to look at inequalities, we aim to understand the deeper issues and drivers of inequity.There has been some work looking at behaviours and practices related to food in Vietnamese ethnic minority communities, finding that nutrition and dietary knowledge is limited, at the same time as access to diverse foods can be challenging due to remoteness and difficult (often mountainous) growing conditions (Ha et al. 2019).For children in particular, weaning practices can be inappropriate, due to a combination of knowledge and food environment and work pressures (Huong and Nga 2013;Harris 2019).
Going deeper to look at equity issues is similarly constrained by data, but some extrapolations can be made from existing data (Harris et al. 2021).The patterns of inequality in nutrition and dietary outcomes are mirrored when looking at the intermediate determinants of equity, where ethnic minorities have consistently worse socioeconomic situation and access to infrastructure and services, including coverage of nutrition-related health services (Error!Reference source not found..2).In particular, electrification, ownership of motorbikes and TVs, and some aspects of delivered health services have increased and become more equitable; but there are still large and growing disparities in improved housing, sanitation, access to health facilities, and overall socioeconomic status.There are historical roots to the marginalisation of ethnic minority communities in Vietnam, including a complex history of Vietnamese imperialism over ethnic minority groups, and minorities subsequently siding with French and then American colonisers and armies in the Indochina wars (McLeod 1999); the uptake of Christianity by many ethnic minority groups as a route to progress (Rumsby 2021); and colonial-era policies around plantation economies and subsequent agricultural booms in the lowlands, as opposed to the minoritypopulated highlands (Hayward 2021).Drawing on these complex histories of contestation among Vietnam's ethnic groups and their political alliances, there are strong narratives around ethnic minority perceptions in Vietnam.Both in the media and in interviews, many characteristics are attributed to ethnic minority groups in terms of their preferences, activities, and attributes -though there is very rarely differentiation made between distinct sociocultural contexts (Harris et al. 2021).

Policy and activism
There is a consistent narrative of the need for inclusion of minority groups into the mainstream for access to economic development, education, and health services.The government recognises the challenges and produces policies which aim to include ethnic minority households in all aspects of national economic and social development, and the Committee for Ethnic Minority Affairs (CEMA) was established in 1998 to address established disadvantages.A large set of policies are designed to address inequities among ethnic groups, perhaps most significantly the two National Targeted Programs (NTPs) (for New Rural Development, NTP-NRD and Sustainable Poverty Reduction, NTP-SPR), containing many sub-programmes focused on economic growth and social service access for marginalised groups.Despite a wealth of sensible policy for nutrition, and despite high malnutrition numbers in ethnic minority communities, it is not however clear that debates on nutrition are joined up to debates on ethnic minority issues.
Beyond purely governance issues, classic reasons for disparity in economic engagement and service use include the geographic remoteness of many ethnic minority communities; lack of knowledge about available programmes or service entitlements among minority groups; and language barriers (Harris et al. 2021).
But policies almost universally assume that minorities want to or need to assimilate into the majority social and livelihood model in order to progress.Indepth anthropological studies in ethnic minority areas have described riskaversion amid uncertain and unpredictable livelihoods that have led many rural households not to fully engage with the central government policy of sinking all household resources into a single enterprise for the economic betterment of the commune or country (Van Suu 2017).This reticence to prioritise potentially improved livelihoods in the long term over family security in the near term has led to a perception that ethnic minority communities are somehow backward in their economic aspirations, and ethnic minority policy has tried to address economic development without necessarily engaging with the underlying causes of uncertainty.National identity and a sense of unity is prioritised over recognising the particular histories, cultures, and preferences of ethnic minority groups, which do not seem to be taken into consideration when preparing or implementing policy across many different sectors, leading to repeatedly disappointing outcomes if programme impacts are assessed on those terms.Engagement with the aspirations and concerns of ethnic minority communities is likely lacking when undertaking policymaking on their behalf (Kyeyune and Turner 2016).Despite many separate policies targeting ethnic minorities, there is little mention of adaptation for the aspirations and preferences of different groups, and no mention of trade-offs for minority households themselves in making the suggested adaptations.This pattern has continued as the National Assembly adopted the Resolution on the Master Plan of Socioeconomic Development in Ethnic Minority and Disadvantaged Regions in November 2019.
Beyond government action, it could be said that there is a need for activism by or on behalf of ethnic minority communities and their diets and nutrition.International organisations -UN and international civil society -historically have far less power in Vietnam than in many lower-income countries (Tran 2018), limited by strong political institutions with tight regulation around the possibilities for action, such as the contested Law on Associations which has been in draft for a decade.National civil society consists mainly of government-registered mass organisations such as Associations and Unions which promote social cohesion but not government accountability.Civil society organisations outside of these do exist, but tend to be set up for specific social assistance purposes (credit and savings groups, cooperatives) or to facilitate participation in government policymaking exercises, and do not engage critically in policy debates (Taylor et al. 2012); it remains to be seen if the Scaling Up Nutrition civil society network established in October 2019 will do more to bring national civil society voices into nutrition policy debates in Vietnam.Freedom to physically associate is historically restricted in Vietnam, and activism by ethnic and religious minorities is said to be systematically suppressed by the Vietnamese government (minorityrights.org).A more recent disruptor has been virtual social networks, where more critical voices have emerged: online women's groups and breastfeeding groups have gained media attention, for example, but these have tended to be popular among urban middle classes; ethnic minorities would tend to be the most marginalised from this kind of technology.

Conclusion
Vietnam could be seen to be a winner in the current global economic paradigm, with sustained economic development managed well enough to drive social development in support of a well-educated and increasingly healthy population.But even under these largely positive conditions there are many Vietnamese people who are not achieving high levels of wellbeing, and this is evident in nutrition and diet outcomes.This study has focused on ethnic minority communities, because that is where the quantitative data is clearest in pointing to outcome disparities for undernutrition and its determinants.Vietnam has achieved the easier portion of stunting reduction through economic growth and sustained commitment to socially oriented policy.Stagnant rates in ethnic minority communities are holding back national declines in undernutrition rates, however, and holding back those individuals and communities exposed to malnutrition.In order to tackle the remaining pockets of high malnutrition, more attention, thought, and funding will need to focus on marginalised ethnic minority communities.The current national development discourse aims to incorporate minorities into mainstream majority systems.The analysis above argues that instead, policy should take into account the particular needs and preferences of different ethnic groups (Hiwasaki and Minh 2022), to tackle identified drivers of malnutrition in ways that are relevant, sustainable, and culturally appropriate.

Background
South Africa has significant food and nutrition challenges, informed by poor diets.economic costs.The Western Cape Provincial Government calculated the costs of the dual burden of malnutrition as standing to lose 'R357bn in household spending from stunting and up to R590bn from obesity to 2040; this translates to a 5 per cent loss to GDP [gross domestic product] from foregone spending alone' (FuturesCape 2018).

Equity and marginalisation context
As indicated above, the burden of food insecurity and poor diets is unequal across the country.South Africa is one of the most unequal countries in the world, with a current Gini coefficient of 63 (World Bank n.d.).This structural inequality profoundly shapes access to healthy diets.
Colonial and apartheid history, together with post-apartheid economic challenges, have led to extremely high levels of unemployment in the country, with the latest official employment figures revealing a 34.5 per cent official unemployment rate.There is significant regional variation, as a result of apartheid and pre-apartheid spatial segregation policies, as Figure 3.3 indicates.Nationally, unemployment is most pronounced in the younger population.In addition to this interprovincial variation, unemployment within urban areas is concentrated in townships and informal settlements.Given this high rate of unemployment, many households depend on government provided social grants.Over half (50.6 per cent) of South African households receive some form of social grant, with these grants serving as the main source of income for almost a quarter of the country's households (24.4 per cent).Child Support Grants are the most commonly held grants, and although they have contributed to a reduction in stunting rates, the monthly allocation is widely held as being too low to meet nutritional needs (Devereux 2017).According to the PMBEJD (Pietermaritzburg Economic Justice and Dignity Group), in August 2022 the Child Support Grant was 23 per cent below the food poverty line and 41 per cent below the cost to secure a basic nutritious diet for a child (PMBEJD 2022).While the grants have wide coverage, there are challenges of access which make the grants iniquitous.Parents who do not have birth certificates for their children (generally children born outside of hospital contexts) struggle to register for the grants.Additionally, Child Support Grant is only for children whose primary caregiver is a South African citizen or a permanent resident, although in some instances holders of refugee permits may also apply.This caveat excludes many vulnerable children.
In addition to these economic inequalities, households experience multidimensional poverty.There is deeply unequal access to basic infrastructure, which shapes diets and nutrition.Although 88.7 per cent of households officially have access to piped water, the quality of this supply is not consistent.In 2021, 30.8 per cent of households reported disrupted water supply.This had high interprovincial variation, with just 4.9 per cent of Western Cape households reporting water disruptions, but 56 per cent of North West residents.Additionally, South Africa is going through a period of energy disruptions and rapidly increasing energy costs, so while 89.3 per cent of households have some form of access to electricity, the unreliability and high cost of energy is profoundly shaping food storage and preparation practices and, therefore, diets become increasingly centred on highly processed foods that have little cooking and storage costs.

Roots in wider food system
The South African food system is not currently delivering affordable healthy diets to the population.Healthy diets are beyond the budgets of many households.BFAP (the Bureau for Food and Agricultural Policy) calculates the cost of a 'Thrifty Healthy Food Basket' quarterly.This is based on the costs of a 'nutritionally balanced combination of 26 food items from all the food groups' and assumes a four-person household consisting of two adults, an older child and a younger child, with both adults earning a full-time minimum wage income and the children receiving government Child Support Grants and school feeding.The most recent (June 2022) calculation of the Basket's cost was R3,621, which is 31.1 per cent of total household income.Each month the PMBEJD calculates the cost of a typical household food basket, based on food price data collected at point of sale from a range of retailers.Its basket is based on the food items and the volumes of these foods that women living in a family of seven members (an average low-income household size) say they typically try and secure each month.This yields very different figures.The latest figures (August 2022) show that the cost of this diet for a seven-person household would be R4,775.59,but the cost of the minimally nutritious diet for a household would be R5,617.31.Currently 55.5 per cent of South Africans live below the upper-bound poverty line of R1,335 per month, and 25.2 per cent live below the food poverty line (R624 per month) (PMBEJD 2022).
While income inequality and unemployment are clear drivers of diet, these mismatches between the cost of a basic diet, the cost of a nutritious diet, and incomes are also rooted in the historical and current drivers of the South African food system.From the colonial era and through the apartheid era, the food system has been subject to multiple dispossessions and the destruction of traditional food systems.The 1913 and 1936 Land Acts formalised the marginalisation of black and small-scale and subsistence farmers (Van Onselen 1986).From production to processing and marketing a system of regulation and formal governance processes used food as a tool of segregation and marginalisation.For example, the establishment of municipal fresh produce markets and abattoirs were designed to meet the interests of commercial agriculture and exclude other value chains.Municipal government strictly controlled the sale of traditional beers (an important source of income for urban black traders) (Rogerson 1986) and street food traders (Beavon and Rogerson 1986) in order to control black urbanism.In the process, this created a highly bifurcated and unequal food system.
There was significant market deregulation and trade liberalisation following the end of apartheid (Kirsten and Van Zyl 1996).This led to further consolidation in the food system from production through to retailing (Greenberg 2010).Between 1990 and 2008, there was a 76 per cent decline in the number of farmers in the country (Vink and Van Rooyen 2009).While the number of farming units has declined, agricultural productivity has not.There are approximately 9,000 maize farmers (smallholder and commercial) nationally, but processing is highly concentrated with 85 per cent of the grain storage capacity being held by 22 silo owners.Seventy-three per cent of market share is held by four companies.The largest four retailers control 97 per cent of grocery sales in the formal sector (GAIN 2012).The openness to global trade has led to increased importation of processed foods and ingredients for processed foods.For example, imports of whey, a by-product of cheese production that is used in baked products and sweet snacks, increased from R15m in 1993 to R80m in 2007 (Igumbor et al. 2012: 4).The current food system has led to negative dietary shifts.In 2010, South Africans consumed 254 Coca Cola products per year, up from 130 per year in 1992 and well above the worldwide average of 89 per year (ibid.: 1).The food system has been characterised by the expansion of shopping malls, with supermarkets and fast-food restaurants as anchor tenants into lower-income urban areas and rural areas (Battersby 2017).This mallification of the food system has had negative health and nutrition outcomes.Otterbach et al. (2021) have correlated proximity to a supermarket or fast-food restaurant with overweight and obesity.The Competition Commission conducted a Grocery Retail Enquiry to assess claims of unfair competition in the sector and released a set of recommendations designed to reduce the power of Big Food in South Africa (Competition Commission South Africa 2019).However, these have not been acted upon and the state is unwilling to regulate these actors as they are seen as providers of employment and development (Battersby 2017).

Current policy context
The South African National Food and Nutrition Security Policy of 2013 recognises South Africa's constitutional right to food but takes an extremely limited diagnostic lens to the problem of food and nutrition security and does not really adopt an equity lens, nor does it address structural inequalities within the food system.The government's school feeding scheme is pro-equity in terms of targeting.However, there is little focus on nutrition at Early Childhood Development Centres and children currently enter the school system at age five or six, which is too late for some child nutrition milestones.Additionally, as noted above, the social grants provided by the state are too low to address malnutrition.Figure 3.4 illustrates the challenge experienced by low-income households regarding acquiring a healthy diet when other non-discretionary costs must be met first.

Conclusion
The South African food system, economy, and geographical distribution of goods, services and opportunities are vastly unequal and inequitable by design.The country's colonial and apartheid histories effectively hard baked maldistribution of resources and misrecognition along the lines of race, gender, nationality, disability and others, and provided extremely limited political representation for all but a tiny minority.Even in the best of political and economic circumstances, the legacy of these inequities would continue to yield highly unequal nutrition outcomes.Unfortunately, post-apartheid food system policy has tended towards neoliberal approaches that have not had an equity focus, and trade decisions have often been inimical to stated nutrition and health objectives.Whether due to ideological positioning or a lack of capacity, the state has tended to depend on 'second-class' interventions that seek to mitigate the negative impacts of the prevailing food system, rather than directly engaging the largely private sector-driven structural problems of the food system.The analysis presented here suggests an urgent need for equity-oriented, rather than poverty alleviation-oriented, policies.However, given the current financial and political weakness of the state, this currently feels unachievable unless poor nutrition is brought to political prominence and new, more inclusive forms of national and local governance are able to emerge.

Inequality and dietary context
Hunger, inequality, and poverty are historic challenges for Brazil, the legacy of a country that was shaped by the slave labour of African peoples and that based its economy on the exploitation of natural resources and the exportation of primary products.In the 1990s, infant mortality and malnutrition rates decreased as a result of improved sanitary conditions, vaccination rates, and women's education levels.However, it was only between the 2000s and early 2010s that important changes occurred, with the lowest levels of extreme poverty, poverty, and food insecurity being achieved.
These results, however, did not express the transformation of the structural determinants of inequalities; so much so that in 2014, when a major political and economic crisis set in, the situation began deteriorating in all aspects to the point that by 2022 more than half of the Brazilian population (125 million people) will have some degree of food insecurity, of which 33 million will be in a situation of hunger (27 million living in cities).These figures are the result of a national survey carried out between November 2021 and April 2022 (PENSSAN 2022).

Key results from the National Survey on Food Insecurity (2022)
The application of the Brazilian Scale of Food Insecurity, with methodology compatible for the comparison between national inquiries periodically conducted since 2004, indicates that currently, 53.2 per cent of the households where the person of reference self-declares as white is in a situation of food security.However, when the person of reference self-declares as black or brown, only 35 per cent of the households are in a food security situation.Hence, 65 per cent of the households where the person of reference is black or brown are in a situation of some degree of food insecurity, with some level of food restriction.
Six in ten households that have a woman as reference is in a situation of food insecurity and severe food insecurity (hunger) increased from 11. Considering other indicators of the nutritional status in Brazil, the temporal trends can be summarised as follows: decrease in the prevalence of nutritional deficit indicators in the period between 1974-75 and 2019; decrease in sociodemographic inequalities in relation to the indicators of nutritional deficit, although there are still inequalities to overcome; increase in the prevalence of overweight and obesity indicators in all age groups, also with sociodemographic inequalities; increase in the prevalence of breastfeeding, but still at levels below the goals of the 2030 Agenda (Castro 2022).

Food consumption
Food consumption in metropolitan regions of Brazil through the historical series of food purchases (1987-88 to 2017-18): There has been a decrease in the participation of in natura or minimally processed and processed foods in the set of household purchases.These groups, which represented almost 80 per cent of the calories consumed at home in 1987-88, currently represent around 60 per cent.On the other hand, ultra-processed foods, which represented only 10 per cent of the calories consumed by the Brazilian population, now represent almost 24 per cent.
In the period between 1995 and 2002, there was the largest increase in the participation of ultra-processed foods in Brazilian families' diets.In the last period , there was also an increase, but with signs of deceleration.When assessing the evolution of the consumption of ultra-processed food, it was observed the significant increase of 5.5 per cent in the consumption of these foods between 2008-09 and 2017-18 (Levy et al. 2022).The diet of the Brazilian population is still composed predominantly of foods in natura or minimally processed and processed culinary ingredients.However, our findings point to trends of an increased share of ultra-processed foods in the diet.This increase of 0.4 percentage points per year between 2002 and 2009 slowed down to 0.2 percentage points between 2008 and 2018.The consumption of ultraprocessed food was higher among households with higher income, in the South and Southeast regions, in urban areas, and in metropolitan regions (ibid.).More recent analyses indicate that there has been a stabilisation in the increase of the consumption of ultra-processed products in higher-income segments, but the rate of growth in lower-income segments continues to accelerate.Previous forecasts already indicated that ultra-processed food would be cheaper than fresh food in Brazil in the middle of this decade; however, the pandemic and the war in Ukraine have worsened this trend, as they have caused an increase in the prices of fresh food and relative cheapening of ultra-processed food, stimulating their consumption.Between 2003 and 2014, several public policies that led to significant results in reducing poverty and food insecurity were implemented, increasing access to education and improving quality of life in general.A group of measures specifically targeted the social groups in situations of greater vulnerability (poor urban families, women and young small farmers, indigenous peoples, traditional communities, family farming).However, mainly from 2016, there were drastic budget cuts and institutional destructuring and these actions were practically extinguished.Similarly, an entire strategy to implement a national food and nutritional security system that aimed to articulate government sectors and define priorities and budget allocation was also paralysed.This system, which had formal mechanisms for social participation and advised the President of the Republic, was also interrupted (Recine et al. 2020).Civil society has always been present and played a leading role in this process of reconstruction and expansion of public institutions, with a focus on ensuring achieved rights.The resistance of the different social movements in order to maintain the spaces of civil participation related to Food and Nutrition Security public policies is still going to be long and arduous, demanding the continued vocalisation and strengthening of partnership networks within the different movements of the organised civil society.

Conclusion
Brazil has achieved promising results in the fight against hunger and poverty, especially between the early 2000s and mid-2010s.Among the factors that contributed to these changes, there was the implementation of a new governance framework for the provision of public policies.However, the discontinuation of this strategy revealed the persistence of the roots of social injustices, such as racism and gender inequalities, that characterise the dynamics that generate inequalities and threaten social and environmental justice.Considering the intermediate drivers of these unequally distributed dietary outcomes (those represented by the middle of the NEF framework), daily living conditions -be it poor housing, lack of access to water, electricity, etc.emerge as a common causal factor.The South Africa case illustrates how these can influence people's food storage and preparation options which can result in a greater reliance on highly processed foods that do not require storage or cooking, which in turn worsens dietary outcomes.Disparities in income are seen to be closely aligned with changes in labour market opportunities available to different groups.For example, in Brazil, unemployed households and those engaged in informal labour and farm workers have some of the highest rates of food insecurity.In the UK, the most deprived areas of cities are often populated by marginalised communities who suffer from poor housing and labour conditions that in turn impacts on healthy life expectancy.Access to critical infrastructure and coverage of nutrition-related health services is another dimension where we see particular groups are disadvantaged in the Vietnam and South Africa cases; less so in the UK and Brazil where the literature focuses more on underlying issues relating to urban, city environments and poor living and working conditions.
Turning to the wider structural drivers of inequitable diets (those represented on the left side of the NEF framework), which focuses on relevant institutional governance, policies, actors and social and cultural norms, the four case studies illustrate how important historical factors such as land use and ownership, and imperial, colonial and post-colonial governance and policies (e.g.associated with agriculture and food), have influenced the current dietary equity context in multiple ways.The dissolution of traditional, localised food systems in favour of policies supporting industrialised, large-scale production, processing and trade appears to be a common factor contributing to marginalisation of particular groups and changing dietary behaviour and practices in the UK, Vietnam and South Africa.In the UK case, the first food system transformation occurred when large estate owners expropriated much of the common land used for grazing or kitchen gardens.In South Africa, policies introduced during the apartheid era were seen to further accelerate the destruction of traditional food systems that sought to marginalise black, small-scale subsistence farmers.Colonial-era policies focusing on plantation-style agricultural production and economies in lowland areas of Vietnam excluded and disadvantaged ethic minority groups living in the highland areas.Public policies designed to address poverty, hunger, and food insecurity are reported to have had some success across the different cases, particularly evident in the Brazil case.However, those designed to target specific vulnerable populations (e.g.children, certain ethnic minorities, racial groups or low-income groups) have been criticised for their poor design or challenges in delivery resulting in little or no sustainable improvements observed amongst these groups to date in any of the country case studies.The role of civil society groups in advocating for improvements in public services and rights for particular marginalised groups is illustrated in both the Vietnam and Brazil cases.In contrast, the UK case highlights tensions between powerful food sector players and government which has limited progress and reform on how unhealthy foods are taxed and marketed -and therefore failed to influence a shift towards more balanced, sustainable diets particularly amongst deprived, low-income groups.

Insight into applying the Nutrition Equity Framework
Reflecting on these findings in relation to the original NEF framework, we find there are some aspects not fully explored through the four cases studies and others that are explored but not covered by the current framework.In terms of intermediate determinants, those related to behaviours and practices captured on the far-right side of the framework are reflected across the case studies; for example, when looking at changing food consumption patterns and practices associated with particular social groups.Health-related practices are less of a focus, although this is perhaps expected given that diets have a slightly different set of determinants more rooted in food systems rather than health systems.On food, care, and health environments, a focus on the care environment and how it relates to dietary outcomes is also missing, with the exception of the burden of women's caring responsibilities noted in the UK case.
Moving to the structural determinants captured on the left side of the framework, for aspects related to social stratification, both features of social position and capital and potential are covered to some extent across the different cases, but would benefit from further in-depth research that explores multiple, intersecting dimensions of social position (rather than focusing on just one or two, e.g.ethnicity and gender) or the role of access to natural resources.With regard to socio-political contexts, the framework component on institutions is covered, for example looking at the evolution of food system governance and policy change, although there is a gap in data on commercial contexts in the Brazil and Vietnam cases.Actors in terms of power dynamics between different key players (e.g.governments, commercial bodies and civil society) is explored to some extent whilst there remains a gap in the literature investigating ideas related to cultural and social norms and values relating to healthy diets.There is also a need to focus on how parts of the framework interact, for instance historical injustices and processes leading to wealth disparities which in turn lead to diet and nutrition inequalities; in many cases studies start with the wealth disparities, rather than understanding what caused these.
In terms of gaps in the NEF framework when applied to the dietary equity context, the analysis of these case studies suggests that the food, care, and health environments component could be expanded to incorporate specific aspects of these environments seen to influence inequities.In particular, the food environment or food systems aspect could be strengthened given the themes highlighted through the case studies related to barriers to availability, accessibility, and affordability for disadvantaged groups.Likewise, the case studies suggest that more emphasis in the framework could be given to the 'inter-generational and inter-territorial experience'.

Next steps in FEC diet and nutrition research
The types of global inequality in diet and nutrition outcomes that we see today are, conceptually and practically, the result of entrenched inequities that reach beyond the immediate concerns of most biomedical and public health approaches and need to be understood systemically, from the outside in; and from the perspectives of malnourished people themselves, from the inside out; as well as properly contextualised in historical terms.Because our focus is on diets rather than nutrients, this history needs to take in all the richness of food and culinary culture and both the processes of marginalisation and resistance of traditional diets in the face of more homogenising global trends.The purpose of this theme, therefore, needs to focus on diets and wellbeing across and between generations and geographies, on the lived experience of diets and culinary culture in all its forms, and on how diets and wellbeing are shaped by a range of food and non-food factors which persist in the form of processes that marginalise and stigmatise the most vulnerable in food and other systems.
Clearly, availability of data and scope (resources) of different studies shape the possibility to fill these gaps.There is scope to more systematically complete the current case studies through further research with the FEC, perhaps focusing on positive as well as problematic cases.From previous discussion, the Diets group will look at food equity issues from different angles, with further discussion and input welcome, perhaps to include: 1. 'Big data' work on similarities and differences across countries -noting limitations in available data; 2. Ethnographic work on lived experiences and intergenerational transmission of poor diets and malnutrition in all its forms; and We will use a common set of approaches: 1. Historical approaches (either documentary/archival or life history) to understand change/transmission/pathways; and 2. Comparative approaches -among countries, levels (global to local), and constituencies (across the life-course and among different axes of marginalisation).
These draw on a range of methods: -Data synthesis, to look at changes in outcomes over time -and at gaps that have not been measured; Overall, we will use the interplay of different angles, approaches, times, and levels to look at food equity issues through different lenses, allowing critical reflection not only on the outcomes of the research, but on how framing different questions and answering them through different methods allows a more rounded view of the issue.Ultimately, we aim to look across the dimensions of the Food Equity Framework (and beyond these) to both assess and address inequality and inequity in diets and nutrition for different people in different places.

Figure 3 . 1
FiguresFigure 2.1 The Nutrition Equity Framework (NEF) Figure 3.1 Percentage change in food purchases 2015-2018/19 in low-income households and all households (UK) Figure 3.2 Inequality in daily living conditions based on social position in Vietnam Figure 3.3 South African labour inequalities Figure 3.4 Household affordability index Figure 3.5 Poverty in Brazil Figure 3.6 Public budget in food and nutrition activities Figure 3.7 Public budget in food and nutritional security activities

Figure
Figure 3.1 Percentage change in food purchases 2015-2018/19 in low-income households and all households (UK)

Figure 3 .
Figure3.1 shows food purchases in low-income households and in all households between 2015-2018/19.When it comes to healthy food items, purchases of vegetables by all households rose 3.3 per cent but low-income households purchased 2.8 per cent less than in 2015.Purchases of fruit by all households rose 1.2 per cent compared to a fall of 5.9 per cent in low-income households since 2015.Food is the largest item of household expenditure for low-income households after housing, fuel, and power costs.The Food Foundation reports that the poorest fifth of UK households would need to spend 47 per cent of disposable income on food to meet the government recommended

Figure 3 . 2
Figure 3.2 Inequality in daily living conditions based on social position in Vietnam

Figure
Figure 3.3 South African labour inequalities

Figure 3 . 4
Figure 3.4 Household affordability index Figure 3.5 Poverty in Brazil 2 per cent in 2020 to 19.3 per cent in 2022.Hunger doubled in families with children under ten years old, increasing from 9.4 per cent in 2020 to 18.1 per cent in 2022.It is more prevalent in households where the person responsible is unemployed (36.1 per cent), works as a family farmer (22.4 per cent) or does informal work (21.1 per cent).Hunger reached 21.8 per cent of the households of family farmers and small rural producers.If summed to moderate food insecurity, the rate reaches 38 per cent of these households.There is hunger in 22.3 per cent (2022) of households where the people in charge have four years or less of formal education.In 2020, this percentage was 14.9 per cent.In households permanent access to water (water insecurity), 22.8 per cent are in a situation of moderate food insecurity and 42 per cent are in a situation of severe food insecurity.

Figure 3 . 6
Figure 3.6 Public budget in food and nutrition activities -political work on structural determinants of poor diets and malnutrition.

-
Document review, to trace and critique change in formal narratives over time; -Interviews and ethnographies, to understand different viewpoints and lived experiences; and -Participatory, citizen science and action research, to incorporate positive change into the research process.

-Breastfeeding in the UK.
2Scotland, however, held a more recent survey in 2018, which showed a rise in breastfeeding continuing at six months from 32 per cent in 2010 to 43 per cent in 2017.3Currently,fewschoolage children are able to meet recommended healthy food intake, with only 0.3 per cent consuming the recommended amount of fruits and vegetables in the lowest income group, rising to 11 per cent in higher income groups(Food Foundation 2022).By the time children reach primary school already one in four are classified as overweight or obese.Poorer diets and dietary outcomes are a greater burden on more marginalised groups: children in most deprived fifth of income groups are twice as likely to suffer obesity by reception.By year 6 (age 10/11), the most deprived decile are on average >1cm shorter (ibid.). 2 See UNICEF 3 Ibid.4 Data 2012-16, National Diet and Nutrition Survey in Food Foundation (2019).

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in Vietnam achieved minimum dietary diversity, while 68 per cent of those in the richest households did (UNICEF 2014).
).In 2014, 35 per cent of children in the poorest ids.

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looked at the food system determinants of dietary transition in Vietnam, finding that dietary inequalities persist: expenditure share in the bottom quintile of households decreased substantially on starchy staple foods between 2002 and 2014, from 51.6 per cent to 29.1 per cent of food expenditures; while expenditure by the richest quintile of households fell from 20.8 per cent to 12.3 per cent.At the same time, expenditure in the poorest households on meat increased substantially (17.9 per cent to 26.7 per cent), while expenditure on meat remained stable in richer households (at ~34 per cent).Expenditure on sweets increased markedly in all socioeconomic groups.While these headline figures give a snapshot of change, the ability of the studies to look at inequality was limited by the level of disaggregation in the available data sets: richer and poorer households, or urban and rural, could be determined, but little detail beyond this.Only one study in Vietnam is found to have looked at the intersection of nutrition and ethnicity, finding that minority children have higher prevalence of multiple forms of undernutrition (and lower overweight prevalence) than those from majority groups(Le et al. 2019).This is despite Vietnam being one of the few countries that maintain disaggregated data based on ethnicity and collects data on the 54 officially recognised ethnic ids.

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and extremely high rates of overweight and obesity (and associated diet-related non-communicable diseases).In 2016, 65.4 per cent of women and 40.5 per cent of men were overweight, with 39 per cent of women and 15.3 per cent of men experiencing obesity.The country is also experiencing increasing rates of child overweight and obesity (Global Nutrition Report 2023).This has high social and ids.

ids.ac.uk IDS Working Paper Volume 2023 Number 591 FEC Working Paper 004 Healthy Diets Depend on Equity and Justice: Understanding the Context in Brazil, South Africa, the UK, and Vietnam 34 4. Discussion 4.1 Comparative synthesis of country studies
Comparison across the four country case studies presented in this paper provides a useful illustration of how diet and nutrition equity dynamics can play out in diverse ways depending on national historical and contemporary contexts.At the same time, despite these differences we see some parallel trends and characteristics suggesting common drivers of unhealthy and inequitable diets.Examining these similarities and differences across different settings can help further our understanding of context-specific versus more universal drivers that might be addressed via similar policies and interventions designed to reduce dietary inequities.Looking first at the social distribution of unhealthy diets (the right side of the NEF framework) in the four countries, we see some similar trends with regard to inequitable dietary and nutrition outcomes between different populations and social groups.All four cases suggest that marginalisation on the basis of ethnicity or race is considered a major determinant of poor diets and malnutrition due to a combination of historical structural factors that disadvantage particular groups.For example, UK data reports higher rates of obesity and overweight amongst Black Caribbean and Black African children compared to White; in Vietnam the poorest diets and undernutrition rates are observed amongst marginalised ethnic communities; in South Africa black households are far more likely to suffer hunger and food insecurity than white households; and in Brazil over half of white households are considered food secure compared to only 35 per cent for those households self-identifying as black or brown.Similarly, age, income and geographic-based nutrition inequities are highlighted across all contexts.In terms of age and gender-related disparities, data from the UK, South Africa (and perhaps Brazil) suggests children and women are especially disadvantaged, with high and increasing rates of overweight and obesity seen in the South Africa data presented (the Vietnam case did not explicitly look at this aspect of equity).In relation to income-based differentials, the Brazil, South Africa, and UK cases all highlight the concerning rise in overweight and obesity rates amongst lower-income groups, with the Brazil case highlighting how the rate of growth of consumption of ultra-processed foods is increasing at a much faster rate for those in lower-income segments, alongside a relative increase in the price of fresh foods.The Vietnam data suggests overweight and obesity is less of a major concern amongst poor populations at present, although food expenditure share across different food groups shows a move towards a more meat-based, high-sugar diet for lower-income households, suggesting further research is needed to explore this.One pattern observed only in the Brazil data ids.

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is a decrease in sociodemographic inequalities related to nutritional deficits, although it suggests efforts should continue to further reduce this gap.Data exploring aspects of intersectionality of a combination of social characteristics, for example gender, age, ethnicity, is incorporated in some cases although the Vietnam case study calls for a greater research focus on this.

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