Nutrition transition, food retailing and health equity in Thailand

Abstract

Aim

Here we examine the influence of changes in food retailing, the food supply and the associated nutrition transition on health equity in Thailand, a middle income country experiencing rapid economic development.

Methods

The dietary transition underway in Thailand is reviewed along with theories regarding convergence to a globalised energy dense obesogenic diet and subsequent socio-economically related dietary divergence along with the implications for health inequity.

Results

Thailand is part way through a dietary, nutrition and health transition. The food distribution and retailing system is now 50% controlled by modern supermarkets and convenience stores. The problem of increasing availability of calorie dense foods is especially threatening because a substantial proportion of the adult population is short statured due to child malnutrition. Obesity is an emerging problem and for educated Thai women has already developed an inverse relationship to socio-economic status as found in high income countries.

Conclusions

Thailand has reached an important point in its nutrition transition. The challenge for the Thai government and population is to boost affordable healthy diets and to avoid the socio-economic inequity of nutritional outcomes observed in many rich countries.

The nutrition transition and inequity in Thailand: the role of food retailing

Dietary transitions and economic development

Nutrition is a critical determinant of human health across the entire life cycle. Accordingly the study of nutritional dynamics and related changes in the production and distribution of food, are important components of public health and this applies to populations afflicted by under-nutrition and by the more recent problem of prevalent over-nutrition. Nutritional problems are typically inequitably distributed in a population and the determinants of that inequity constitute the upstream drivers of the nutrition-associated population health outcomes.¹

As countries develop economically their populations experience a “nutrition transition” whereby, accompanied by rising incomes and urbanisation, traditional diets based on starchy staples are replaced by diets higher in animal protein, dairy products and processed and refined grains. This leads to a dietary “convergence” towards a more westernised or more globalised diet.^2,3 Once such convergence has occurred further dietary changes arise reflecting socio-economic differences. For example, Hawkes has observed that in many western or more economically developed nations globalisation of the diet was followed by a dietary “divergence”. Comparatively well off educated consumers become more aware of the adverse health effects of globalised diets and began to demand and pay price premiums for more healthy low in fat and salt and with high fruit, vegetable and fiber content.⁴ Such socio-economic dietary divergence is leading to potential inequities in health outcomes as these more healthy diet options are not available to lower income groups.^5,6

This “divergence” pattern of food consumption in developed countries along with lifestyle and other issues are thought to be influencing the generally lower levels of obesity and other diet related health problems found among higher socio-economic status groups in developed countries. In lower income developing countries the opposite has been found; higher socio-economic groups seem to be early adopters of Western dietary convergence and are also the group which displays the highest levels of obesity. As incomes rise and countries develop economically they have been found to move to a threshold where the relationship between obesity and socio-economic status reverses which generally happens at lower income levels for women than for men.⁷ There are many factors which seem to play a part in mediating the change including both the increased consumption of energy dense “obesogenic foods” and the decrease in physical activity associated with urbanized “modern” lifestyles. Figure 1 outlines this process of dietary convergence followed by within country divergence and its association with obesity and diet-related disease.

Figure 1.

Prevalence of obesity in the Thai population and the number of modern retail outlets in Thailand

The role of modern retail formats in the changes in diet in transitional countries is noteworthy. Supermarket entry into the retail sector of developing countries may have both a positive and a negative impact on diet. The globalised food chains which supermarkets create undoubtedly increase the diversity of food available to consumers, leading to the potential for improvements in diet. But, these globalised food chains also have the largest comparative advantage in supplying processed, energy dense, “problem foods” which play a large part in the nutrition transition’s negative impacts.^3,6 Supply chain efficiency and economies of scale are more effective in reducing the price of processed foods high in sugar, salt and oil than on raw unprocessed foods.⁸ The process of divergence of diets whereby more well off consumers begin to demand more healthy diverse foods is catered for by supermarkets looking to capture all segments of the market. However, for poorer consumers dietary convergence towards a globalised obesogenic diet remains powerful because of cost constraints.

Food and nutrition in Thailand

Thailand is a Southeast Asian nation which has experienced a rapid political, economic and lifestyle transition over the last few decades. This has included a period of sustained growth in GNP since the late 1950’s (though with a short period of stagnation following the Asian Crisis of 1997) accompanied by rising incomes and greatly diminished poverty levels.^9,10 This economic transformation has also included a process of rapid urbanisation and transformation of the workforce from its agrarian roots to an industrial and service economy.¹¹ As Thailand’s economy has grown its population has become increasingly urbanized and overall poverty levels have fallen. But the benefits of this process have not been distributed equally throughout the Thai population. In fact between 1962 and 2000 (the period of most rapid growth in Thailand) income inequality as measured by the Gini coefficient rose from 0.410 to 0.525.^12,13 This income inequality has also manifested in inequity in the health and nutritional status of the Thai population, particularly between rural and urban groups. Lower income groups experience worse self rated health,¹⁴ higher levels of communicable diseases ,¹⁵ higher smoking rates ,¹⁶ higher injury rates,¹⁷ lower attained adult heights ¹⁸ and more childhood malnutrition .¹⁹

Accompanying the Thai economic transformation has been a remarkable change in the food being consumed by the population and a rise in diet related disease. Since the early 1980s sugar consumption has nearly tripled in Thailand along with large increases in the amounts of oils and animal protein and decreases in the amount of fruit and vegetables consumed.^20,21 Obesity and other diet related diseases have been growing rapidly and have become increasingly important public health priorities,^21,22 with around one third of Thai adults now obese. Table 1 shows the rapid growth in obesity since 1991 with prevalence growing almost 4-fold in 20 years. Until recently the pattern of obesity has followed that found in other developing countries as described above with more well off urban consumers who are early adopters of the dietary convergence offered by the expansion of globalised retail experiencing the greatest burden of obesity. Recent research however has shown that Thai women are approaching the tipping point where higher socio-economic status, and particularly higher education, are associated with lower BMI.^22,23 In light of the above comments on dietary convergence (globalisation) being followed by (socio-economic) dietary divergence within countries as their economies develop we may conclude that more educated Thai women have developed a growing concern with healthier eating patterns and smaller body size.

Table 1. Overweight/ Obesity Prevalence in the Thai population ^20,22,37.

Year	Males with BMI >25 (%)	Females with BMI >25 (%)
1991	7.7	15.7
1996	13.2	25.0
2002	27.7	32.5
2005	27.9	35.2
2010	28.3	39.9

Accompanying these changes in diet, nutrition and health in Thailand has been a remarkable and rapid transformation in food retailing which has until recently been based on two institutions - the fresh food market and the traditional small family-run retail shops (Figure 2). The last few decades have seen these retail formats being joined by “modern” retail, meaning supermarkets, convenience stores and hypermarkets. Hypermarkets are very large retail outlets with the full spectrum of consumer goods under one roof unlike supermarkets which concentrate on food products.²⁴

Figure 2.

Through the late 1990’s and the beginning of the 2000s modern retail began to gain a foothold in the Thai food retail sector led by transnational food corporations (TFCs) including UK based Tesco and French Carrefour. The main growth occurred at the two opposing ends of the modern retail spectrum, hypermarkets and convenience stores at the expense of supermarkets and traditional retail.²⁵ As Thailand’s development and transformation began to influence rural consumers more in the 1990s and 2000s the expansion of modern retail extended into regional centres and then even into smaller regional towns as rural incomes rose and rural people became more accustomed to urban style living. Table 2 outlines the rapid growth of the 3 main modern retail formats over the decade from 1997-2007 with perhaps the most striking growth being in the convenience store format expanding from 1180 stores to over 6000 in ten years.

Table 2. Number of modern retail outlets in Thailand 1997-2007²⁷.

Type of retail outlet	Number of Outlets
	1997	2002	2007
Supermarket	50	110	166
Hypermarket	60	128	225
Convenience store	1180	2418	6263

Apart from store numbers growing the share of modern formats in the food retail market in Thailand has also been growing rapidly. From only around 5% in the late 1980s this share grew to 26% in 1997 before the large growth in foreign investment by TFCs in the late 90s led to the rapid growth in the number of stores mentioned above. From there the share rapidly grew to 40% at the turn of the decade and now stands at around 50%, a doubling in less than 10 years (Table 3),^26-28 At present the modern retail proportion of food trade in Thailand is mainly made up of dry and processed foods; the traditional wet markets in Thailand continue to dominate the fresh food market.²⁹

Table 3. Modern and traditional retail market share in Thailand²⁶.

Year	Modern (%)	Traditional (%)
1999	35	65
2000	37	63
2001	40	60
2002	42	58
2003	44	56
2004	46	54
2005	48	52

This rapid expansion in modern food retailing has been accompanied by a fall in the market share of traditional retail and a corresponding fall in the number of fresh markets and traditional retailers. For example one investigative report in the Bangkok Post newspaper suggests that the number of fresh markets in Bangkok has fallen from 160 to 50 in the past decade.³⁰ Now, Thais who shop primarily at traditional retail formats are the lower socio-economic groups, older persons and those who value “traditional, cultural” foods more highly.³¹ Prices for fresh fruits and vegetables have also been shown to be consistently lower at traditional fresh markets in Thailand than in modern retail formats.^24,28,32 Thai hypermarkets sell processed products 12% cheaper, and fresh foods 10% dearer, than do traditional retailers. Hypermarkets also add non-price incentives (loyalty discounts and consumer credit via credit cards) as well as lines of cheap private label processed products again making processed foods more affordable than raw/ fresh foods.^6,33

The process of dietary convergence towards a globalised diet and subsequent divergence between the diets of high and low income groups is already underway and the simultaneous growth in income inequality means large proportions of the population will be affected by these changes with a risk of health inequities developing. Thailand has reached an important point in its nutrition transition. Energy dense, processed, westernized foods are now widely available and affordable throughout the country to all socio-economic groups through the agency of transnational food company investment. Higher income and educated consumers are beginning to demand more diverse and healthier diets just like their counterparts in more developed nations. The challenge for the Thai government and the population is to ensure that the affordable, healthy dietary choices offered by traditional fresh market retailing remain available despite the massive influx of modern retail. Furthermore, ideally the lower socio-economic groups should not follow the nutritional pathway noted in many developed countries leading to high levels of obesity and diet related diseases connected to the increasingly affordable obesogenic foods.

The problem of inequity in nutrition outcomes and propensity to obesity is exacerbated in the Thai context by the rapid nature in which economic development has occurred. Members of the lower socioeconomic groups who now are at risk from the changes in diet discussed above are individuals who only one a few decades ago, as children, experienced high levels of malnutrition and often experienced low birth weights and small body size in early life. Individuals who begin their lives in these conditions and then experience high levels of calorie intake in later life are at an even higher risk of experiencing the negative health effects of over-nutrition including obesity and related diabetes and heart disease.^34-36

Policy implications and further research

There are several ways that these nutritional problems can be approached in settings such as Thailand today. The importance of fresh food markets for meeting the nutritional needs of lower socio-economic groups can be supported by the Thai government and associated planning bodies. As well attention can be paid to consumer education and nutrition labeling. This is an important process but may differentially benefit educated, wealthier consumers and does not address the issue of comparative pricing and marketing of products.⁵ Other approaches which have met with some success in other countries are restrictions on marketing of unhealthy foods and price manipulation. These ideas may even extend beyond the national level and extend to international governance as envisaged by the World Health Organisation which conceptualises using international trade regimes to encourage a more healthy globalisation using processes currently used to ensure food safety in the international food trade.⁸

To understand better the process underway in Thailand and to identify how it is affecting different segments of the population, epidemiological and sociological research is addressing this topic. Based at Sukhothai Thammathirat Open University in Bangkok and The Australian National University in Canberra, this work has involved accompanying a large national cohort of Thai adults since 2005 as they negotiate the changing food environment and experience associated health outcomes. Further details are available at:(http://nceph.anu.edu.au/Thai_Cohort_Study/index.php) and (http://www.stoucohort.com/index_VEg.html ). It is anticipated that such multi-disciplinary research centred on the epidemiology of Thailand’s nutrition transition will lead to health-promoting food policies.