Mediterranean Food Consumption Patterns ...

Sciknow Publications Ltd.

AJNFS 2014, 1(2):37-52 DOI: 10.12966/ajnfs.04.04.2014

American Journal of Nutrition and Food Science ©Attribution 3.0 Unported (CC BY 3.0)

Mediterranean Food Consumption Patterns Sustainability: Setting Up a Common Ground for Future Research and Action Roberto Capone, Hamid El Bilali*, Philipp Debs, Gianluigi Cardone, Noureddin Driouech Mediterranean Agronomic Institute of Bari (MAI-B), International Centre for Advanced Mediterranean Agronomic Studies (CIHEAM), via Ceglie 9, 70010 Valenzano (Bari), Italy *Corresponding author (Email: [email protected])

Abstract - Food consumption patterns are critical for sustainability. Many issues directly or indirectly related to food consumption patterns should be addressed in the Mediterranean area. A sustainable food system supports food security and makes optimal use of natural and human resources. The review paper aims at highlighting the main aspects and concepts regarding Mediterranean food consumption patterns sustainability that should be taken into consideration in order to set up a region wide research and action agenda. Current Mediterranean food consumption patterns are not sustainable. Unsustainable food consumption patterns are putting increasing stress on Mediterranean ecosystems and social systems. Food consumption and production patterns are among the most important drivers of environmental degradation. The social and economic costs of diet-related illnesses are straining individuals, families and national healthcare budgets. The Mediterranean diet is widely considered a healthy dietary pattern and a greater adherence to it has been associated with significant nutritional and health improvements. It has also been acknowledged for its lower environmental footprints. However, there is an ongoing decrease of adherence to the Mediterranean dietary pattern. Moving towards sustainable food system in the Mediterranean region means addressing systemically the consumptive demand as well as productive supply elements. Curbing the amount of food loss and waste is a tangible starting point as well as promoting the Mediterranean diet as a sustainable dietary pattern. Steps must be taken to assess the nutritional, health, economic, environmental and social sustainability of the current food consumption patterns and to develop appropriate policy guidelines and instruments. Keywords - Food consumption patterns, Mediterranean diet, Sustainability, Mediterranean

1. Introduction Humanity is facing deeply interlinked economic, social and environmental crises that stem, in large part, from current unsustainable patterns of consumption and production. Humanity is now consuming more resources than ever, both per person and in absolute terms. Therefore, fundamental changes in the way societies consume and produce are indispensable for achieving global sustainable development (UNEP 2012). FAO (2012a) pointed out that ending hunger and achieving food security require that food consumption and production systems attain more with less, which encompasses fostering sustainable intensification of food production, encouraging sustainable food consumption and reducing food losses and waste. The food system concept not only helps to identify the full range of activities involved in the food system, but also helps to identify the actors involved, the roles they play, and the many and complex interactions amongst them (Ericksen et al. 2009). According to Goodman (1997) “Food systems represent all processes involved in feeding a population, and

include the input required and output generated at each step. A food system operates within, and is influenced by, the social, political, economic and environmental context”. The food system activities are grouped into four categories: producing food, processing and packaging food, distributing and retailing food, and consuming food. The first three categories constitute the food supply chain (Ericksen 2007). Food systems overlap with agricultural systems in the area of food production, but also comprise the diverse set of institutions, technologies and practices that govern the way food is marketed, processed, transported, accessed and consumed. Food systems influence not only what is being consumed and how it is produced and acquired, but also who is able to eat, and how nutritious their food is (FAO 2012a). The global food system will experience an unprecedented confluence of pressures over the next 40 years. On the demand side, global population size will increase from nearly seven billion today to eight billion by 2030, and probably to over nine billion by 2050; many people are likely to be wealthier, creating demand for a more varied, high-quality diet requiring additional resources to produce. On the production side, competition for land, water and energy will in-

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American Journal of Nutrition and Food Science (2014) 37-52

tensify, while the effects of climate change will become increasingly apparent. The need to reduce greenhouse gas emissions and adapt to a changing climate will become imperative. Over this period globalisation will continue, exposing the food system to novel economic and political pressures (Foresight 2011). With rising incomes and urbanization, dietary patterns with pronounced regional and cultural differences are shifting towards consumption patterns higher in animal products, which are increasing water demand (Renault &Wallender 2000; Lundqvist et al. 2008). Dietary patterns with high meat consumption require more energy, water and land resources (Pimentel & Pimentel 2003; Gerbens-Leenes&Nonhebel 2005). An increase in animal-based production will require greater land and resource requirement, as livestock farming demands extensive land use. One hectare of land can, for example, produce rice or potatoes for 19–22 people per annum. The same area will produce enough lamb or beef for only one or two people (Institution of Mechanical Engineers-UK 2013). Food is strongly linked to health and sustainable development (APHA 2007). There is growing evidence of the cost of diets on the environment, society and public health (Haines et al. 2009; Holdsworth 2010; Hawkesworth et al. 2010; O‟Kane 2012; Burke Delaney 2012; Clonan&Holdsworth 2012). Diets impact health, including increased risk of obesity, cardiovascular diseases and cancers. Diets are also a significant factor in a number of critical sustainability issues such as climate change; public health; social inequalities; biodiversity; energy, land and water use; etc. (Reddy et al. 2009). Although consumer health awareness continues to grow with the increasing availability of health information going hand in hand with increased risk for lifestyle diseases. Selection of foods that are acceptable to an individual increasingly takes place in a context where availability is substantially influenced by the food industry and food retailers (Kearney 2010). In early 80s, the notion of “sustainable diets” started to be explored to recommend diets healthier for the environment as well as for consumers (Gussow and Clancy 1986) but then was neglected for many years. In 2010, FAO and Bioversity International organized an international scientific symposium on “biodiversity and sustainable diets”. As one of the major outcomes of the symposium, a consensus position was reached on the following definition of "sustainable diets": “Sustainable diets are those diets with low environmental impacts which contribute to food and nutrition security and to healthy life for present and future generations. Sustainable diets are protective and respectful of biodiversity and ecosystems, culturally acceptable, accessible, economically fair and affordable; nutritionally adequate, safe and healthy; while optimizing natural and human resources” (FAO/Bioversity 2010). Diets affect various dimensions (agricultural, food, nutritional, environmental, social, cultural, economic) that interact with one another. From this point of view, the Mediterranean

is the area where more than any others should be addressed many issues (biodiversity loss, soil erosion, water scarcity, etc.) directly or indirectly related to Mediterranean food consumption patterns (Lacirignola& Capone 2010). Across the Mediterranean region, there is “unequalitarian drift” in the current relation between northern Mediterranean countries and southern and eastern ones, where many difficulties are encountered due to the existing economic and social disparities. In fact, the macroeconomic indicators of the Mediterranean region emphasise the high heterogeneity among the countries and a growing gap between the advanced economies in the northern shores and less developed ones in the southern/eastern ones. Moreover, other social and economic features make a contribution to the considerable development differences between the two Mediterranean shores (Hervieu&Thibault 2009): the demographic divide; the densely populated rural areas; the natural resources (soil and water) scarcity; the erosion of the Mediterranean diet model; and the climate change and the loss of biodiversity. Changes in the landscape and land ecosystems have increased in recent decades, especially in the Mediterranean. The main pressures on these ecosystems and their biodiversity come from tourism, urban development in coastal areas, overfishing, intensive farming and irrigation, and the abandonment of traditional agricultural practices. Because of the fast rate at which its ecosystems are being destroyed, the Mediterranean region, so rich in exclusive species, is considered a biodiversity hotspot. The regions have a high number of endemic species but with a habitat that has been gradually degraded in recent years (Numa&Troya 2011). The objective of the paper is to highlight the main aspects and concepts regarding Mediterranean food consumption patterns sustainability. The ultimate aim is to stimulate a multidisciplinary discussion on the sustainability of the current food consumption and production patterns in the Mediterranean region and beyond in order to strategically and comprehensively set the stage for identifying the research activities and policy actions needed to move towards more sustainable Mediterranean food systems.

2. Material and Methods The paper is based on secondary data from different sources including FAO; FAO Regional Office for the Near East; UNEP; UNEP/Plan Bleu; CIHEAM; AQUASTAT; Forum on Mediterranean Food Cultures; Water Footprint Network; International Food Policy Research Institute (IFPRI); World Health Organisation (WHO); WHO-Regional Committee for the Eastern Mediterranean; Global Footprint Network; European Environment Agency; Agence de l'Environnement et de la Maî trise de l'Energie (ADEME), France; Institution of Mechanical Engineers-UK; Barcelona Centre for International Affairs (CIDOB); United Nations System High Level Task Force on Global Food Security (HLTF); The Economic Intelligence Unit, The Economist; UNESCO; The Mediterranean Diet Foundation; Barilla Centre for Food and Nutrition;


International Association for the Study of Obesity (IOTF); WFP; IFAD. The thematic scope of the paper is within the domain of sustainable food consumption. The geographical scope of the paper is the Mediterranean area with a particular focus on Southern and Eastern Mediterranean countries (SEMC). Nevertheless, consumption and production are strongly linked within the food chain. Therefore, many topics from the production side are covered. Moreover, the Mediterranean food system is linked to the global one through trade so many issues raised in the paper are global rather than regional. In fact, many issues regarding food consumption are defined by both local and global causes. The geographical coverage of this study is similar to that of the Mediterranean Strategy for Sustainable Development (MSSD) (UNEP/MAP 2005) including 21 countries around the Mediterranean. The main groups are Northern Mediterranean Countries (NMCs) (Cyprus, Spain, France, Greece, Italy and Malta); Balkan Countries (BCs) (Albania, Bosnia and Herzegovina, Croatia, Montenegro, and Slovenia); and Southern and Eastern Mediterranean Countries (SEMCs) (Algeria, Egypt, Israel, Lebanon, Libya, Morocco, Palestinian territories, Syria, Tunisia, and Turkey). The UE-28 Mediterranean countries gather 8 countries: Croatia, Cyprus, Spain, France, Greece, Italy, Malta and Slovenia. In addition to these countries some data were collected as well for Portugal, Serbia and Macedonia (FYROM). For the purpose of the present paper was made reference to the concept of food system sustainability developed in the framework of SUSFOOD project financed in the frame of the Seventh Framework Program (FP7) of Research the European Union. In fact, the ERA-Net SUSFOOD (SUStainable FOOD production and consumption) project defines sustainability in the food area as a food system that supports food security, makes optimal use of natural and human resources and respects biodiversity and ecosystems for present and future generations, which is culturally acceptable and accessible, environmentally sound and economically fair and viable, and which provides the consumer with nutritionally adequate, safe, healthy and affordable food (SUSFOOD 2013).

3. Results and Discussion Countries bordering the Mediterranean are experiencing quick, profound and simultaneous changes: climatic changes and their impacts on already fragile ecosystems; rapidly growing population and cities on the southern shore; and globalization of economies and emerging new standards of life that are modifying traditional behaviours. The urbanisation of the society, the integration of women into the labour market, the retail development is deeply modifying the dietary behaviour. Such changes are disrupting the long-established ecological, social and economic equilibriums of the area (Boulier 2012). The different evolution trends and the rapid population

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growth in the Southern Mediterranean region are the cause of the demographic divide. The rural population is still on the rise in the South Mediterranean region, and in the rural areas the number of people who live below the poverty line is increasingly higher. Water, a scarce and unevenly distributed resource, is the first hindrance to food security because water scarcity poses a serious threat to agricultural production. Furthermore, in the Mediterranean water is often at the heart of political and socio-economic conflicts which are not easily controlled (Hervieu&Thibault 2009). The Mediterranean receives on average only 3% of global water resources. In some countries, these mainly come from trans-boundary water resources (UNEP/MAP-Plan Bleu 2009). A water-poor country is defined as a country with less than 1,000 m3 of water per person per year. Sixty percent of people living in water-poor countries globally live in the Mediterranean region. There are considerable inequalities within the region in terms of water availability and the extent of renewable resource use (FAO2013). In the Mediterranean region, water resources are limited, fragile and unevenly distributed over space and time (Blue Plan 2006). According to AQUASTAT (2012), in 2009, France, Italy, Spain and Turkey accounted for 67% of renewable fresh water resources (flows available within their own borders on an annual basis) in the region. The Southern and Eastern Mediterranean countries (SEMCs) accounted for a little more than one-quarter (27%) of the region‟s water resources in 2009. If Turkey is excluded, they accounted for only 6%, yet they are home to 40% of the region‟s population (AQUASTAT 2012). Half of the “water poor” world population (i.e. less than 1,000 m3 per capita per annum) is concentrated in the Southern Mediterranean region (CIHEAM 2008). It has been estimated that by 2025 potentially 180 million people will be affected by water problems, 60 million of whom will suffer water shortage of less than 500 m3 per capita per annum (UNEP/MAP-Plan Bleu 2009). According to AQUASTAT database, the per capita availability of water, including imported quantities, shows similar disparities between northern Mediterranean countries (NMCs) and SEMCs. With the exception of Lebanon and Turkey, less than 1,000 m3 of water is available per person per year in Southern Mediterranean countries. The Balkan states are in a more favourable situation (AQUASTAT 2012). The water exploitation index for natural renewable freshwater resources is used to measure the relative pressure on those resources arising from their annual use. Exploitation above 40% of the sustainably available resource indicates a situation of severe water stress. This is the case in Egypt, Libya, Malta, Israel and Syria, where the index exceeds 80% (Ewing et al. 2010). Irrigation accounts for almost 65% of anthropogenic abstraction and can even exceed 80% in the Southern and Eastern Mediterranean countries (Thivet&Blinda 2007). According to the projections of the Blue Plan, which takes the year 2000 as the base year, water demands could increase by a further 15% by 2025, especially in the Southern and

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Eastern countries, where an increase of 25% is expected (Blue Plan 2006).Furthermore, Mariotti et al.(2008) predicted an average decrease of 20% in surface water availability by 2070–2099. In fact, the impact of climate change on the Mediterranean environment is already noticeable (Blue Plan 2008). Pressures will become more severe for the agriculture sector that consumes the largest volume of all water users in the Mediterranean since it accounted for 64% of overall demand in the period 2005-2010 (49% in the North, 74 and 81% in the South and East) (Molden et al. 2007). One part of the solution to the problem of limited resources and environmental services is to adjust patterns of consumption and production to reduce their demand on these resources (European Environment Agency 2013). Data from the 1996-2005 period show that the water footprint (WF) (Box 1) of consumption varies widely amongst Mediterranean countries, especially in terms of internal and external WF of consumption. In fact, the share of the external WF of consumption ranged from 7.3% to 91.8% in Palestine and Malta, respectively. The water footprint of national consumption ranges between 1055 m3 per year and per capita in Palestine and 2505 m3 per year and per capita in Portugal. Northern Mediterranean countries have higher water footprints of consumption per year and per capita compared to SEMC and the Balkans. The per capita water footprints in the Mediterranean, especially in Southern and Eastern Mediterranean countries, are lower than those recorded in North America but higher than the water footprint of consumption of Finnish citizens (Mekonnen& Hoekstra 2011).

Box 1. Water footprint. The water footprint (WF) is the demand of freshwater resources required to produce goods and services and it represents a measure of human‟s appropriation of freshwater resources: freshwater appropriation is measured in terms of water volumes consumed (evaporated or incorporated into a product) or polluted per unit of time. The water footprint includes the use of blue water (ground and surface water), green water (rain water or moisture stored in soil strata), and grey water. The grey water footprint refers to pollution and is defined as the volume of freshwater that is required to assimilate the load of pollutants given natural background concentrations and existing ambient water quality standards (Hoekstra et al. 2011). The water footprint of consumption of a country is defined as the total volume of freshwater that is used to produce the goods consumed by its inhabitants. It is the sum of direct and indirect water use of domestic and foreign water resources through domestic consumption (Vanham&Bidoglio 2013). Most of the water footprint of consumption is due to the consumption of agricultural products (Figure 1). The share of the water footprint of agricultural products consumption in the total water footprint of consumption ranges from 61.8% in Serbia to 97.7% in Tunisia. The average value is approximately 91% of the total WF of consumption (Mekonnen& Hoekstra 2011).

100 80

%

60 40 20

Internal

External

Tunisia

Morocco

Algeria

Syria

Bosnia

Jordan

Israel

Portugal

Spain

Lebanon

Libya

Croatia

Palestine

Turkey

Greece

Egypt

Malta

Cyprus

Italy

France

Albania

Slovenia

Macedonia

Serbia

0

Total

Fig. 1. Water footprint of agricultural products consumption Source: Authors‟ elaboration based on data from Mekonnen& Hoekstra 2011.

Mekonnen and Hoekstra (2011) also evaluated the virtual water balance in the period from 1995 to 2005 based on an assessment of virtual-water flows related to trade in crop, animal and industrial products. Only Tunisia, Syria and Serbia present a negative total net virtual water balance.

The other Mediterranean countries have a positive net virtual water balance. This is due to the fact that most of Mediterranean countries are not self-sufficient for many products so they import them thus import also virtual water. The other Mediterranean countries show water savings


ranging from 340 Mm3 to 62,157 Mm3, in Macedonia and Italy, respectively. This can be explained by the fact that the production of agricultural/industrial goods is very water efficient in NMC as compared to the other SEMC countries i.e. virtual water contents of goods are relatively lower. The development of the Mediterranean region cannot be “sustainable” unless basic common goods are protected and enhanced. Priority has to be given to the protection of the sea, the coast, the climate and air quality, water resources, soil and biodiversity, traditional knowledge of nature, the cultural and landscape heritage, together with the reduction of exposure to natural hazards, such as floods, fires, droughts, earthquakes and tsunamis. It is vital to break the links that make economic development dependent on an intensive exploitation of natural resources. Therefore, it is of paramount importance to promote change in consumption and production patterns. The management of water, energy, soil and coastal area resources must be improved, and the growth in waste generation and pollutant emissions reduced (UNEP/MAP 2005). Food losses and waste are undermining the sustainability of the current Mediterranean food consumption patterns. In the Near East region, it is estimated that 10-15% of non-perishables (e.g. grains) and up to 60% of perishables are lost during the whole production chain. In addition, post-cooking losses are also significant. Total losses in wheat in Egypt, from harvesting until baking, are estimated at 13%-15%. Losses that occur in the rice supply chain are about 25%. Estimated losses at the farmer's and merchant's level ranges from 4-10% for grain and pulses (FAO/RNE2011). In Italy, some 20 million tonnes of food waste are formed every year throughout the supply chain. Every French citizen throws away 7 kg of food every year that is still in the original package (ADEME 2010). Wasting food means losing not only life-supporting nutrition but also precious resources, including land, water and energy (Institution of Mechanical Engineers-UK 2013). Food loss and wastage amount to major squandering of resources, including water, land, energy, labour and capital, and needlessly produce greenhouse gas emissions. Transitioning to more sustainable diets and minimizing waste can also reduce demand for water; a 50%decrease in food losses and waste at the global level would save 1,350 km3 a year (FAO 2012a). Reducing waste across the whole food system will increase the amount of food available for human consumption for the given level of inputs, thereby improving input use efficiency (Ingram 2011). Food consumption patterns and diets affect various sustainability dimensions in the Mediterranean area (Lacirignola& Capone 2009, 2010). They also impact food and nutrition security of the Mediterranean population. Food system sustainability and food security are strongly linked. Variables that are the mainspring of food security in the Mediterranean region are numerous and their prioritisation depends very much on context. While purchasing power, lifestyles and eating habits are recurrent problems throughout the region, production and logistic conditions are problems

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more specific to the Northern Mediterranean, whereas cultural models and consumer and producer education are the main difficulties in the South. The main food security variables identified by Padilla (2008) are population pressure, poverty, structural inadequacies in the production sector, distribution systems, government policy options, ability to compensate for inadequate food supplies, and civil security and political stability. One of the most important challenges faced especially by Southern and Eastern Mediterranean countries is food and nutrition security (FAO/RNE 2011). The Middle East and North Africa (MENA) region faces a number of very distinct food security challenges. The region is the most food import dependent region in the world, the population is projected to double by 2050, unemployment, poverty and malnutrition levels are high (IFPRI 2010). The food imbalance in Southern and Eastern Mediterranean Countries (SEMC) is obvious and all foresight analyses converge towards a worsening of food shortages. According to Agrimonde, the MENA region is at risk of experiencing a critical situation in 2050. In 2003, the gap between local resources and consumption reached 35 %. In 2050, this gap would be reaching nearly 60%, which would make the region the most vulnerable in the world in terms of food security (Rastoin&Cheriet 2010). Many of those consumers classed as being in extreme poverty spend nearly 70% of their incomes on food (Rajiv 2010). Cereals, especially wheat, prices increase can have dramatic impacts on southern and eastern Mediterranean consumers. In North Africa and Middle East, cereals per capita consumption is significant (265 kg/year in Egypt; 246 in Morocco; 238 in Libya; 230 in Algeria; 228 in Tunisia) and the ratio of imports to total cereal consumption is high (87% in Libya; 55% in Tunisia; 49% in Algeria; 36% in Egypt; 35% in Morocco) (FAO 2011). FAO data show that the Cereal price index increased more than the Food price index while Meat price index increase was lower in the period 2000-2012. Economic analyses have shown that diets with a lower energy density - i.e. calories provided by whole grains and fresh produce - tend to be associated with higher food costs than calories from refined grains, added sugars, and added fats (Rolls et al. 2005). Food and nutrition security in the MENA region today is not so much a problem of calories, but of lacking vitamins and other micronutrients (CIDOB 2012). In most Mediterranean countries, food security seems assured for now in quantitative terms, as less than 5% of the population is in a chronic malnourished state (in terms of energy intake), although this apparent security relies on imports. According to FAO, criteria based mainly on a serving‟s calorie content, Mediterranean countries are not in critical condition nowadays. Indeed, less than 5% of the population in these countries is below 2400 kcal/day/person (Rastoin&Cheriet 2010). However, the countries in the eastern and southern Mediterranean are only just overcoming food insecurity or still have pockets where the food situation is precarious (Padilla et al. 2005). Diets in SEMC are unbalanced, with the co-existence of

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micronutrient deficiencies and the massive emergence of dietand lifestyle-related chronic diseases (cardiovascular and respiratory diseases, cancers and diabetes). The human, social and economic costs of this epidemic are enormous and could hinder the region‟s economic growth. Hunger and undernourishment have significant economic costs, including reduced lifetime productivity and earnings and unsustainable resource use (FAO 2012a). Experts agree that the effects of poor nutrition are life-long, intergenerational and irreversible; they include reduced life expectancy, impaired cognitive development, impaired immunity, and increased maternal and child mortality (Shekar& Lee 2006; Asian Development Bank 2004). Attention to nutrition is critical for ensuring the development of human capital and enabling current and future generations to attain their full physical and cognitive potential (UN-HLTF 2012). The main issue of food and nutrition security in Southern and Eastern Mediterranean Countries (SEMC) is undoubtedly a public health issue. The drift in the food consumption pattern caused by the globalization of agro-industrial products that are too high in empty calories causes a slow emergence of true pandemic potentially very costly in human, social and economic terms (Rastoin&Cheriet 2010). With a limited and fragile natural resource base, high population growth and an increasing demand for food, the Near East and North Africa region is structurally unable to feed itself. In addition, both the prevalence of high poverty rates in some countries and inadequate food consumption patterns are major causes of food insecurity and malnutrition. The Region has wealthy but food-deficit countries as well as poor countries with higher levels of food production, which make the food security challenges of this region somewhat unique (FAO/RNE 2011). The uprisings or revolutions in some SEMC have shown the vulnerability of these countries in terms of food security. They have highlighted the limits of sectoral approaches used in the past to manage interdependent issues connected to food security (Hassan-Wassef 2012). Food security – including food availability, food affordability and food quality and safety - is still a challenge in many Mediterranean countries especially southern and eastern ones (Table 1). In the final declaration of their 9th meeting - held in Malta on September 27, 2012 - the Mediterranean Agriculture ministers underlined “…the role of the Mediterranean diet as a driver of sustainable food systems within the strategies of regional development and on that of traditional local products, since quantitative food security must also be complemented by qualitative approaches” (CIHEAM 2012). The sustainability of the Mediterranean food systems is under a pressing threat as was highlighted in the Mediterranean Strategy on Sustainable Development (MSSD). As a matter of fact, in the MSSD was forecasted a threat to Mediterranean food systems as well as a decline of the Mediterranean‟s healthy diet patterns:“…Mediterranean agricultural and rural models, which are at the origins of Mediterranean

identity, are under increasing threat from the predominance of imported consumption patterns. This trend is illustrated in particular by the decline of the Mediterranean dietary model despite the recognized positive effects on health. The prospective scenario for the expected impacts of trade liberalization, climate change and the lack of efficient rural policies offers a gloomy picture in some southern and eastern Mediterranean countries, with the prospect of aggravated regional imbalances, deeper ecological degradation and persistent or accrued social instability.” (UNEP/MAP 2005). Table 1. Global Food Security Index in selected Mediterranean countries. Global Food Security Index1 2012 (Source: The Economist 2012); Best score is 100. Countries

Quality &

Overall Score

Affordability

Availability

Algeria

40.1

38.2

39.1

47.6

72

Egypt

50.4

38.1

59.8

55.3

52

France

86.4

83.4

88.5

88.2

4

Greece

78.7

75.2

80.3

82.9

18

Israel

77.1

79.1

71.1

88.5

21

Italy

78.5

81.5

73.3

85.3

19

Jordan

49.8

51.8

49.0

47.1

49

Morocco

49.1

49.5

47.5

52.6

57

Serbia

56.8

58.8

51.4

66.3

49

Portugal

80.4

76.9

81.2

86.5

14

Spain

80.3

81.0

77.6

86.0

16

Syria

40.9

33.6

44.9

47.9

70

Tunisia

52.2

52.0

48.6

63.0

49

Turkey

62.2

55.6

66.6

66.2

33

Rank/105

safety

In the Mediterranean, there is a growing awareness of the social, cultural, health and economic dimension of „food‟, shared by all Mediterranean people. The ancient Greek word “diaita” means equilibrium, lifestyle. Therefore, the traditional Mediterranean diet is more than just a diet; it is a whole lifestyle pattern with physical activity playing an important role (Dernini 2011). In 2010, the Mediterranean diet as a “lifestyle” was inscribed on the UNESCO List of Intangible Cultural Heritage (Box 2). Its purpose was to create a critical mass of awareness, expertise, resources and political goodwill necessary for the development of joint activities to reduce the increasingly rapid erosion of the Mediterranean diet. This can be achieved by increasing public understanding and awareness on the 1

The Global Food Security Index elaborated by The Economist, considers the core issues of affordability,availability, quality and safety across a set of 105 countries.The index is a dynamic quantitative and qualitative benchmarking model, constructed from 25 unique indicators.


sustainable benefits of the Mediterranean Diet, with particular regards to its health, social, cultural and economic dimensions (Dernini 2008). The “Mediterranean diet”, equivalent to “Mediterranean food cultures”, is the ensemble of practices, representations, expressions, knowledge, skills, spaces and associated objects that people of the Mediterranean have built, and historically recreated, in interaction with nature. The Mediterranean diet expresses the intimate relationship between the population and nature (Dernini 2011; FMFC 2005). The health benefits of the Mediterranean Diet are well known by the scientific community, since the pioneer Seven Countries Study, conducted by Ancel Keys, established the association of a traditional Mediterranean dietary pattern with a markedly reduced incidence of coronary heart disease mortality (Keys 1970, 1980; Keys & Keys 1975). On the basis of this initial knowledge, scientists constructed dietary scores of adherence to the traditional Mediterranean Diet by indexing positively those beneficial foods which are mostly consumed in traditional Mediterranean diets and negatively the foods less consumed and more typical of the western industrialized world (Issaet al. 2011; Bach et al. 2006; Gerber 2006; Serra-Majemet al. 2004, 2006; Fidanzaet al. 2004; Sánchez-Villegas et al. 2003; Menotti et al. 1999; Trichopoulouet al. 1995). Indeed, numerous more recent studies confirmed that good adherence to the traditional Mediterranean Diet is systematically associated with a markedly reduced risk of cardio - vascular events and mortality (Trichopoulouet al. 2003, 2005 and 2009; Martí nez- González et al. 2002, 2009; Estruchet al. 2006, 2013; Buckland et al.2008, 2009; Mendez et al. 2006; Panagiotakoset al. 2006; SánchezVillegas et al. 2006; Zazpeet al. 2011); with a lower incidence of the metabolic syndrome (Tortosaet al. 2007; Babioet al. 2009; Kastoriniet al. 2011; Kesse-Guyotet al. 2012) and of type 2 diabetes (Martí nez-González et al. 2008). Data from a series of case-control studies showed in general that high intake of foods typical of the traditional Mediterranean dietary pattern – i.e. fruit, vegetables, whole grains, olive oil and fish – were associated with a reduced risk of developing various types of cancers (La Vecchia 2004; Bosettiet al. 2009; Verneleet al. 2010). Mediterranean traditional foods are interesting sources for a wide diversity of micronutrients (Amiot 2011) allowing a good coverage of nutrient requirements (Serra-Majemet al. 2009; Maillot et al. 2011). Many studies provided a strong evidence for a beneficial effect of higher conformity with the Mediterranean dietary pattern (Bach-Faiget al. 2011; Naska 2003). The loss of agricultural diversity occurring around the Mediterranean basin is having negative repercussions on the food security and livelihood of populations living in the region. An exacerbation of the genetic erosion of agro-biodiversity due to globalization trends and climate change is reducing the sustainability of local production systems and the ability to safeguard the Mediterranean Diet at the local level through the continued use of indigenous species and varieties (FMFC 2010).

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The Mediterranean-type diet has also been analyzed for its low environmental impacts (Gussow 1995; Duchin 2005; Baroniet al. 2007; EC/JRC 2009; Barilla Center for Food and Nutrition 2010; Sáez Almendroset al. 2012). Mediterranean diets promote biodiversity use, conservation and sustainable natural resources management. They are more respectful of ecosystems and have lower environmental impacts than Northern Europe and American diets (Capone et al. 2012b, 2012c). Mediterranean food consumption patterns promote the use of a wide range of cereals, fruit and vegetables, not only cultivated products but also spontaneous and wild species, thus enabling them to be conserved along with the local, indigenous and traditional knowledge relating to these species. Moreover, by using less meat and fewer animal products, Mediterranean diets reduce the impacts of the livestock sector on biodiversity and natural resources (Capone et al. 2012b). A dialogue process was started in 2009 by the Forum on Mediterranean Food Cultures and the Mediterranean Diet Foundation for gathering among the international Mediterranean diet scientific community a consensus position on a new updated and unpatented Mediterranean pyramid with no copyright. As outcome of this process a new revised Mediterranean diet pyramid was developed as a new pictorial representation and a simple mainframe able to adapt itself to the current needs of the Mediterranean people, with respect to the different local specific variants of the Mediterranean diet related to the geographical, socio-economic and cultural Mediterranean contexts (Figure 2). The concepts of seasonality, of local products, of variety of colours for fruits and vegetables were introduced together with frugality, main meals, conviviality and physical activity. The Mediterranean diet (MD), based on a variety of local foods, strictly linked to the Mediterranean environment, was presented as a resource in biodiversity and nutrition toward global food security and sustainable development as well as an intangible cultural heritage to be safeguarded and enhanced (Bach-Faig et al. 2011; Dernini et al. 2012). The diversity of Mediterranean food cultures is presently at risk of extinction because of the standardization of life styles, of the loss of consciousness, meaning and appreciation. All this brings about the deterioration of the Mediterranean heritage and the loss of interest of new generations towards their own heritage (Dernini 2011). The MD is a varied diet that needs a correspondent variety in the food production, which could be considered a contribution to the preservation of the ecosystem biodiversity. The Mediterranean diet, recognized as being one of the healthiest diets in the world, through the variety of its food cultural heritage, is still little known from the point of view of the biodiversity and nutritional well-being associated to it (Burlingame &Dernini 2011). Biodiversity is one out of the three pillars that hold firm the new revised pyramid of Mediterranean diet. It is intimately linked and highly complementary to the other two pillars – cultural diversity and environmental diversity. Owing to its great spontaneous and domesticated diversity, the

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Mediterranean region has always provided indigenous populations with an array of food species that allowed them to develop local food systems nutritionally adequate, healthy as well as attractive for the diversity of tastes, flavours and cul-

tural appeal related to century-old traditions (FMFC 2010).

Fig. 2. The new Mediterranean diet pyramid (Source: Bach-Faig et al. 2011) Following the inscription of the Mediterranean diet in the UNESCO‟s List of Intangible Cultural Heritage of Humanity, the new revised Mediterranean pyramid aimed at better popularizing the concept, and especially its applicability for present daily lifestyle to counteract the current dramatic decline of the healthy Mediterranean diet pattern all around the Mediterranean area (Bach-Faig et al. 2011, Dernini et al. 2012). The SEMC are faced with a shocking paradox. The Cretan way of life and its food model, developed in past times based on specifically Mediterranean agricultural products offer exceptional virtues, especially from a health point of view. However, eating patterns in the Mediterranean are moving away from this traditional model. Population growth and increase in people‟s living standards have induced substantial changes in eating habits (lower consumption of vegetable products, and increased consumption of meat, dairy products and processed food). These changes have undeniable impacts on the agricultural and food systems (CIHEAM 2008a). The Mediterranean area in general and SEMC in particular are passing through a “nutrition transition” in which malnutrition problems (protein–energy under-nutrition and micronutrient deficiencies) coexist with over-nutrition problems (overweight, obesity), and food-related chronic non-communicable diseases. This nutrition transition is alarming as it has negative impacts not only on health systems but also dramatic economic, social and environmental implications. These interdisciplinary issues are interdependent or related, directly or indirectly, to the sustainability of Mediterranean food consumption patterns especially the decrease of adherence to the traditional Mediterranean diet (WHO/EM 2010).

Many developing countries are undergoing diet transitions bringing them closer to the diets prevalent in the richer countries, i.e. with more energy-dense foods. There follows an increase in the incidence of diet-related non-communicable diseases, which are superimposed on the health problems related to undernutrition that still afflict them. Wider adoption of food consumption patterns akin to those of the Mediterranean diet hold promise of contributing to mitigate adverse effects of diet transitions (Alexandratos 2006). Despite its well documented benefits there is a decline in adherence to the Mediterranean dietary pattern in the Mediterranean region (IOTF 2005; Garcia-Closas et al. 2006; Belahsen&Rguibi 2006; da Silva et al. 2009; Vareiro et al. 2009; Lairon 2010; Sofi et al. 2008). The evolution of food consumption in the Mediterranean countries is not encouraging, as these countries have followed the trend towards higher shares of energy-dense foods (Alexandratos 2006). Paradoxically, just as the Mediterranean diet is becoming more popular in the world and increasingly recognised by the international scientific community, the Mediterranean populations are moving further and further away from this dietary model (Lacirignola& Capone 2009). There are many causes (Lacirignola& Capone 2009): the feminization of the economic life; smaller families and household members leaving home; compulsory education and training by a collective taste; overall decline of traditional products in the South, not due to apathy but to fewer occasions for consumption; renewed interest in the North; and the emergence of supermarkets and "modern" foods in the shops in the South. Malnutrition remains a major health problem in the Eastern Mediterranean with consequences that are too grave to be ignored. It is the single biggest contributor to child mortality


(WHO/EM 2010). Obesity and overweight are becoming a new challenge not only in the northern Mediterranean countries but also southern and eastern ones. The prevalence of overweight and obesity has reached alarming rates in the Eastern Mediterranean (Hossain et al. 2007; Sibai et al. 2003; Jabre et al. 2005; Chakar&Salameh 2006). In the Eastern Mediterranean, it is estimated that non-communicable diseases accounted for 52% of all deaths in 2005. Among the population aged 20 years and older, the prevalence of diabetes is reported to be 11%, hypertension 26%, dyslipidemia 50%, overweight and obesity 65% and physical inactivity 77% (WHO 2010). This rise in non-communicable diseases is

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paralleled by a rise in the direct cost of health care resources needed for disease management. Indirect costs and the intangible costs are even greater (WHO/EM 2010). Data for adults show high levels of overweight in many Arab countries including Egypt (WHO 2010). Data indicate a much higher prevalence of obesity among adult women whereas overweight is more marked among adult men (WHO/EM 2010). High prevalence of obesity in women has been reported in many Eastern Mediterranean countries (El Ayachi et al. 2005; Ghannem&Fredj 1997; Galal 2002). According to WHO (2011), overweight and obesity rates in Mediterranean countries are high and continue to rise (Table 2).

Table 2. Obesity, overweight and malnutrition (undernourishment) in selected Mediterranean and Balkan countries. Countries

Overweight 2011 (%) (WHO 2011)

Obesity 2011 (%) (WHO 2011)

54.4 45.5 67.9 60.7 57.7 64.1 61.8 61.9 54.0 46.8 58.6 61.2 53.7 61.9

21.3 16.0 33.1 26.5 24.2 30.0 27.4 27.8 21.1 16.4 24.8 27.1 22.3 27.8

Albania Algeria Egypt Bosnia and Herzegovina Croatia Jordan Lebanon Libya Macedonia Morocco Serbia Syria Tunisia Turkey

Generally speaking, it can be stated that the Mediterranean Diet is being increasingly eroded due to the globalization of life-styles and that loss of awareness and understanding of the problem, together with the younger generations‟ lack of interest is leading to an inevitable erosion of the Mediterranean dietary cultural heritage (Lacirignola& Capone 2009).

Undernourishment 2010-2012 (%) (FAO, WFP & IFAD 2012)