Received: 19 September 2021 Revised: 15 November 2021 Accepted: 30 November 2021

DOI: 10.1111/obr.13412

NUTRITION/PUBLIC HEALTH

The nutrition transition, food retail transformations, and policy

responses to overnutrition in the East Asia region: A
descriptive review

Oliver Huse1 | Erica Reeve1 | Phillip Baker2 | Daniel Hunt3 | Colin Bell1 |
Anna Peeters4 | Kathryn Backholer1

1
Global Obesity Centre, Institute for Health
Transformation. Faculty of Health, Deakin Summary
University, Geelong, Australia Background: The East Asia region is facing an increasing burden of overweight,
2
Institute for Physical Activity and Nutrition.
obesity and related noncommunicable diseases, resulting from an ongoing nutrition
Faculty of Health, Deakin University, Geelong,
Australia transition. This study aimed to document the growing burden of overweight and
3
Independent Researcher and Freelance Public obesity, and the accompanying dietary shifts, in the East Asia region and describe the
Health Consultant, Bath, UK
4
policy responses to this.
Institute for Health Transformation, Faculty
of Health, Deakin University, Geelong, Methods: We present noncommunicable disease risk factor collaboration data on
Australia
trends in the burden of malnutrition, and Euromonitor International data on trends in
Correspondence dietary purchases, in the East Asia region. We searched the NOURISHING and GINA
Oliver Huse, Global Obesity Centre, Institute
databases to identify food and nutrition policies implemented in these countries.
for Health Transformation, Faculty of Health,
Deakin University, Geelong, Victoria, Australia. Results: There is an ongoing nutrition transition in the East Asia region, notably in
Email: oliver.huse@deakin.edu.au
upper-middle and lower-middle income countries. The prevalence of overweight,
Funding information obesity, and accompanying health conditions, purchases of ultra-processed foods
Australian Government, Grant/Award Number:
and beverages, and purchasing from supermarkets, fast-food and takeaway outlets,
Research Training Program scholarship
and other convenience retailers, are increasing. The policy response to this nutrition
transition is limited, with the majority of policies implemented in higher-income
countries.
Conclusions: East Asian countries are facing a growing burden of malnutrition, due in
part to the dietary shifts occurring here. An ecological approach to policy interven-
tion is needed to drive transformative food systems change.

KEYWORDS
East Asia, nutrition policy, nutrition transition, overweight and obesity

1 | I N T RO DU CT I O N Between 1990 and 2013, the prevalence of overweight and obesity in

The global burden of obesity has nearly tripled since 1975, as intakes
of unhealthy foods and beverages have increased and resulted in an
energy imbalance between calories consumed and calories expended.1
When compared with other regions, Asian countries have experienced
historically low rates of overweight, obesity and diet-related non-
communicable diseases (NCDs). However, rates are now rapidly
increasing with serious implications for sustainable development.2–9
the Asia-pacific region increased from 34.6% to 40.9% (an increase of
18.3%), and it is estimated that the absolute numbers of people living
with overweight in the East Asia region is now around 1 billion
adults.10 Consequently, Asian countries have an increasing burden of
type 2 diabetes,7,11–14 liver disease,7,8 cardiovascular disease
(CVD),6,7,12–14 and other NCDs associated with unhealthy diets.7,13,14
For example, the pooled prevalence of liver disease across Asian
countries was estimated to be 27.4% in 2014,8 while the prevalence

Obesity Reviews. 2022;23:e13412. wileyonlinelibrary.com/journal/obr © 2022 World Obesity Federation 1 of 20

https://doi.org/10.1111/obr.13412
2 of 20
of diabetes has been predicted to increase by 68% in China, 59% in
India, and 41% across other Asian countries, between 1995 and
15
2025.
Exacerbating this is a predisposition to CVD and diabetes risk
among some Asian populations at a lower BMI relative to other
populations.7,11,16 Moreover, in Asia these conditions now coexist
9,17 9,18,19
with persistent undernutrition, particularly in children. Fur-
thermore, undernutrition, overweight and obesity are inextricably
linked, whereby fetuses of underweight mothers are exposed to a
low-nutrient environment in-utero, which may drive increased energy
13,16,20
storage and decreased metabolism, placing them at higher risk
for weight gain across the life cycle. Evidence suggests that consump-
tion of energy-dense, nutrient-deficient ultra-processed foods and
beverages is replacing consumption of nutrient-rich whole foods and
minimally-processed foods in infants and young children, further con-
21
tributing to stunting.
There are many conceptualizations of what comprises a healthy
or unhealthy diet. The NOVA classification22 is one such conceptuali-
zation that differentiates foods by the purpose and degree of
processing. This recognizes that healthy diets are typically those com-
prising largely un-/minimally-processed foods (such as fresh fruits
and vegetables and fresh meat and seafood), often combined with
processed culinary ingredients (such as pure salt, sugar and oils) and
limited amounts of processed foods (such as canned vegetables and
traditional breads), to prepare culturally appropriate meals and dishes.
A key indicator of unhealthy diets is the consumption of ultra-
processed foods (such as soft drinks, packaged snacks and many meat
products). Ultra-processed foods and beverages are formulations of
cheap industrial sources of dietary energy, nutrients and additives,
using a series of processes. They typically contain little-to-no whole
foods, are sold in a ready-to-consume or heat-up state, are high in
fat, salt and/or sugar, and are low in fiber, protein, and micro-
22
nutrients. Strong evidence links the consumption of these products
with higher risks of all-cause mortality, obesity, cardio-metabolic
23–27
diseases, cancer, gastro-intestinal disorders, and depression.
Henceforth, when we refer to an unhealthy diet, we are referring to
one in which ultra-processed foods and beverages make a dispropor-
tionate contribution to total energy intake. While no specific cut-offs
22
are provided by the NOVA classification system, it is generally
accepted that any intake of ultra-processed foods and beverages is
unhealthy, and such food and beverage products do not constitute
part of a healthy diet.23–27
In what is frequently called a nutrition transition, the rising rates
of overweight, obesity and NCDs reflect dietary changes, including
increased consumption of animal products, caloric sweeteners, refined
carbohydrates, and vegetable oils,28–31 and more recently by increas-
32–35
ing consumption of ultra-processed foods and beverages. In
Asian countries, the nutrition transition has been characterized by
changes to the broader food system, accompanied by increased
intakes of sugars, salts, fats and animal products.12,31,36,37 Other
changes to Asian diets have included decreased consumption of
traditional foods such as rice and increased consumption of other
wheat and grain products; increased consumption of animal products;
HUSE ET AL.
increased consumption of non-traditional, temperate zone fruits and
vegetables, and; increased consumption of ultra-processed conve-
nience foods and beverages.31,36,37
Recently, scholars have begun paying more attention to the links
between the nutrition transition and food systems change.33,38–41 A
food system is defined as all the elements (such as the environments,
people, institutions, inputs, processes, and infrastructure), and activi-
ties, that relate to the production, processing, distribution, preparation
and consumption of food, and the outputs, including socio-economic
and environmental outcomes, of these activities.42 The nutrition
transition occurring in Asia reflects transformative changes to food
systems, including; a shift from home-production and local wet
markets acting as the primary food outlets in South and Southeast
Asia12,43 to supermarkets and modern convenience stores coming to
the forefront of food and beverage supply-chains12,43–46; technologi-
cal shifts in the food system such as new food transport, storage and
processing technologies47,48; increased domestic production of ultra-
processed convenience food and beverages.36,49 This has occurred
alongside the expansion of transnational food and beverage corpora-
tions throughout the region, primarily through direct investment into
their manufacturing capacities and supply chains, and growing market-
ing and promotional activities.12,32,37,43,50 Key food systems drivers of
the nutrition transition have been identified, including income growth,
urbanization, globalization, and trade liberalization.12–14,37,51 These
food systems drivers have provided economic benefits to Asian
nations but have also led to a rise in NCDs on-top of a persistent
burden from communicable diseases.12,52 Further to this, these drivers
have had ecological impacts on the region and globally, including
increased plastic waste and deforestation.53,54
Important drivers of the nutrition transition include the policies,
regulation, and knowledge frameworks that structure thinking and
action within food systems.55–60 Governments can influence food
environments through a range of mechanisms, including actions
targeting food supplies (production standards and subsidies), food
environments (food and menu labeling requirements, marketing
restrictions, and taxation policies) and communications targeting
behavior change (dietary guidelines, media promotion of a healthier
diet, nutrition education at schools and workplaces).61,62 However,
globally policies aimed at addressing malnutrition are limited in both
scope and strength.33,57,63 An ecological approach to policy interven-
tion, targeting multiple components of food systems simultaneously,
is needed to drive transformative food systems change.33,40,61,64,65
Despite the growing double burden of malnutrition throughout
Asia, and the importance of its food systems drivers, few studies have
drawn on health and market data to systematically describe the
multiple aspects of the ongoing nutrition transition and food systems
transformations happening in Asia. Furthermore, research and policy
interventions in the region have predominantly focused on undernu-
trition and understanding of the full picture of the policy response to
overweight and obesity across the region is incomplete.9,66 This focus
is largely due to the historical persistence of undernutrition, and the
much more recent emergence of overweight and obesity.9,17–19 Stem-
ming the rapidly increasing rates of overweight, obesity and NCDs in
HUSE ET AL. 3 of 20

the East Asia region requires an integrated understanding of the
overarching trends in overweight and obesity, the shifts in the broad
food system and the existing policy actions. Although previous studies
have reported on elements of the nutrition transition across Asia,
these studies are fragmented across the literature. Furthermore, much
of the existing evidence reports on individual diseases, dietary risk
32,44–46,67–69
factors or elements of food system transformations.
While these individual studies are important contributors to the
literature, there are many aspects of the nutrition transition that all
contribute to a broad shift in diet and disease patterns.
Acknowledging the gaps in knowledge identified above, our study
aims to describe the ongoing nutrition transition and associated food
systems transformations occurring in the East Asia region, and
document government responses. We address three objectives. First,
to describe recent trends in the prevalence of overweight, obesity,
type 2 diabetes and raised blood pressure among both adults and
children, across Asian nations within the East Asia region. Second, to
describe recent trends in ultra-processed food and beverage sales,
“core” food sales, and trends in retail distribution channels and food
service sales, in these nations. Third, to identify and describe national
government-led food policy actions aimed at addressing overweight,
obesity, and unhealthy diets, in the East Asia region.
2 | METHODS
We used a descriptive analysis method, combining quantitative data
on the burden of overweight, obesity and related health conditions,
and trends in dietary purchases in East-Asian nations with a semi-
structured audit of policy actions by governments in the region.
per capita as low income countries (LIC; ≤USD1,045), lower-middle
income countries (LMIC; USD1,046 - USD4,095), upper-middle
income countries (UMIC; USD4,096 - USD12,695) and high income
countries (HIC; ≥USD12,696), according to World Bank lending
classifications,71 to align with evidence suggesting that the rate at
which the nutrition transition is occurring is greatest in LICs and
LMICs.29–31,72
2.2 | Quantitative analysis
2.2.1 | Overweight, obesity and non-communicable
disease data sources
We extracted data for trends in overweight, obesity and related
health conditions from the NCD Risk Factor Collaboration (NCD-
RisC).73 The NCD-RisC data collection and pooling methods are
described extensively elsewhere.74–76 In brief, NCD-RisC is a world-
wide network of health researchers that provides data on NCD risk
factors, such as height, weight, type 2 diabetes, and blood pressure
status, for 200 countries. Data from population surveys are combined
through pooling analyses to produce estimates of NCD risk factors
(including BMI).74,75,77 NCD-RisC data has been drawn from a range
of measured nationally and sub-nationally representative surveys,
repeatedly verified by NCD-RisC members, and subsequently peer
reviewed and published for viewing by a broader academic audi-
ence.74–76,78,79 Table 2 lists the NCD-RisC data that was extracted for
this study.

TABLE 2 NCD RisC included data categories and definitions

2.1 | Included countries Years of data

Data category NCD RisC definition extraction

All East Asian countries were eligible for inclusion in this study Age-standardized Fasting plasma glucose 1998, 2002,
71 prevalence of ≥7.0 mmol/L, or; 2006, 2010,
(Table 1). Countries were grouped by gross national income (GNI)
type 2 diabetes diagnosis with type 2 2014
among adults diabetes, or; use of
(aged ≥18 years) insulin or
hypoglycaemic drugs.
TABLE 1 Included countries by income category
Age-standardized Systolic blood pressure 1998, 2002,
Income category Included countries prevalence of ≥140 mmHg, or; 2006, 2010,
raised blood diastolic blood pressure 2014
Low income North Korea
pressure among ≥90 mmHg
(≤USD1,045)
adults (aged
Lower-middle income Cambodia; Lao People's Democratic ≥18 years)
(USD1,046– Republic (Lao PDR); Mongolia;
Prevalence of Overweight; BMI: 2000, 2004,
USD4,095) Philippines; Viet Nam
overweight and 25 kg/m2 to <30 kg/m2 2008, 2012,
Upper-middle income China; Malaysia obesity among Obesity; BMI: ≥30 kg/m2 2016
(USD4,096– adults (aged
USD12,695) ≥20 years)
High income Brunei Darussalam; Hong Kong (China); Prevalence of Overweight; BMI: 1SD to 2000, 2004,
(≥USD12,696) Japan; Macao; Republic of Korea overweight and 2SD greater than the 2008, 2012,
(South Korea); Singapore obesity among population mean 2016
children (aged Obesity; BMI: >2SD
Note: Country inclusions were decided based on the World Health
≤19 years)
Organization's Western Pacific Region definition.70
4 of 20
2.2.2 | Dietary data sources
The following sources of dietary data were used: sales volumes of
select “core” and “ultra-processed” food and non-alcoholic beverage
products; purchases from grocery retail outlets and; purchases from
food services.
No comparable longitudinal and nationally representative surveys
for comparing intakes of foods and beverages were available. Instead,
as has been done for previous studies,32,33,67 sales volume data for
food (kg per capita) and beverage (L per capita) product categories
of interest were extracted from the Euromonitor International
(Euromonitor) Passport Global Market Information Database, 2019
Edition.80 The Euromonitor database is not a scholarly database and
has some limitations for health research purposes. Sales volume data
does not capture products sold through informal channels; nor does it
capture food wastage (products sold but not consumed).33,81,82
Further, Euromonitor data has not been formally validated (i.e., it has
not been compared to expenditure or survey data), though is validated
33,81,82
through quality checks with in-country experts. However,
Euromonitor has several advantages. Unlike survey data it is not sub-
ject to recall bias and data is consistently reported across all countries
over time using standardized measures.33,81 Euromonitor data has
32,33,39,41,67
been used in many published studies and is a recognized
commercial data source.82
Food and beverage categories of interest are shown in
Appendix S1. Food groups were derived from the literature on the
12,31,36,37
nutrition transition in this region. Data were extracted for all
food and beverage categories of interest sold through food service
and retail outlets located within relevant countries, for the years
2006, 2010, 2014, 2017, and 2020. Data were also extracted for
trends in grocery retail outlet purchases by type of outlet, and trends
in food service purchases (value of purchases in USD per capita), to
assess the shift in food distribution from traditional to modern
retail outlets.
For the world's 80 largest country markets, including China, Hong
Kong (China), Japan, Philippines, Malaysia, Singapore, South Korea,
and Viet Nam, Euromonitor compiles sales volume data from a combi-
nation of sources. These include trade associations; industry bodies;
business press; company filings; company financial reports, and; offi-
cial government statistics. Data are then validated by individuals
working within the food industry.80 For the remaining 130 countries,
including Cambodia, Lao PDR, Mongolia, Brunei Darussalam, and
80
Macao, only modeled data are available. Due to the reduced reliabil-
ity of this data, and inability to directly compare modeled data with
actual data, we did not report on any dietary, retail or food service
data for these latter countries.
Food and beverage categories were broadly based on the NOVA
classification system.22 For this study, we combined “unprocessed or
minimally processed foods” and “processed foods” into a category we
describe as “core” foods. We chose to present ultra-processed foods
(UPFs) and ultra-processed beverages (UPBs) as two distinct food
groups (rather than breaking them down further into sub-categories)
to reflect the evidence that UPFs and UPBs increase the risk of a
HUSE ET AL.
range of non-communicable disease and are collectively targets for
policy actions.23–27
Grocery retail outlets were classified as “traditional” (non-chained
grocery outlets, including small businesses and specialist stores) or
“modern” (grocery retailers that have emerged alongside the growth of
chained retail, specifically; Convenience stores; Hypermarkets; Super-
markets; Discounters, and; Forecourt retailers).80 Food service outlets
were classified as “full service restaurants” (all sit-down restaurants
where the focus is on food over beverages), limited service restaurants
(fast-food and takeaway outlets), self-service cafeterias (outlets with
no or minimal service), cafes/bars (all outlets where the focus is on
beverages over food) and street stalls/kiosks (small, sometimes mobile,
foodservice providers characterized by a limited product offering).80
2.2.3 | Analysis
Analysis of quantitative data was descriptive and is presented as per
capita trends over time. Data is presented for each country where data
was available, and countries were grouped by per capita GNI (as LIC,
LMICs, UMICs, and HICs), as defined by the World Bank lending clas-
sifications.71 GNI was selected as a classifying variable as, while it is
not an ideal measure of development, it has been closely linked with a
range of standard of life indicators, is likely to predict known drivers of
the nutrition transition, including purchasing power, trade and urbani-
zation, and is accurate to measure and easy to interpret.83,84
Outcome variables were selected based on data availability, and
to broadly capture changes in diets and food systems that contribute
to the nutrition transition in East Asia, as identified in the existing
literature.12,31,36,37,43–46 Trends are presented in order of proximal to
distal impacts on human health (i.e., NCD outcomes are presented
first, followed by overweight and obesity, dietary trends and then
changes to retail and foodservice). All data presentation was
conducted using the ggplot285 add-in for R software environment for
statistical computing and graphics.86
2.3 | Semi-structured policy audit
We used a range of global and country-specific data sources to
identify and describe national government-led food policy actions
aimed at addressing overweight, obesity, and unhealthy diets.
2.3.1 | Search strategy
National Government-led policy responses to overweight, obesity and
unhealthy diets in East Asian countries were identified by searching
the World Cancer Research Fund's NOURISHING database, and
the World Health Organization's (WHO) Global database on the
Implementation of Nutrition Action (GINA).87,88 The NOURISHING
database details food and nutrition policy actions implemented on a
national level.87 The database is updated by policy analysts who
HUSE ET AL.
surveil media, NCD documents, policy sources, and conduct proactive
regional scans.89 GINA is a global platform for sharing standardized
88
information on adopted nutrition policies. GINA data is compiled by
self-reporting from those involved in the policy implementation
process, and WHO global policy reviews and monitoring. While the
self-report nature of GINA is a limitation of this data source, its rele-
90
vance for mapping nutrition policies has been previously described.
To account for GINA data being self-reported, policies were further
verified through a supplementary search for official government docu-
ments related to each policy. A policy that was originally identified
through GINA was only included if it could be verified through the
existence of such official documentation. This strategy search was
supported by a semi-structured search of relevant government
websites, databases and legislation, academic literature, gray litera-
ture, media articles, and any engagement with the WHO's Health
Promoting Schools framework.91 The purpose of this semi-structured
supporting search was two-fold: (1) to provide additional data on
policies identified through NOURISHING and GINA, and (2) to
identify any additional policies that may not have been identified
through NOURISHING or GINA. The search was further verified for
all countries against the WHO's Noncommunicable Diseases Progress
Monitor 2020.92
The search was structured to specifically identify policies that
have been recommended by international authoritative health bodies
as necessary to address overweight, obesity and unhealthy diets
among children and/or adults.93–97 Policies that were eligible for
inclusion were (i) unhealthy food and beverage marketing restrictions;
(ii) fiscal food policies; (iii) front of pack labelling (FOPL) policies;
(iv) policies addressing school food environments; and (v) mass media
and communication campaigns. Policies were included if they were
adopted or in place over the last 20 years (to focus on recent policy
action developments).
2.3.2 | Analysis of policy documents
For each included policy, the country of adoption, policy name, year
of implementation, final year of policy (if redacted), a brief description
of the policy, whether the policy was mandatory or voluntary
(if relevant), and whether a formal evaluation of the policy had been
conducted. When a formal evaluation of a policy had been conducted,
we also included a brief summary of the findings. Policy actions were
grouped by country. Results from this policy audit are presented
through a narrative synthesis.
3 | RESULTS
Here we describe the ongoing nutrition transition in East Asian
countries. The results are structured as followed. First, we describe
trends in the prevalence of type 2 diabetes and raised blood pressure,
followed by trends in the prevalence of overweight and obesity.
We then present food and beverage, and food outlet purchasing
5 of 20
trends. Finally, we present the results of an audit of policies intro-
duced in this region to address overweight, obesity and unhealthy
diets.
3.1 | Quantitative analysis
3.1.1 | Burden of overweight, obesity and diet-
related non-communicable diseases
Between the years 1998 and 2014, the prevalence of type 2 diabetes
declined or remained relatively stable in all included HICs (Figure 1). In
HICs, the prevalence of type 2 diabetes tended to increase among
men but decrease among women. The prevalence of type 2 diabetes
increased in all included UMICs and LMICs over the same period. This
increase in UMICs and LMICs ranged from 0.5%-point increase in type
2 diabetes prevalence among women in Vietnam (LMIC) to a
4.3%-point increase in type 2 diabetes prevalence among men in
Mongolia (LMIC). among LICs (North Korea), the prevalence of type
2 diabetes was at a similar level to UMICs and LMICs in 1998 but
remained stable to 2014.
The prevalence of raised blood pressure among men and women
in HICs declined between the years 1998 to 2014 (Figure 2). Relative
to these HICs, the prevalence of raised blood pressure among men
and women in UMICs and LMICs tended to exhibit a more stable
trend over the same time period and as a result was greater in more
recent years. For example, in Lao PDR (LMIC) the prevalence of raised
blood pressure was 25% among men and women in both 1998 in
2014. In China (UMIC) the prevalence of raised blood pressure was
22% among men and 19% among women in 1998 and 22% among
men and 17% among women in 2014. In contrast, in Brunei
Darussalam (HIC) the prevalence of raised blood pressure was 28%
among men and 20% among women in 1998 and 22% among men
and 16% among women in 2014. among LICs (North Korea), the
prevalence of raised blood pressure was at a similar level to UMICs
and LMICs in 1998 but declined slightly to 2014.
Figure 3 shows the prevalence of overweight and obesity
between 2000 and 2016 among adults aged ≥20 years in East Asian
countries. The combined prevalence of overweight and obesity was
greatest in HICs, followed by UMICs and then LMICs and LICs, with
the exception of Mongolia (LMIC), where the prevalence of over-
weight and obesity was highest of all included countries. All countries
showed an upward trend in the prevalence of overweight and obesity
combined, though this upward trend was far steeper for UMICs and
LMICs. This is exemplified in Viet Nam (LMIC) and Malaysia (UMIC)
where from 2000 to 2016 the prevalence of overweight and obesity
combined increased by 105% (from a combined prevalence of 8.0% to
16.4%) among men and 67% (12.7% to 21.3%) among women in Viet
Nam and 70% among men (25.5% to 43.4%) and 42% (31.2% to
44.4%) among women in Malaysia. Conversely, the prevalence of
overweight and obesity combined increased by 26% (37.3% to 47.2%)
among men and 7% (35.6% to 38%) among women in Hong Kong
(China) (HIC) over the same period.
6 of 20 HUSE ET AL.

F I G U R E 1 NCD-RisC73 data on the age-standardized prevalence of type 2 diabetes among men and women in East Asian countries. Type
2 diabetes defined as fasting plasma glucose ≥7.0 mmol/L, or diagnosis with type 2 diabetes, or use of insulin or hypoglycaemic drugs. HIC; High
income country, UMIC; Upper-middle income country, LMIC; Lower-middle income country, LIC; Low-income country. BRN; Brunei Darussalam,
KHM; Cambodia, CHN; China, HKG; Hong Kong (China), IDN; Indonesia, JPN; Japan, LAO; Lao PDR, MYS; Malaysia, MNG; Mongolia, PRK;
North Korea, PHL; Philippines, SGP; Singapore, KOR; South Korea, TWN; Taiwan, THA; Thailand, VNM; Viet Nam

F I G U R E 2 NCD-RisC73 data on the age-standardized prevalence of raised blood pressure among men and women in East Asian countries.
Raised blood pressure defined as systolic blood pressure ≥140 mmHg, or diastolic blood pressure ≥90 mmHg. HIC; High income country, UMIC;
Upper-middle income country, LMIC; Lower-middle income country, LIC; Low-income country. BRN; Brunei Darussalam, KHM; Cambodia, CHN;
China, HKG; Hong Kong (China), IDN; Indonesia, JPN; Japan, LAO; Lao PDR, MYS; Malaysia, MNG; Mongolia, PRK; North Korea, PHL;
Philippines, SGP; Singapore, KOR; South Korea, TWN; Taiwan, THA; Thailand, VNM; Viet Nam
HUSE ET AL. 7 of 20

F I G U R E 3 NCD-RisC73 data on the age-standardized prevalence of overweight and obesity among men and women in east Asian countries.
Overweight defined as BMI of 25 to <30 kg/m2. Obesity defined as BMI of ≥30 kg/m2. HIC; HIC; High income country, UMIC; Upper-middle
income country, LMIC; Lower-middle income country, LIC; Low-income country. BRN; Brunei Darussalam, KHM; Cambodia, CHN; China, HKG;
Hong Kong (China), IDN; Indonesia, JPN; Japan, LAO; Lao PDR, MYS; Malaysia, MNG; Mongolia, PRK; North Korea, PHL; Philippines, SGP;
Singapore, KOR; South Korea, TWN; Taiwan, THA; Thailand, VNM; Viet Nam

Figure 4 shows the prevalence of overweight and obesity
between 2000 and 2016 among children aged ≤19 years in East Asian
countries. All included UMICs and LMICs show an upward trend in
the prevalence of both overweight and obesity for boys and girls.
among HICs, Brunei Darussalam, Hong Kong (China), Taiwan, and
South Korea show an upward trend in the prevalence of overweight
and obesity among children, while Singapore and South Korea show a
stable trend. Although the absolute prevalence was low, the upward
trend in the prevalence of overweight and obesity among children is
far steeper in UMICs and LMICs compared to any HICs. For instance,
from 2000 to 2016 the combined prevalence of childhood overweight
and obesity in Cambodia (LMIC) increased by 262% (from a combined
prevalence of 3.7% to 13.6%) among boys and 162% among girls
(3.3% to 8.6%), the combined prevalence of childhood overweight and
obesity in Malaysia (UMIC) increased by 132% (13.0% to 30.2%)
among boys and 106% (11.3% to 23.3%) among girls, and the
combined prevalence of childhood overweight and obesity in
South Korea (HIC) increased by 42% (23.7% to 33.7%) among boys
and 34% (15.8% to 21.2%) among girls. The prevalence of childhood
overweight and obesity was notably high in North Korea (LIC) and
increased between 2000 and 2016.
3.1.2 | Dietary trends
Between the years 2006 and 2020, annual per capita purchase
volumes of core food groups increased in all East Asian countries with
available data (Figure 5). Purchasing of core food groups was highest
in HICs, and China and Malaysia (UMICs), where the per capita
volume of core foods purchased exceeded 300 kg per capita, per
annum, at all included timepoints. The exception to this was Japan,
where purchasing of core food groups did not exceed 275 kg per
capita, per annum at any time point. Purchasing of core food groups
was also lower in Thailand (UMIC) and Indonesia, the Philippines and
Viet Nam (LMICs), though the trend in core food purchasing was
increasing for all four countries (for instance, per capita purchasing of
core foods in Thailand increased by 21% from 2006 to 2020). In all
countries, core food purchasing was driven by high purchasing of fish,
meat and seafood, and fruits and vegetables, while purchasing of rice
(a traditionally staple food) was relatively lower.
Between 2006 and 2020, per capita purchase volume of UPFs
and UPBs increased in all East Asian countries with available data
(Figure 6). Overall, purchasing of UPFs and UPBs was higher in HICs
compared to UMICs and LMICs, with the highest purchase volume
in Japan (278.7 kg per capita in 2020). Purchasing of UPFs and UPBs
was lower in UMICs and LMICs, for example UPF and UPB purchas-
ing in 2020 was 62.9 kg/L per capita in China (UMIC) and
104.9 kg/L per capita in Indonesia (LMIC). The rate of increase for
UPF and UPB purchases was greatest for UMICs and LMICs. For
instance in Indonesia (LMIC), per capita UPF and UPB purchasing
increased by 449% from 2006 to 2020, in China (UMIC) per capita
UPF and UPB purchasing increased by 65%, while in Taiwan (HIC)
per capita UPF and UPB purchasing increased by 9% over the same
period.
8 of 20 HUSE ET AL.

F I G U R E 4 NCD-RisC73 data on the age-standardized prevalence of overweight and obesity among boys and girls in East Asian countries.
Overweight defined as BMI of ≥1SD to ≤2SD than the population mean. Obesity defined as BMI of >2SD than the population mean. HIC; High
income country, UMIC; Upper-middle income country, LMIC; Lower-middle income country, LIC; Low-income country. BRN; Brunei Darussalam,
KHM; Cambodia, CHN; China, HKG; Hong Kong (China), IDN; Indonesia, JPN; Japan, LAO; Lao PDR, MYS; Malaysia, MNG; Mongolia, PRK;
North Korea, PHL; Philippines, SGP; Singapore, KOR; South Korea, TWN; Taiwan, THA; Thailand, VNM; Viet Nam

F I G U R E 5 Euromonitor international data80 on purchasing (kg per capita, per annum) of core foods in East Asian countries. HIC; High income
country, UMIC; Upper-middle income country, LMIC; Lower-middle income country. CHN; China, HKG; Hong Kong (China), IDN; Indonesia, JPN;
Japan, MYS; Malaysia, Philippines, SGP; Singapore, KOR; South Korea, TWN; Taiwan, THA; Thailand, VNM; Viet Nam
HUSE ET AL.
F I G U R E 6 Euromonitor international data80 on purchasing (kg per capita, per annum) of UPFs and UPBs in East Asian countries. HIC; High
income country, UMIC; Upper-middle income country, LMIC; Lower-middle income country. CHN; China, HKG; Hong Kong (China), IDN;
Indonesia, JPN; Japan, MYS; Malaysia, Philippines, SGP; Singapore, KOR; South Korea, TWN; Taiwan, THA; Thailand, VNM; Viet Nam
Figure 7 shows annual per capita expenditure at “modern” com-
pared to “traditional” grocery retailers. Total expenditure at grocery
retails was highest in HICs, where a relatively greater proportion of
grocery purchases were made at modern, relative to traditional, retail
outlets. Within UMICs and LMICs, traditional grocery retailers made
up a larger proportion of total grocery expenditure. For instance, in
2020, traditional grocery retailers made up 54% of all grocery
purchases in Malaysia (UMIC) and 92% of all grocery purchases in
Vietnam (LMIC), compared to 18% of all grocery purchases in
South Korea (HIC). Likewise, the trend in the proportion of all grocery
purchases made at modern retailers was steeper in UMICs and LMICs;
the proportion of all grocery purchases made at modern retailers
climbed from 34% to 46% in Thailand (UMIC) and 9% to 20% in
Indonesia (LMIC) between 2006 to 2020, compared to 51% to 54% in
Taiwan (HIC), over the same period.
Figure 8 shows annual per capita expenditure at consumer
foodservice outlets. Consumer expenditure at foodservice outlets was
greatest in HICs, where expenditure at foodservice outlets was more
than double UMICs and greater again compared to LMICs. All
included countries demonstrated an upward trend in consumer
expenditure at foodservice outlets. This trend was most obvious in
UMICs and LMICs, relative to HICs. For example, in China (UMIC)
consumer expenditure at foodservice outlets increased by 307% from
2006 to 2020, in Vietnam (LMIC) consumer expenditure at
foodservice outlets increased by 230%, while in Hong Kong (China)
(HIC) consumer expenditure at foodservice outlets by 59% over the
same period. For most countries, foodservice expenditure was largely
driven by expenditure at full-service restaurants. However,
9 of 20
expenditure at limited-service restaurants (fast-food and takeaway
outlets) and cafés/bars was also observed to be contributing dispro-
portionately to trends in total foodservice expenditure.
3.2 | Semi-structured policy audit
A total of 40 recommended policies aimed at addressing overweight,
obesity and unhealthy diets in East Asian countries were included.
The full list and description of included policies can be found in
Appendix S2. The number of recommended policies per country
ranged from 7 (Singapore, Thailand) to 0 (Indonesia, Lao PDR,
North Korea, Vietnam). The majority of recommended policies were
adopted in HICs (52.5%; 21 policies), followed by UMICs (32.5%;
13 policies) and LMICs (15%; 6 policies). HICs had adopted an average
of 3.5 recommended policies (range 1–7), UMICs had adopted an
average of 4.3 recommended policies (range 1–7), and LMICs had
adopted an average of 1 recommended policies (range 0–4). Two of
the identified policies were confirmed as either having ended or
having been replaced with an alternative policy prior to 2021, with
the remaining 38 policies ongoing. Here we narratively synthesize the
findings on the 40 recommended policies that have been
implemented across the region.
The most commonly adopted policy related to guidelines for food
and beverage environments within schools (n = 15). In Brunei
Darussalam, Cambodia, Japan, Malaysia, Mongolia, the Philippines,
South Korea, and Taiwan, these school food guidelines are mandatory,
while in Hong Kong (China), Singapore, and Thailand, they are
10 of 20 HUSE ET AL.

F I G U R E 7 Euromonitor international data80 on expenditure (USD per capita, per annum) at grocery retail outlet types in East Asian
countries. HIC; High income country, UMIC; Upper-middle income country, LMIC; Lower-middle income country. CHN; China, HKG; Hong
Kong (China), IDN; Indonesia, JPN; Japan, MYS; Malaysia, Philippines, SGP; Singapore, KOR; South Korea, TWN; Taiwan, THA; Thailand,
VNM; Viet Nam

F I G U R E 8 Euromonitor international data80 on expenditure (USD per capita, per annum) at consumer foodservice outlet types in East Asian
countries. HIC; High income country, UMIC; Upper-middle income country, LMIC; Lower-middle income country. CHN; China, HKG; Hong Kong
(China), IDN; Indonesia, JPN; Japan, MYS; Malaysia, Philippines, SGP; Singapore, KOR; South Korea, TWN; Taiwan, THA; Thailand, VNM;
Viet Nam
HUSE ET AL.
voluntary. Evaluations of school food and nutrition guidelines have
been conducted in Hong Kong (China),98 Japan,99 Malaysia,100
101–103 104
Singapore, and South Korea. In Hong Kong (China),
evaluation of the voluntary EatSmart School Accreditation Scheme
revealed a greater reduction in the prevalence of obesity among
students at participating schools (0.49% annual reduction in
prevalence) compared to non-participating schools (0.31% annual
reduction in prevalence).98
In Japan, students' diet quality was significantly better on school
days when students were consuming food subjected to the School
99
Lunch Act guidelines, compared to non-school days. In Singapore, a
range of specific guidelines are captured under the umbrella of the
Healthy Meals in Schools Programme. School engagement with these
voluntary programs has been high,102 and fruit and vegetable con-
sumption has been shown to increase among students in participating
schools.103 Also in Singapore, the (now replaced) Model Tuckshop
Programme increased accessibility of healthy foods for school stu-
dents, but with no measurable impact on overall food purchases.101 In
South Korea, mandatory restrictions on the sale of sugary drinks
(as part of the 2007 School Meals Act) have been shown to be effec-
tive in reducing sugar sweetened beverage consumption. However
evidence on the impact of the “Green Food Zones” (a ban on the sale
of foods considered to be high-calorie and low nutrition as part of the
Special Act on Children's Dietary Life Safety Management) has rev-
ealed mixed results.104 In Malaysia, despite the mandatory Guide for
Healthy School Canteen Management, schools still overwhelmingly
offer unhealthy foods and beverages—29.1% of pre-packaged foods
and beverages sold in Malaysian schools were classified as “red” (most
unhealthy) products.100
Six countries have introduced FOPL policies to better inform con-
sumers of healthier and less healthy food and beverage options. Of
these six countries, five were HICs (Brunei Darussalam, Singapore,
South Korea) or UMICs (Malaysia, Thailand), with the Philippines as
the only LMIC to adopt such a policy. For all countries except
Thailand, the use of a FOPL on packaged food products is voluntary.
Thailand was the only country to adopt two FOPL policies; a volun-
tary “healthier Choices Logo” to identify healthier options, and a
Guideline Daily Amounts (GDAs) Label which is mandatory on certain
processed foods and communicates the fat, sugar, salt and energy
content of the product. Existing FOPL policies in East Asia do not
meet best-practice guidelines. They are frequently voluntary to imple-
ment and only denote healthier products (i.e., are not warning FOPL).
South Korea was the only country to have adopted a traffic-light
front-of-pack labelling system (albeit voluntary in nature), whereby
healthy and unhealthy foods could be identified. Singapore was the
only country where a FOPL policy (the Healthier Choices Symbol) had
been evaluated.103,105 Consumption of products marked with the
Healthier Choices Symbol has been associated with improved diet
quality,103 and a randomized control trial found that the Healthier
Choices Symbol increased the purchase of marked products by 5%.105
Seven countries, Brunei Darussalam, Malaysia, the Philippines,
Singapore, South Korea, Taiwan, and Thailand, have all introduced
some degree of controls on the marketing of unhealthy foods and
11 of 20
beverages. Brunei Darussalam has voluntary regulations that restrict
unhealthy food and beverage marketing to children across a range of
settings and media. South Korea and Taiwan have mandatory
restrictions on the marketing unhealthy foods and beverages during
children's television programming. Malaysia and Singapore have
similar restrictions, however these are voluntary guidelines. The
Philippines has mandatory restrictions on the marketing of unhealthy
foods and beverages in schools, though marketing is still permitted in
the vicinity of schools. Thailand requires warning messages be
displayed alongside advertisements for unhealthy foods, but this is
limited to specific categories of ready-to-eat food. No country has
met best-practice guidelines for marketing restrictions, with existing
policies either being voluntary to implement and/or failing to consider
the range of media and settings that food and beverage corporations
advertise through. South Korea is the only country where marketing
restrictions had been evaluated.106,107 Mandatory restrictions on
unhealthy food and beverage marketing during children's television
hours resulted in a significant decline in the quantity of targeted food
and beverage marketing,106 and resulted in greater adherence to
other nutrition policies and encouraged product reformulation.107
Five countries have introduced fiscal policies to improve
population diets. Four countries (Brunei Darussalam, Malaysia,
Thailand, and the Philippines) have implemented a tax on sugar sweet-
ened beverages, which for all countries is enacted through mandatory
legislation. In Thailand, beverages with a sugar content of 6 g or more
per 100 ml are subject to varying tax rates (dependent on sugar
content). Evaluation of this tax has revealed a 2.5% reduction in aver-
age purchases of sugar-sweetened beverages, with greater reductions
seen among children aged 6–14 years.108 China has implemented fruit
and vegetable production subsidies, paid to farmers and agricultural
producers. While there are likely to be nutritional benefits to such a
policy, it was implemented as a competitive measure and no
evaluation of the nutrition flow-on effects have been conducted.
Mass communication campaigns to promote healthy diets were
identified in Hong Kong (China), Malaysia, Singapore, South Korea
and Thailand. Such campaigns commonly target reductions in intakes
of specific nutrients or aim to reduce the burden of specific health
conditions. For example, in Singapore the “War on Diabetes”
campaign was associated with significantly increased likelihood of
meeting dietary recommendations.109 Likewise, in Thailand, the
“Sweet Enough Program” was found to reduce sugar intake among
schoolchildren in Chang Mai.110
4 | DI SCU SSION
Our study is the first to descriptively analyze comparable data on
multiple indicators of the nutrition transition, including data on diet-
related NCDs, what and where foods and beverages are purchased,
and food and nutrition policy across East Asian countries. Our results
show that countries in the East Asia region are at various stages of a
nutrition transition and all are moving rapidly toward the ubiquitous
availability and higher consumption of ultra-processed foods and
12 of 20
beverages. Notably, we show that while the burden of overweight,
obesity and related health conditions (type 2 diabetes and raised
blood pressure) are highest in HICs, it has increased most rapidly in
UMICs and LMICs, such that in some UMICs the combined prevalence
of overweight and obesity roughly equals or exceeds that seen in
some HICs in recent years. We have also shown there is an increasing
trend in purchasing of both core and UPFs and UPBs across the
region.
Where people purchase their food from is also changing, from
traditional to modern food retailers and with increased expenditure at
food service outlets (notably full-service restaurants, fast-food and
takeaway outlets, and cafes/bars). In HICs across the region,
consumption of UPFs and UPBs, and patronage of modern food retail
and food service outlets is high but shows a stable trend. In UMICs
and LMICs, purchasing of UPFs and UPBs, and expenditure at modern
food retailers and food service outlets, is comparatively lower, but is
increasing at a rate that is far more rapid when compared to HICs.
Our results presented herein reflect changes to diets and food
30,33,38–40,72,111–113
systems globally.
It is not unexpected that our results show an increasing burden of
overweight, obesity and related health conditions in East Asian coun-
tries over time. Globally, NCD mortality is high, and based on current
trends it is likely that most countries will fail to meet Sustainable
Development Goal (SDG) target 3.4 (to reduce premature mortality
114
from NCDs by a third by 2030). Indeed, premature mortality from
type 2 diabetes has worsened in recent years. The existing literature
describes an increasing prevalence and burden of a range of NCDs
across Asia.6,7,11–14 Likewise, the results from our study align with
evidence demonstrating an increasing burden of overweight and
obesity in Asia.4–9 Notably, increasing prevalences of overweight and
obesity have been previously reported in country-specific studies
2,3 115 116
conducted in China, Malaysia, and the Philippines. We
observe a particularly high prevalence of overweight and Obesity in
Mongolia, and this is also supported by the literature, which depicts
both a high prevalence of, and a rapidly increasing trend in, over-
weight and obesity in this country.117–119 We also show an increasing
burden of type 2 diabetes and raised blood pressure, particularly in
UMICs and LMICs. It is worth noting, however, that the discrepancy
in the prevalence of such conditions between HICs, UMICs and LMICs
may be due to a range of factors, including disparities in treatment
options,120,121 alongside consumption of UPFs and UPBs.23
Our results showing an increase in purchasing of core foods in
East Asian countries are consistent with the literature on the nutrition
36,37
transition in this region. Increasing consumption of animal prod-
ucts, including animal-sourced foods (such as meat and seafood)122
and dairy products68 and dairy products, has been recorded and our
study aligns with the existing evidence. For example, studies
conducted in Malaysia and Vietnam have demonstrated increasing
consumption of meat, seafood, eggs and dairy.123,124 Our study also
shows a decreasing rice purchase volume, with an increasing purchase
volume of breads, cereals, and other grains. Again, this is supported
by the literature suggesting rice consumption is declining in this
region.37,126–128 As was the case in the present study, evidence
HUSE ET AL.
suggests that consumption of other grains, such as breads and cereals,
is increasing.37,128 We also observed an increasing trend in the pur-
chasing of fruits and vegetables.37 However, evidence on this aspect
of the nutrition transition is mixed, with some regional data suggesting
that overall intake of fruit and vegetables is inadequate in this
region,128,129 while country-specific studies conducted in Malaysia
and Vietnam report that total fruit and vegetable intakes are increas-
ing.123,124 It is possible that rising fruit and vegetable intake is a fea-
ture of the nutrition transition in Asia, though future research into
fruit and vegetable intake in this region may be warranted.
The results presented herein broadly align with the literature that
shows sales of processed and UPFs and UPBs are increasing in the
East Asia region.32,67 In 2014, Baker and Friel,32 using Euromonitor
data, demonstrated that sales of processed foods and beverages had
increased in most UMICs and LMICs in Asia. Increasing intakes of
UPF and UPB have also been reported through country-specific stud-
ies conducted in Malaysia and Vietnam.123,124 Our results support and
extend these earlier findings, reaffirming that the purchase of UPFs
and UPBs increased over time for LMICs and UMICs, while UPF and
UPB purchases were higher but relatively more stable among HICs
across time. While this study specifically focused on UPFs and UPBs
(as opposed to all processed foods and beverages), the evidence
linking UPFs and adverse health outcomes is stronger than for all
processed foods.22,131 As such, our findings have considerable impli-
cations for population health and nutrition policy-making. Among
HICs, while sales of UPBs also increased, sales of UPFs did not
(though sales of UPFs remain at a level that is likely to be far above
WHO sugar/fat consumption guidelines131). among HICs, Japan has
particularly high UPF purchasing levels. This may be explained by
unique Japanese dietary trends, including high intakes of noodles and
chilled processed seafood.32,133 However, additional research is likely
required to understand this further.
We also demonstrate an increased reliance on and preference for
“modern,” compared to traditional, grocery retailers and increased
expenditure at food service retail outlets, notably full-service restau-
rants, fast-food outlets and takeaway outlets, and cafés/bars. Such a
shift to the increased patronage of modern food retail and food
service outlets are consistent with earlier studies on the nutrition
transition.28–31,36,37 The process of rapid “supermarketisation” (the
rise of the supermarket as a dominant food and beverage retailer) in
Asia has also been documented by Reardon et al in 2003 and
2012.44–46 The findings in the present study also support a 2016
study by Baker and Friel,67 who demonstrated an increased propor-
tion of UPFs and UPBs purchased through “modern” grocery retailers,
and increased per capita food service sales in Asian countries. We
extend this work by capturing dietary purchasing practices for core
foods, as well as UPFs and UPBs, and by providing further detail on
the types of food service outlets where purchases are made.
Expansion of modern food retail outlets has had varying impacts on
diet quality in Vietnam, improving some aspects of dietary intake
while reducing others.133 Conversely, modernization of the food retail
environment in Thailand has been identified as a driver of UPF and
UPB consumption.134 Given the multiple and variable impacts that
HUSE ET AL.
food retail modernization is likely to have on population diets, govern-
ments should consider a suite of policy actions to ensure that changes
133,134
to food retail environments support healthy dietary choices.
While this study did not address within-country inequities in the
burden of malnutrition, nor exposure to dietary risk factors, it is also
important to consider within-country inequities and their likely role as
both a driver and a consequence of the nutrition transition. Tradition-
ally, among countries that are earlier in the transition, those of a
higher socioeconomic status (SES) are more likely to consume a lower
quality diet. It is well established that as the nutrition transition
progresses, the socioeconomic patterning of diets and diet-related
diseases shifts from a negative association (higher SES have lower
quality diets) to a positive association (higher SES have higher quality
diets).30,136,137 For example, it has been reported that those of a
higher SES consume a less healthy diet and are at a higher risk of
overweight and obesity relative to those with a lower SES in
Vietnam137,138 and Indonesia.139 Conversely, within HICs, such as
Japan and South Korea,138,140 and UMICs, such as China, Malaysia,
134,141–143
and Thailand, where the nutrition transition is further
advanced, those with a lower SES have been found to consume a less
healthy diet and are at a higher risk of overweight and obesity com-
pared to those with a higher SES. Given the equity implications of the
nutrition transition it is important that governments implement food
and nutrition policies that reach and impact everyone in the popula-
tion, particularly those with more limited social and economic
resources.
There are many drivers of the nutrition transition in East Asian
countries which may explain our results. Income growth in Asian
countries (particularly now in LMICs and UMICs) has led to shifts in
consumers' diets, away from traditional, rice-based meals toward
more “luxury” food products, including fruits and vegetables, meat
and dairy and UPF and UPBs.11,12,36,37 Indeed, evidence shows that,
in Asian countries, consumer demand for rice decreases as per capita
income increases37,145,146 while demand for traditionally “western”
37,146,147
foods (animal products, UPF and UPBs) increases. Income
growth in Asian countries has also been accompanied by urbanization,
as people move from rural to urban areas.12,36 Urban settings
increase access to “modern” foods and promote lifestyle and societal
11,12,36,37,51
changes, shaped by the marketing efforts of food and
beverage industry to reposition their fundamentally health-harming
147–149
products as beneficial or socially-desirable. The changes include
dietary shifts, characterized by an increased demand for energy-dense,
convenience foods, and other typically “western” products.12,36,37,43,51
12,36,37,43,51
Indeed, in East Asia those who live in an urban area are
more likely to consume an unhealthy diet (and subsequently be over-
weight or obese), than those living in a rural area.150–153 Urbanization
is also accompanied by empowerment of women to enter the work
force, further driving up demand for convenience foods12,36,51 and
highlighting the urgent need for the production and supply of healthier
convenience foods, rather than the ultra-processed and energy dense
convenience products which are currently more frequently available.
Trade liberalization and globalization are also likely drivers of
the described nutrition transition in East Asia.12,37,43–46 Trade
13 of 20
liberalization, facilitated by trade agreements that reduce cross-border
movements in goods, services and investment, has contributed to
domestic food and beverage markets being flooded with a greater
range of internationally produced products to appeal to consumers,
notably UPFs and UPBs.12,37,43 As consumer demand for these new
products increases, domestic production often increases to
36,49
match. This increase in domestic production is often driven by
investments in food systems from multinational food and beverage
corporations (foreign direct investment; FDI), and this FDI is in turn
facilitated by trade liberalization.36,49 Trade liberalization has also con-
tributed to the supermarketisation of the region, whereby transna-
tional grocery and convenience store retailers are increasingly
established in urban and peri-urban areas, often displacing traditional
wet markets, where the sale of locally-sourced fresh foods is the
norm.12,43–46 Our results support this retail transition where we
observe a purchasing shift from “traditional” to “modern” food retail
outlets. Evidence shows that increased purchasing from such outlets
is associated with increased purchase and consumption of cheap,
energy dense, UPFs and animal products.43–46,155 While sourcing food
from more modern retail outlets, such as supermarkets, can lead to
increased access to safer foods, shopping at supermarkets is also
linked with less healthy diets.154,155
It is also important to acknowledge the role that transnational
food and beverage corporations are playing in shaping food systems
and driving the nutrition transition in Asia.32,67 In 2016, Kickbusch
et al156 coined the term “the commercial determinants of health” to
refer to the “strategies and approaches used by the private sector to
promote products and choices that are detrimental to health”. As
transnational food and beverage corporations continue to expand into
Asian markets, the influence of these commercial determinants of
health over population diets is likely to grow. There has been
increased penetration of food and beverage corporations into Asian
markets, and with this has come extended supply chains and
increased industry influence over food and nutrition environ-
ments.30,49,50,69,159 Over time, it is likely that expansion of transna-
tional corporations will force smaller competitors to either grow in
size or be forced to exit food and beverage markets. The expansion of
transnational corporations can be seen through the pervasion of food
marketing, the majority of which is for unhealthy UPFs, in Asian
nations.149,158–161 Marketing of unhealthy foods and beverages
increases brand awareness, brand loyalty and total energy
intake.162–167 It is therefore not surprising that authoritative health
bodies, such as the WHO, recommend children be protected from
the marketing of unhealthy foods and beverages.112,168,169
Nevertheless, our policy audit demonstrates that there is limited
policy in place across East Asian countries to do so. Most of the
identified policy actions were either information based or within
specific settings; the lack of policy in other areas may be influenced
by the tactics of these large food and beverage corporations.170–172
Food and nutrition policies represent a key strategy for governments
in Asia to ensure a healthy nutrition transition and counteract the
pervasive influence of transnational food and beverage corporations
in Asian economies.
14 of 20
To turn the tide on the increasing rates of overweight, obesity and
NCDs it will be essential that healthy foods are readily accessible,
affordable and appealing, and more so than unhealthy options. Consid-
erable and high-quality evidence supports the role of Government-led
policies to drive a nutrition transition that promotes health, wellbeing
and sustainability.55–60 It is widely accepted that a suite of policy
actions is needed to drive transformative food systems change, rather
than adopting and implementing isolated policy actions.40,64 Despite
this, our audit of food policies that address overweight, obesity and
unhealthy diets within East Asian countries demonstrates that while
many governments have policies in place, the majority of these have
been adopted in HICs, with minimal implementation LMICs. Policies
are also frequently voluntary, particularly in the case of FOPL and mar-
keting restrictions. Voluntary action by industry has been shown to be
less effective than statutory measures, with unhealthy products being
less likely to adopt voluntary FOPL,173,174 and voluntary marketing
restrictions unlikely to change the content of food and beverage mar-
keting.175,176 Further, many of the identified policy actions, such as
FOPL and mass communications, were information-based policies.
Such policies are often less effective than structural policies, as they
require individual choices to be made by consumers in order for the
policy to be effective, whereas structural policies change the food
environment such that individual choices have a lesser impact on pol-
icy success.177,178 We have also shown that, when they are conducted,
evaluations of nutrition policies in East Asia have only been done so in
HICs and UMICs, limiting opportunities for translating findings and evi-
dence to LMICs. Policy makers must also be cognisant of the double
burden of malnutrition in East Asian countries,9,17 as a siloed approach
addressing just one form of malnutrition may create unintended nega-
tive consequences for another. Double duty actions that address both
over and undernutrition have been recommended.179
4.1 | Strengths and limitations
This study is not without its limitations. Significantly, this review was
written from an external perspective, with none of the authors resid-
ing in the region, though several have extensive regional research
experience. Nevertheless, we acknowledge that our own external
experiences and biases may influence the interpretation of results.
Broadly, this paper also adopts a regional perspective to describe
the nutrition transition across East Asia. Data is drawn from compara-
73 80
ble regional datasets, specifically the NCD-RisC and Euromonitor
databases. However, there were six countries in the region that did
not have Euromonitor data available and were thus excluded from our
analysis. While nationally representative surveys that capture health
and dietary data could have been used in place of the Euromonitor
data (for these and all other included countries), national surveys are
not standardized between countries and hence comparability is diffi-
cult. Further, standardized Multiple Indicator Cluster Surveys (MICS)
and Demographic and Health Surveys (DHS), which are conducted
across all countries, do not provide dietary data that captures key vari-
ables of interest to this study, in particular purchasing or consumption
HUSE ET AL.
of ultra-processed foods.180 It is important that these countries are
supported with ongoing dietary monitoring and surveillance and/or
that existing nationally representative surveys from these countries
are integrated and harmonized with regional datasets. This is will
allow a more nuanced understanding of regional diets and transitions
across time.
While we demonstrate both an increasing burden of overweight
and obesity and an ongoing nutrition transition occurring in East Asian
countries, we do not calculate the statistical significance of any pres-
ented trends and instead just describe the data as it appears. As such
we cannot infer whether any apparent changes are statistically
significant.
In assessing the burden of overweight and obesity in included
countries we drew on a large database of population-based data,
which is verified by NCD-RisC members through repeated checks.
Pooled NCD-RisC data draws only from surveys with measured
height, weight and biomarkers, eliminating the potential for bias due
to self-reporting. However, only 42% of pooled surveys worldwide
reported data for those older than 70 years and thus it is likely that a
sizable proportion of the burden of overweight, obesity and related
health conditions in East Asian countries was not captured. Further,
NCD-RisC data are only available for overweight, obesity and under-
weight as measured by BMI, and for type 2 diabetes and raised blood
pressure. However, the accuracy of BMI as a measure of adiposity for
Asian populations has been questioned.181 It is likely that, by only
looking at type 2 diabetes and raised blood pressure, we
underrepresent the increasing prevalence of NCDs in the East Asia
region.
As previously mentioned, a key limitation of the Euromonitor
database is that it does not capture the informal food retail environ-
ment.33,81,82 This is significant as food and beverage purchases from
informal retail outlets are noted to be more common in LMICs, and
often make up the majority or even totality of food and beverage pur-
chases from retail outlets in these countries.182 However, while there
are differences in the food environments at informal and formal food
retail outlets, several key similarities remain. These include the avail-
ability of both unprocessed, processed, and ultra-processed foods and
beverages, the relative affordability of processed foods, the presence
of marketing and promotions, and comparatively more expensive
fruits, vegetables, and staple foods. Hence, while future research
would do well to capture such informal markets, the failure of the
Euromonitor dataset to do so is unlikely to overly under- or over-
estimate the healthiness of consumer diets.182
In triangulating the NOURISHING and GINA databases and an
unstructured literature search when searching for policy actions
implemented in included countries, we have maximized our potential
to capture the range and depth of policies introduced in East Asian
countries that address overweight, obesity and unhealthy diets. How-
ever, the NOURISHING database is limited by not including a range
of policy elements, including governance mechanisms, population
monitoring and surveillance systems, and policy goals and targets.183
We have also only described key “health-motivated” policy actions
adopted in East Asian countries, not all of the policy actions that could
HUSE ET AL.
impact population-level food consumption (such as trade policies).
Furthermore, it is possible that we have missed relevant or pending
policy actions by only collecting publicly available data. Future
research may build up on the policy audit completed here by
corresponding directly with in-country policy experts to capture a
broader change of policies. We also only collected government-led
policies that have been implemented at the national level and may
have missed important sub-national policies. The audit was completed
in English also, which is not the national language of many countries
included here. As such, some policy actions may have been missed as
translations were either incomplete or unavailable. Finally, we
describe only the volume and type of policy actions and do not report
on any evaluations of effectiveness or other outcomes. Nevertheless,
a national coordinated policy approach to addressing overweight,
obesity and unhealthy diets is recommended, and the policy audit
herein shows that this is not happening in many East Asian countries.
5 | C O N CL U S I O N
East Asian countries are facing a growing burden of malnutrition, with
overweight and obesity becoming increasingly problematic as the
prevalence of overweight, obesity, type 2 diabetes, and high blood
pressure continues to rise across most countries. This paper provides
two clear findings that underpin this problem.
First, sales of UPFs and UPBs, and expenditure at modern food
retail outlets and food service venues are increasing across the region.
While the burden of overweight and obesity, and intakes of UPFs and
UPBs, are comparatively low in UMICs and UMICs relative to HICs,
these are increasing rapidly in both UMICs and LMICs. It will be
important to address these early before these UMICs and LMICs
reach a similar level to HICs. Second, despite the widespread con-
sumption of UPFs and UPBs and their health and economic impacts,
resulting policy responses adopted across the region are limited in
their number, scope, and strength.
Governments of East Asian countries should consider a suite of
policy actions to address the drivers of this nutrition transition. This
should include internationally recommended policies such as fiscal
policies (e.g. sugar sweetened beverage taxation), unhealthy food and
beverage marketing restrictions, FOPL, school food environment
guidelines, and mass communications.93–97 Where possible, these
policies should be legislated and mandatory, rather than relying on
voluntary adoption, which has shown to be largely ineffective.173–176
Governments should also look to address the growing concern that
are the commercial determinants of health.156 Policy development
should include resources for independent policy evaluation to ensure
policies are having their intended effect and to expand the evidence
on effective nutrition strategies in East Asia.
ACKNOWLEDGMENTS
OH was funded by an Australian Government Research Training
Program scholarship for the duration of this study. PB received
funding for related projects from The World Health Organization, The
15 of 20
Australian Department of Foreign Affairs and Trade, and the
Australian Research Council, and conference support from the
Australia New Zealand Obesity Society and UNICEF China. CB
receives project funding from the National Health and Medical
Research Council of Australia (APP1132792 and APP1169322). KB is
the recipient of a National Heart Foundation Future Leader Fellow-
ship (102047).
CONFLICTS OF INTEREST
OH and KB are part of a project funded by VicHealth and UNICEF
East Asia and Pacific that aimed to develop a research agenda to
support improvement in the healthiness of urban retail food environ-
ments in the East Asia-Pacific Region. KB receives consultancy funds
from UNICEF East Asia and Pacific. All other authors have no conflicts
of interest to declare.
OR CID
Oliver Huse https://orcid.org/0000-0002-9366-8012
Phillip Baker https://orcid.org/0000-0002-0802-2349
Kathryn Backholer https://orcid.org/0000-0002-3323-575X
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How to cite this article: Huse O, Reeve E, Baker P, et al. The
nutrition transition, food retail transformations, and policy
responses to overnutrition in the East Asia region: A
descriptive review. Obesity Reviews. 2022;23(4):e13412.
doi:10.1111/obr.13412