Paving the way: Urban Health, Food Systems, and the Imperative for Holistic City-Led Action

Food systems and urban health key connections

Food systems have direct and indirect effects on health.⁵ They can directly influence health by determining whether people have enough food to eat (sufficiency) at all times (stability) [i.e. food security], whether people have financial access to nutritious foods, the relative availability and “attractiveness” of foods [i.e. to achieve healthy diets], and whether food is free from health-harming biological or chemical contaminants [i.e. food safety]. Food systems also indirectly influence health through their ecological, economic and social impacts.

Traditionally viewed as a problem predominantly faced by rural areas, food insecurity [2] is growing in urban areas, in part driven by rapid urbanization. Recent analysis reveals that, globally, food insecurity is only slightly lower in urban areas than in peri-urban or rural areas (25.5% vs. 29.9% and 31.9%, respectively). The greatest levels of urban food insecurity lie in Africa and Latin America (54.3% and 32.2%, respectively), while this is 11.8% in Northern America and 8.1% in Europe.⁶ While the relative rate of food insecurity is lower in urban than rural areas, given the large size of urban populations, the vast majority of food insecure people worldwide (76%) live in urban and peri-urban areas.⁷ However, variations exist between- and within-countries and also within-cities.⁶ For example, food insecurity prevalence is likley to be higher in urban areas with informal settlements and migrant populations. Similarly, levels of food insecurity may be higher among women than men, though this relationship may be mediated by other factors such as education level and household income.⁸

Urban food environments are unique in that the urban population purchases most of the foods that it consumes making urban populations highly dependent on the foods that are available to them and their relative prices. In addition, higher costs of living (and smaller housing units) which often characterise urban living, constrict household food budgets leading many households to compromise on the dietary quality of food purchases, especially as nutritious foods such as vegetables, fruits and animal sourced foods are often more expensive than highly processed foods.^8,9 Other factors more prominent in urban settings, such as limited food preparation time relative to effort, space constraints for food storage and preparation, pervasive food marketing across various media, and easy physical access to foods high in unhealthy fats, sugars and/or sodium, contribute to shaping today’s urban diets.⁷

Food insecurity, combined with these other social and environmental structures in urban areas has contributed to the rise in diet-related diseases and the persistence of the multiple forms of malnutrition we see today. Malnutrition in all its forms (including both undernutrition and overweight and obesity) is responsible for an estimated 26% of global preventable mortality.¹⁰ Levels of undernutrition (stunting and wasting [3]) remain high in urban areas in Africa and Asia, affecting about 25% of children in these regions. These carry important implications for health, particularly relating to physical growth and cognitive development and increased susceptibility to, and risk of dying from, common infections. Stunting may also increase the risk of developing noncommunicable diseases (NCDs) in adulthood. In contrast, child overweight remains higher in urban areas than in rural areas, ranging from around 5% in Africa and Asia, up to 9% in Latin America and the Caribbean. Overweight and obesity are important risk factors for several NCDs including diabetes, heart disease and certain kinds of cancer.⁸ However, these profiles are changing around the world as overweight and obesity levels continue to rise, while levels of undernutrition remain stagnant.⁶ The relative rates of these transitions in malnutrition profiles across settings can have important implications for the burdens that national and local governments face. Several countries and urban settings now face the co-existence of multiple forms of malnutrition, known as the ‘double burden of malnutrition’.^6,8

Beyond the healthfulness of diets, the safety of the food supply in urban areas is equally important since even if nutritious food is available, it cannot benefit individuals if it is unsafe. Food safety issues may arise across the food system from production to consumption. Within urban settings, inadequate or poorly enforced regulatory standards together with densely populated urban environments can foster unsafe food environments, including from unsafe water, poor food production and handling practices, and inadequate food storage infrastructure⁸ [See Box 1 for more details on specific urban settings]. Even where fresh foods sold through traditional markets or supermarkets are safe, food safety issues can be introduced in home meal preparation, especially where safe water and adequate storage or refrigeration are not guaranteed. Food contaminants have been linked to a wide range of health outcomes, from acute gastrointestinal illnesses, to poisoning, to long-term development of certain cancers.¹¹

While new estimates are set to be published in 2025, the latest available data from 2010 suggests that globally, foodborne hazards may cause over 600 million cases of illness and 420,000 deaths annually.¹⁴ Children are disproportionately affected by foodborne diseases, with 40% of cases occurring in children under age 5 years. Likewise, burdens are not distributed equally across the globe. The African region faces by far the greatest burden of food-borne diseases followed by the South-East Asia and Eastern Mediterranean regions.¹⁴ As cities experience the impacts of climate change including extreme weather events (flooding) and heat islands, their food supply systems become increasingly vulnerable to food safety concerns with concomitant implications for food security and nutrition.⁷

Ultimately, urban food systems have a significant impact on health, with food insecurity and malnutrition remaining critical issues for cities worldwide. The unique challenges of urban environments demand tailored context-specific solutions to improve health outcomes for urban populations. As urban populations grow, it becomes increasingly important to understand the underlying factors that help shape urban food systems and their impact on health, to develop effective strategies for addressing these pressing issues.

Housing development

Housing remains a critically undervalued element in the discourse on healthy urban food systems. Whilst housing issues such as crowded housing and poor cooking facilities were previously acknowledged in a WHO report,¹⁶ this section focuses on three ongoing aspects of housing that pose significant challenges to food security and nutrition: housing design, urban planning (“urban sprawl”), and economic policy (“cost of living”).

Firstly, the ongoing pressure to accommodate increasing populations in urban areas has led to a proliferation of smaller living spaces. There is an inherent tension between the commonly cited benefits of urban density and building upward (higher wages, green space preservation, decreased energy consumption, walkability, and access to services), and other measures of quality of living spaces (including size and utility).¹⁷ While this trend is not inherently negative due to broader urban benefits brought about by compact living design, at the housing level it often results in diminished kitchen sizes and functionality. Consequently, if cities place increasing emphasis on the provision of affordable nutritious foods by local retailers, this may yield limited advantages if residential accommodations make refrigeration and at-home meal preparation increasingly difficult. Furthermore, the provision of inadequate storage space impedes residents’ ability to purchase food in bulk, a cost-effective strategy commonly employed to manage food budgets.¹⁸ Additionally, as housing influences the types of food we can store and prepare, this shift in food practices bears implications for food supply chains, which are responsive to consumer demands. The recent surge in meal delivery systems (described in greater detail below), propelled by the COVID-19 pandemic but also reflective of urban lifestyles and housing models, characterizes this trend. In response, recent housing design standards (e.g., in the Greater London area), have incorporated detailed guidelines specifically targeting kitchen design, aimed at bolstering size and functionality.¹⁹

The second concern related to housing pertains to urban planning (“urban sprawl”). Both push and pull factors contribute to the expansion of residential land far from city centres. This growth has been shown to manifest differently in different contexts. In high-income countries, growth in city outskirts is typically considered a positive measure of urban welfare, characterized by suburban or low-density development. Properties in these areas usually cost less, there is more space for larger homes and gardens, environments are generally quieter and more natural, and there are social (and sometimes agricultural) opportunities, leading some to favour such areas. However, this lower-density setting also impacts the food retail landscape, with larger chain and big-box retailers taking advantage of lower commercial land costs and expanding road transport infrastructure often displacing smaller, independent shops. The placement of these retailers, typically segregated from residential areas, exacerbates car dependency with negative environmental and health consequences.

Further, vulnerable and disadvantaged groups, including migrants, may be relegated to lower-cost, lower-quality areas further from economic and cultural opportunities. In low-middle-income countries, this growth is often characterized by informal or illegal, unplanned urban expansion, such as shanty towns in Africa and slums in Asia [see Box 2 for more detail on informal settlements and slums].⁷ In both cases, such expansion often encroaches upon land that is, or could be, utilised for agricultural purposes, thus distancing the food supply from urban cores. Despite ongoing dialogue on optimal urban design, the construction of new, inadequately planned urban areas on the peripheries of major cities persists.

The third issue concerns the cost of housing, whether through ownership or rental. With an increasing proportion of household budgets allocated to mortgage or rent payments, pressure mounts on household food budgets. For example, recent census reports from New York City, USA indicated that housing is typically the largest expense for families with more than a third of household income dedicated towards rental payments.²⁰ Combined with rising food prices, households face immense pressure to meet their basic nutritional needs and may cut back on their food expenditures to compensate. This trend fosters the purchasing of cheap, nutrient-poor, energy-dense and undiversified foods. Though social protection and food assistance programmes aimed at improving access to a healthy diet exist in many cities, these are often insufficient to fully address food insecurity as they do not cover all household food needs or other living expenses (health, housing, education, etc.), nor do they address barriers to cooking (such as space and storage constraints).⁸ In such instances, it is clear a single policy response is inadequate; instead, a multifaceted response targeting the multiple issues is required.

Digitalization

Urban food environments are changing due to digitalization, with significant health and structural consequences, both positive and negative. New digital platforms that connect consumers, retailers, and workers through apps and GPS-enabled mobile devices have changed the market for home-delivered food while also creating a large, precarious, and underpaid labour force of “food gig workers.” Similarly, digital marketing of food has become ubiquitous, targeting—aggressively and with precision—the consumer segments most vulnerable to buying inexpensive, unhealthy food: high in unhealthy fats, sugars and/or sodium, and typically highly processed.²¹ These innovations have been adopted very quickly and have diffused worldwide, affecting urban food environments before policies and programmes have had a chance to catch up to protect consumers and workers.

Some of the most critical changes caused by digitalization, particularly for urban policy, affect food provisioning. Digital food provisioning includes e-commerce food retail channels that have transformed how some consumers select and buy food.²² Many of these changes have emerged in the past decade, with adoption accelerating in 2020 due to the COVID-19 pandemic as distancing precautions, business restrictions, and population lockdowns caused businesses and consumers to shift to online sales channels for food provisioning.^22–24 Since then, online shopping for both groceries and prepared meals has continued to grow, and food has been forecasted to be the fastest-growing category of e-commerce sales worldwide.²⁵

Digitalization has the potential to benefit those populations with inadequate access to healthy diets by increasing the convenience and access to nutritious foods, with positive implications for health and equity.¹⁵ However, with unhealthy foods aggressively promoted and readily available on digital platforms, digitalization can also limit healthier and increase the availability and “attractiveness” of unhealthy choices and lock people into potentially unhealthy buying and consumption patterns. Findings on the impact of online groceries on diets are mixed, with some studies finding healthy food consumption associated with online grocery use and others finding online shoppers less willing to buy perishable food than shelf-stable and often less healthy options.²⁶ The growth of delivery platforms has also made it easier for consumers to buy food from restaurants. However, the food offer on delivery platforms is often predominantly unhealthy.²⁷ Food safety is an additional concern, as proper handling practices across the delivery supply chain are rarely considered.⁸ Although online purchasing can ease access for mobility-limited consumers, this positive impact may be constrained by other disparities such as the digital divide.

Digitalization can also harm “brick-and-mortar” [4] food retailers, eventually resulting in fewer (and potentially less healthy) buying options. For example, while it may increase retail competition in areas under-served by brick-and-mortar supermarkets, digitalization may also advantage global online retailers with advanced supply chains, undermining independent grocers and leading to market domination. Platform-based food delivery companies may enable small independent businesses to access new consumers, in turn affording consumers more convenient access to groceries and prepared meals.⁸ However, for these small businesses, platform fees may cut into profits, potentially resulting in a concentration of large transnational chains that can buffer the higher costs, at the expense of smaller local family-owned businesses.

Another aspect of digitalization is linked to the provision of food information through technology, and the extent of information necessary for, and to be retained on, physical labels and information made available when purchasing foods online, and through meal delivery apps.

Labour transitions, particularly in the food sector

Across low-, middle-, and high-income countries, the food system is a major source of jobs and economic activity in urban areas.^28,29 Food system workers are employed in different sectors of the food value chain, where they produce, process, transport, and sell food as well as manage food waste. Overall, food system business and employment make up a large part of urban economies, while cities’ food service and retail sectors—e.g., restaurants, cafes, food vendors, and markets—contribute to food access and the unique character of urban areas, which includes the culture and variety of cafes and restaurants among others.²⁹ Increased demand from urban consumers for nutrient-rich foods as well as processed and convenience food is a driver of job creation along the food value chain, particularly in the processing, marketing, and service sectors.⁸ Additionally, recent decades have seen a rise in female employment outside the home; a recent study in west Africa found that women made up the majority (80%) of those working in food processing and vending sectors.³⁰

Given these trends, growth in food system employment and food system enterprises has the potential to provide economic opportunity and jobs for expanding youth and other vulnerable populations.^8,28,31 However, food system jobs are also widely critiqued for their low wages, job insecurity, lack of adequate health benefits, difficult or dangerous working conditions, lack of opportunity for advancement, and precariousness.^32,33 Informal food sector activities and casual labour are particularly important to low-income urban populations, though they provide only low daily earnings.⁷ The rise in demand for digital services (including food provisioning) is accompanied by a growing demand for online gig work. Today the ‘gig economy’ [5] is estimated to account for up to 12 percent of the global labour market and, while still dominated by high-income countries, demand in low-middle income countries is increasing and at a faster rate.⁷ Digital platforms have recently come under scrutiny for the way that they treat gig workers as independent contractors, not employees, meaning that these workers do not get the protections and benefits of conventional workers, including compensation for workplace injuries, sick leave, and collective bargaining rights, among others. Overall, non-standard or unstable jobs have been documented to be more common among lower-grade occupations, women, ethnic minorities and immigrants.^34–36

Poor working conditions and low wages have direct and indirect consequences for health, including lack of access to health care and inadequate housing. The type and conditions of urban employment are also central to ensuring urban food security because urban residents primarily obtain food by purchasing it with the income they have earned through work. Those living in poverty—including low-wage food system workers—are at increased risk for food insecurity and may consume energy-dense foods of low nutritional quality because that is what is most affordable.^8,37 The COVID-19 pandemic and associated lockdowns exemplify these vulnerabilities for urban workers. Food retail, food service, and hospitality industries were disproportionately affected by measures to reduce the spread of disease, as many workers were either considered essential to the maintenance of critical infrastructures and thus risked greater exposure to infection, or faced job insecurity due to business and border closures (for seasonal migrant workers).³⁸

In addition to the negative health implications for food system workers, these food labour practices pose food safety risks for the wider urban population when workers handle food while sick, which is particularly important to consider in countries without social healthcare, as workers are less likely to have workplace-provided health insurance.³⁷ Physical risk factors such as stress, environmental impacts, occupational hazards, and low wages, have been associated with poor physical and mental health outcomes.³⁹ These can have a double impact when they affect the main household earner potentially simultaneously reducing access to nutritious foods for entire families.^8,35

Changes in employment including increased out-of-home female employment can have implications for food purchasing and consumption patterns in the global North and increasingly in the global South. Since women often still carry the primary responsibility within the household to purchase and prepare food, additional time spent out of home and commuting may drive increased purchasing of pre-prepared convenience and highly processed foods which are often less healthy than meals prepared at home. Several studies across contexts have found positive associations between women’s empowerment and household dietary diversity.⁶ However, as this diversity may also include an increased selection of unhealthy foods high in fats, sugars and/or sodium⁴⁰ complementary interventions which target urban food environments will also be key.

Dietary transition

Another interconnected trend over the past decade affecting human health and affected by food systems is dietary transitions, characterized by a dramatic shift in the types and quantities of foods and beverages consumed, towards more diverse diets (higher in animal sourced foods, fresh vegetables and fruits) but also greater consumption of unhealthy, highly processed foods high in unhealthy fats, sugars and/or sodium.⁸ Consequently, increased dietary diversity has not automatically resulted in improved diet quality, with significant differences across regions and socioeconomic status in urban areas. Key drivers of this trend include globalization of food systems, urbanization (and the points discussed above: housing, digitalization and labour participation, especially of women), economic growth and income growth.^41,42

Many factors associated with dietary transitions converge in urban areas, making them particularly vulnerable to their impacts on population health. Urban food systems are commonly characterized by more diverse food sources (food vendors, restaurants and supermarkets), high exposure to food marketing, and limited opportunities to grow nutritious foods. The result is greater access to and demand for a broader range of food options. One major shift, especially in Asia and Latin America, has been the expansion of supermarkets and hypermarkets at the expense of conventional markets, largely because of policy liberalization and privatisation, public infrastructure investments and globalized distribution of modern food technologies, and demand for readily available and safe foods. Today, supermarkets are often part of multinational chains or dominant national chains. While supermarkets may increase access to safe and nutritious food, year-round, they have also been associated with the increased supply of unhealthy processed foods. Supermarkets may also displace local food businesses (both formal and informal) with important ramifications for food security and market consolidation.^7,8

Within urban areas, neighbourhood food environments differ significantly, especially with respect to opportunities to access healthy diets, as mentioned above. Some urban areas have no or only few food shops or outlets that sell fresh or healthier foods (food deserts), while others have a high density of shops and outlets that serve mainly energy-dense or highly processed foods high in unhealthy fats, sugars and/or sodium (food swamps). Often these are found in under-invested neighbourhoods, for example in Rio De Janeiro, Brazil, in which residents of low-income communities (such as those in impoverished or informal neighbourhoods) and low-income households living in affluent areas, often have limited access to healthy diets.⁴³ The availability and the affordability of a healthy diet is especially significant as urban populations rely heavily on food purchases.⁷ The fact that the relative price per calorie is often lower for unhealthy foods than for healthier foods, across regions and country income groups, also has important implications for diets. For example, in Hanoi, Viet Nam lower-income groups’ food purchases account for 46% of total household expenditure.^8,35,42 An analysis of food consumption in deprived neighbourhoods of three cities in Ghana and Kenya revealed widespread consumption of unhealthy (mainly local) foods, often in lower socioeconomic status groups. Similar findings have been documented in high-income countries.⁴⁴ Opportunity of time and convenience of meal preparation are important co-factors governing food choices and diets in urban settings (explored above).

Urban growth and dietary changes also affect food production and supply. Growing demand for certain products, including specific crops, vegetables, animal-sourced foods, and dairy products can have important effects on food production and supply chains, shifting production away from traditional crops and lengthening supply chains. For example, according to some studies, a greater demand for vegetables and dairy products in New Delhi, India, in both high-, low- and middle-income urban households, has resulted in a shift in production in the rural areas around New Delhi away from cereals towards vegetable production and livestock keeping.⁴⁵ Expansion in the production of cheap raw ingredients such as sugar, oils, and wheat as well as food processing technologies is also feeding the growth of highly processed food industries and changing diets globally, though at different rates.⁶ In addition, increased demand for foods and products with a high environmental footprint, such as pre-packaged highly processed foods, or animal-source foods requiring significant resources (including water, energy, and land), may hurt the environment and exacerbate climate change,⁴⁶ including through increased emissions.⁴⁷

The four trends described above are interconnected (see Figure 1). Housing design may discourage home cooking, leading residents to rely instead on out-of-home food purchases from street food vendors or meal delivery services. Digitalization while making meal delivery options more convenient, can also increase precarious employment conditions which in turn will have an impact on housing and food affordability. Dietary transitions facilitate the rise in the production, distribution and sale of unhealthy highly processed and convenience foods, re-enforcing changes in urban environments related to food delivery services and home food preparation. In light of these trends, certain key issues need to be considered by national and local leadership to raise the ambition and effectiveness of urban food policies. The following section delves into the shared challenges behind the trends discussed above and uncovers opportunities to reverse their harmful health impacts. By seizing these opportunities, cities can become powerful catalysts for positive change, driving a healthier, more sustainable food system for all.

How can a holistic, integrated approach to urban food systems address health and societal challenges?

Multi-faceted policies and initiatives aimed at addressing urban poverty—including issues such as employment, adequate housing, access to digital technology, and urban planning for food access—are important strategies for ensuring urban food security. At the city level, initiatives that support local food economies can encourage sustainable livelihoods and provide vital support to small-scale food businesses. Equally important is to protect informal and small food businesses from negative trade and regulatory impacts. These comprise both a large workforce in many urban areas and are an important supplier of food for those employed in the informal sector. Because of the connections between poverty and food insecurity, considering the needs of low-income workers in urban policy decisions can help mitigate negative impacts on their access to food and consequently their health.²⁰

By taking a setting-based approach, city governments can tailor policies and interventions to meet residents’ specific needs whether at home, in schools, at the workplace, or in digital environments.²⁹ This approach is contrasted with the traditional top-down policy frameworks that focus on individual sectors, treat symptoms rather than root causes, and overlook the needs, priorities, and experiences of people and communities on the ground.⁵³ In this way, cities have been pioneering a holistic approach to food systems policy using systems thinking to bring together actors from multiple sectors along the food supply chain. This collaborative and multi-faceted approach is essential for tackling the complex dynamics that drive the food system.⁵¹ For example, in 2019, the Municipality of the Metropolitan District of Quito, Ecuador endorsed the Quito Agri-Food Strategy. This strategy, developed by multiple actors including government entities at various levels, advocacy groups, international actors, academia, and the private sector, enables agrifood systems to be included in city planning tools.⁸

The interconnected nature of the challenges presented above highlights the need to incorporate food and food security in policy making across sectors. This ‘Food in All Policies’ approach, which mirrors the WHO’s Health in all Policies framework,⁵⁴ offers an integrated and systems-based approach to food policy making. By engaging a wide range of stakeholders, this approach demonstrates how food can help achieve their aims or the role that their polices play in achieving food-related goals.⁵⁵ In addition to adopting the ‘Food in All Policies’ approach, policy makers should embed a human rights approach in urban food policies and interventions, recognizing the intersections between the right to food, the right to the city, and the right to health. Working horizontally across sectors and vertically across multiple scales will be crucial to addressing some of the structural barriers to food systems change. For example, it has been two decades since planners began to call for attention to food systems,⁵⁶ yet the ongoing urban housing crisis and continued urban sprawl demand a renewed effort to integrate planning, housing regulation, and food systems. This will help create a better understanding of the effects of urban development and create policies that ensure homes are places in which it is possible to prepare, store, and recycle food safely. Beyond a systems approach, optimal food system policy must also prioritize equitable and inclusive policy processes that empower those most negatively affected by the food system to define its problems and shape the solutions.⁵⁷ Processes that promote agency within the food system and centre the voices of marginalized communities are important for the equitable transformation of the food system.⁷