The nutrition transition in low- and middle-income countries: The role of socioeconomic factors, culture, and the food environment

Abstract

Many low- and middle-income countries (LMICs) are undergoing a nutrition transition, where diets are shifting from traditional staples to energy-dense processed foods, often contributing to poor nutrition outcomes, including overweight and obesity. In a fast-changing world, understanding the contributing factors and pockets of vulnerability enables better targeting in a resource-constrained context with competing development priorities. This dissertation contributes to this policy discussion by examining overlooked and novel drivers of the nutrition transition in LMICs and identifying when and where prevention can yield the greatest health gains. Using longitudinal and large-scale survey data from Indonesia and various econometric modeling approaches, this dissertation links nutritional outcomes with crisis exposure, cultural practices, and the expansion of digital platforms to uncover both risks of malnutrition and poor health and potential mitigation strategies. <br /> The first essay shows that early-life exposure to crisis imposes lasting health costs. Children under five in households that faced high rice prices and economic hardships during the Asian financial crisis in the late-1990s were more likely to suffer from stunting and, as adults, remained shorter with a higher body mass index (BMI). These patterns likely contribute to Indonesia's rising overweight and obesity rates. This essay also demonstrates the heterogeneous impacts of crises across population groups. Macroeconomic shocks often hit urban populations harder than rural ones, boys more than girls, and children with lower-educated mothers more than those with mothers who have higher education levels. These findings highlight the need for tailored crisis mitigation strategies and for leveraging protective factors in intervention efforts. <br /> The second essay examines household dynamics that contribute to gendered differences in nutritional investments. Patriarchal norms, especially patrilocality, are linked to lower female BMI, with the largest negative effects among underweight women. In contrast, matrilocality and bridewealth practices appear protective for women's well-being. The positive association between certain customs and BMI is strongest for those already overweight, while patrilocality's adverse effects are concentrated among the underweight, underscoring a polarizing influence of culture on nutrition. These findings shed light on the invisible dynamics that can hamper effective intervention and highlight the need to explicitly integrate cultural practices into the policy sphere. <br /> The third essay moves the discussion from the household level to the environment level. This study assesses the impact of modern food environments on the nutrition transition by exploiting the staggered rollout of Indonesian “super apps” (mobile applications providing food delivery, ride-hailing, e-commerce) in 2015-2018. This study shows that exposure to super apps increases BMI and the risk of being overweight or obese. This finding can be explained by an increase in the consumption of unhealthy and processed foods. At the same time, these super apps and online platforms have the potential to reduce undernutrition and improve dietary diversity. These findings indicate the double-edged roles of modern food environments and the need to mitigate their negative effects through improved regulations and policies. <br /> Together, this dissertation contributes to a better understanding of drivers of the nutrition transition in LMICs, offering important evidence in identifying critical windows and settings for intervention: crisis-responsive policies, gender-sensitive strategies, and balanced governance of digital food platforms.