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Thai Food Culture in Transition
Chapter 27
Thai Food Culture in Transition: A Mixed Methods Study on the Role of Food Retailing Matthew Kelly, Cathy Banwell, Jane Dixon, Sam-ang Seubsman, and Adrian Sleigh The Australian National University, Canberra, Australia
INTRODUCTION In the modern world, urbanization, industrialization, and technological change have transformed food systems, affecting food production, processing, distribution, and retailing. A new globalized food environment has been created with transnational food corporations increasingly controlling all four of these aspects of the food system. Accompanying the changes have been profound changes in diet for much of the world’s population. Traditional diets, particularly in urban areas, are being replaced by diets higher in fats, salts, sugar, and animal products and often with lower intakes of fresh fruits and vegetables—a nutrition transition. Such fundamental changes to the food system, along with increasing food availability and diversity, have helped countries worldwide reduce their levels of malnutrition and produce healthier populations in the short term. But in recent decades countries around the world, even the poorest countries, have begun to experience an epidemic of obesity and diet-related disease (Drenowski and Popkin, 1997; Chopra, 2002). Thailand is a country with a strong food culture that is intimately connected to local agriculture and retail markets, which provide affordable sources of healthy fresh foods. It is important in this context to examine ways in which changes to this food culture may impact the health status of the Thai people. The ways in which local food cultures and diets react to these upstream influences in the global food system are complex and difficult to characterize. Teasing apart the positive and negative influences of a modernizing food system in developing country contexts is particularly problematic. However, the task is researchable and in this chapter we describe one approach adopted by a contemporary study in Thailand. This research assesses the interaction between the When Culture Impacts Health. http://dx.doi.org/10.1016/B978-0-12-415921-1.00027-0 Copyright © 2013 Elsevier Inc. All rights reserved.
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rapid modernization of food retailing in Thailand, Thai food culture and food preferences, and nutrition and health outcomes for Thai people in a context of rapidly rising obesity and diet-related diseases. To accomplish this, building on an overarching longitudinal study of the health-risk transition in Thailand (The Thai Cohort Study; TCS), an innovative mix of quantitative and qualitative methods is employed, as detailed below in the section Thai Food Culture Transition Study.
THAI TRANSITIONS Economic Growth, Poverty Reduction, and Health Transitions Thailand is a Southeast Asian country that has achieved a rapid and fundamental transformational economic growth and development over the past four decades. This has been achieved from a very low economic base; after World War II Thailand was considered one of the world’s poorest countries and had not been observed to have experienced substantive economic growth for a century before this time. Since the 1960s, however, and accelerating in the 1980s, industrial development, as well as the commercialization of agriculture, resulted in 40 years of GDP growth (Warr, 2005). Thailand is now an upper middle income country with an annual GDP per capita of $4600 (World Bank, 2011). Economic growth in Thailand has occurred in a period of globalization and has involved profound social, cultural, and lifestyle changes for the Thai population. In 1960 over 80% of the Thai workforce was agricultural, and by the late 2000s this figure had fallen to around 35% (Kelly et al., 2010b). The changes in employment have also been accompanied by a process of urbanization; nearly half of all Thais now live in urban areas (Webster, 2005). These workforce changes and moves toward more modern urban lifestyles have repercussions for the health behaviors and nutrition profiles of Thai people.
Health and Nutrition Transitions in Thailand In Thailand the major health challenges of poverty—malnutrition, high mortality, and infectious disease—are being replaced by increased longevity, lower mortality, and an increasing prevalence of chronic disease. Between 1964 and 2006 Thai life expectancy increased from 56 to 70 for males and from 62 to 78 for females; the maternal mortality ratio fell from 374.3 to 9.8 per 100,000 live births and the infant mortality rate from 49 to 21 per 1000 live births (Wilbulpolprasert, 2008). However, recent decades have seen increases in cardiovascular disorders, diabetes, obesity, cancers, and traffic injuries. Eight of the top ten causes of death in Thailand can now be related to modern lifestyles (ESCAP, 2008). An important factor in this change in health profile is the rapid change in the diet of the Thai population. Traditional Thai diets can be considered to be protective against chronic diseases, being rich in cereals, legumes, and fresh
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fruit, vegetables, and herbs, with the majority of protein coming from fish. Urbanization and modernization have meant an increasing demand for both more convenient foods and more modern foods, which are more processed and higher in fats, animal proteins, and sugars (Kosulwat, 2002). Indeed while per capita sugar consumption in Thailand was estimated at about 7 kg/year by 1983, this figure was 33.2 kg by 2006 (Wilbulpolprasert, 2008) and between 1969 and 2003 the estimated intake of kilocalories in Thailand increased from 2110 to 2400 (Food and Agriculture Organization, 2006). In addition to increases in the amount of fat and animal protein consumed, just as concerning may be decreases in fresh fruit and vegetable consumption, with only around one-quarter of adult Thais meeting recommended intakes (Satheannoppakao et al., 2009). Through this period severe malnutrition has been virtually eliminated in Thailand while in the last 20 years obesity has rapidly developed as a new problem with prevalence growing four times in the last two decades. By 2009 obesity (body mass index ≥ 25) affected 40.7% of women and 28.4% of men. This is now an important public health concern in Thailand (Kosulwat, 2002; Aekplakorn et al., 2007; Wilbulpolprasert, 2008). In addition to obesity, related health problems of diabetes, gallbladder disease, and some cancers are expected to become significant problems for the Thai population in coming years.
Changes in the Food Retailing Sector in Thailand In Thailand the fresh market (talad sot) has for centuries been a center of Thai communities. Marketplaces are part of the ritual, symbolic, and cultural life of Thai people and function as repositories of local food culture and ingredients, regionally and nationally. Importantly, markets in Thailand also function as social centers maintaining social capital for Thai communities and a source of livelihood for large numbers of poorer Thais, especially women, who predominate as stall holders in fresh markets (Jaibun, 2006). In recent decades these traditional formats have been joined by modern food retailing outlets including convenience stores (especially 7-11 stores), supermarkets, and hypermarkets. This process began in the 1980s with the opening of the first supermarkets in Bangkok. Retail change accelerated after the 1997 Asian Financial Crisis and resulting deregulation of foreign investment in food retailing with transnational food corporations (TFCs) including Tesco and Carrefour increasing their store numbers, store sizes, and spreading the reach of modern food retailing into provincial centers outside Bangkok for the first time (Kelly et al., 2010a). Since 1997 the number of modern food retail outlets in Thailand has increased from 1290 to 6654 with the largest growth occurring at the two ends of the food retail spectrum in hypermarkets and convenience stores. Perhaps even more striking is the growth of market share of modern food retail, which was only around 5% in 1980 but grew to nearly 50% by 2006 (AC Nielsen, 2006; Shannon, 2009).
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As supermarkets control more of the food supply and diet-related diseases escalate it is important to consider the links between supermarkets and nutrition outcomes. Supermarkets respond to consumer demand to some extent (in Western countries they are starting to respond to health concerns), but they also create consumer preference (Hawkes, 2008). Supermarkets also have differing influences on nutrition in developing and already developed countries. In most Western developed countries supermarkets are an essential source of dietary diversity and affordable fresh foods. They achieve this position through their economies of scale and vertical supply chain efficiencies including subcontracting farmers to grow food directly for them. In developing countries, however, supermarkets may have a more ambiguous effect on public health. Supermarkets often first concentrate on the processed, packaged foods that they can deliver cheaply and where they receive the highest profit margin, allowing aggressive price discounts and promotions. The processed packaged foods offered through modern retail outlets are also often new novel foods that attract customers; however, these are often the very foods associated with negative outcomes of the nutrition transition (Hawkes, 2008; Hattersley and Dixon, 2010). At the international level, studies, including a joint World Health Organization/ Food and Agriculture Organization (WHO/FAO) expert consultation, implicate the spread of food outlets selling energy-dense foods in population weight gain (Joint WHO/FAO Expert Consultation, 2003; Burns and Inglis, 2006). The increasing market share of modern retail in Thailand now is beginning to impact traditional food retail outlets. Consequently, making obesogenic foods more available and affordable as described above may also make affordable fresh healthy foods more expensive and harder to access. Prices for fresh fruits and vegetables have also been shown to be consistently lower at traditional fresh markets in Thailand than in modern retail formats (Schaffner et al., 2005; Vandergeest, 2006). Thai hypermarkets sell processed products 12% cheaper and fresh foods 10% cheaper than traditional retailers (Minten and Reardon, 2008). In Thailand public health policy responses to the rapidly growing problem of diet-related chronic disease are well under way. Programs target physical activity, healthy body size, and appropriate diet particularly for school-age Thais. However, economic change, foreign investment laws, and international trade agreements mean that the Thai food environment is now fundamentally linked to the globalized trade in food and modern retail outlets that now control around half of the Thai food retail sector. It is important therefore for Thailand to understand, in a more holistic manner, the factors influencing nutritional outcomes for its people. There have been few studies to date that investigate how changes in the food environment, and particularly changes in the food retailing sector, impact population nutrition in developing countries. Here we discuss a collaborative study conducted by the Australian National University and Sukhothai Thammathirat Open University (STOU) in Bangkok, which tackles this topic.
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THAI FOOD CULTURE TRANSITION STUDY Research Question The aim of the collaborative food culture transition study is to understand how changes in the food system in Thailand, particularly in food retailing and provisioning behavior, interact with changes in diet and health outcomes. The objective is to analyze the interaction between the food environment in Thailand and individual- and household-level food provisioning behavior and links between this food provisioning and health and nutritional outcomes. The research question posed to answer this objective was what effect has the rapid growth in modern food retailing in Thailand had on individual food provisioning behavior and nutritional outcomes? We hypothesize that persons who mainly shop at modern food retailers will make distinctive food choices and these will be reflected in their nutritional outcomes.
Difficulties in Measuring Food Environments and Connecting with Health Outcomes Measuring the influence of environmental factors on health is complex. The physical design of a person’s environment, the socioeconomic structure, or even the dominant culture can all influence how an individual interacts with his or her environment and the health implications of that interaction (Lake and Townshend, 2006). These observations also apply to individuals’ food environments. The influence on health outcomes of supermarket presence depends on the range of goods sold at the supermarket, the relative prices of food types, and the mix of food retail outlets that are available within that food environment. Importantly, although studies have been carried out on the relationship between food environments and health, very few have been able to establish a causative relationship, that is, low availability of fresh foods in poorer areas may be due to low demand from those societal groups rather than low supply causing unhealthy diets (Cummins and Macintyre, 2006). What is clear, however, is that individual health behaviors including food intake are influenced by many factors at multiple levels, and frameworks now exist for empirically describing food environments with factors including availability, accessibility, and relative pricing of different food types all contributing to the obesogenicity of a given food environment (Ford and Dzewaltowski, 2008).
Methodology for Thai Food Culture Transition Study The Thai setting is significantly different from those described in much of the existing literature on food environments, food retailing, and nutrition. Indeed, there are very few examples of this type of study in developing nations where the modernization of food retailing is more recent and traditional food retail outlets persist and perhaps a greater variety of food sources are available. In
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the study described here we attempt to address this issue of the links between food retail environment, food provisioning choices, and nutritional outcomes in Thailand. Rather than attempting, as the studies discussed above, to measure objectively the constitution of particular food environments, we have chosen to use people’s own perceptions of what constitutes their local food environment and what food retail choices they have available to them and to link those perceptions to these individuals’ food shopping and dietary patterns. The Thai food culture transition study adopts a mixed quantitative and qualitative approach and connects to a long running study of health transitions in Thailand, the TCS. The TCS involves researchers based at the Australian National University in Canberra and STOU in Bangkok. The study involves a large multidisciplinary team consisting of epidemiologists, anthropologists, sociologists, demographers, and nutritionists in both Australia and Thailand who are bringing their combined expertise to bear on understanding the changes that are occurring in the health of the Thai population. The varied expertise involved in the team allows a unique analysis of the sociocultural as well as medical determinants of these health transitions. The team has been conducting joint research for nearly eight years and has produced much new information with nearly 60 publications so far addressing varied aspects of the health status of the Thai population. In 2005 the TCS sent a 20-page questionnaire to all 200,000 registered STOU students. Completed questionnaires were received from 87,134 people who then formed the baseline cohort for the study. Topics covered in the baseline questionnaire included sociodemographic and economic details, height and weight, injury and disease history, food and physical activity, tobacco and alcohol use, and transport behavior. In 2009 a four-year follow-up was conducted with a response rate of around 70% (60,000 respondents). The follow-up questionnaire covered broadly similar topics to the baseline. The members of the TCS have a similar geographic and demographic distribution to the general Thai population but are somewhat more urbanized and more highly educated. Urbanization and tertiary education are important mediators in the adoption of modern ideas and behaviors and thus this Thai Cohort will be an ideal group in which to study the effects of the transitions under way in Thailand, perhaps indicating future trajectories in the general Thai population (Sleigh et al., 2008).
Quantitative Study The quantitative part of the research on food culture transition will utilize data derived from the TCS. A subsample of 3,500 members of the Thai Cohort living in the four distinct regions of Thailand and Bangkok also will be sent a supplementary questionnaire covering various aspects of their food environment and food provisioning behavior. The questions asked are divided into the following sections: A. Personal information on the respondent: household size, rural/urban residence, household income, and body size (height and weight). B. Local food environment of respondent: mix of stores available now and in the past and relative accessibility of different food store types.
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C. Food shopping behavior: frequency of visiting different food store types, types of food purchased at each store, time and money spent on food shopping. D. Food consumption behavior of respondent: frequency of eating certain types of foods, fruit and vegetable consumption, and a 24-hour food diary. Data derived from these supplementary questionnaires will then be linked to the other information already provided by respondents in the 2005 and 2009 whole cohort questionnaires and informative associations analyzed. Information from these previous questionnaires will include sociodemographic information, physical and mental health indicators (including disease history and self-rated health), health risk behaviors (including smoking and alcohol), and family history. It will then be possible to characterize respondents as using modern, traditional, or mixed venues and describe these groups in terms of socioeconomic status, urban rural residence, demographic characteristics, health indicators, and importantly, terms of dietary differences. Implied will be the assessment of whether shoppers who favor modern food retail outlets have progressed further along the nutrition transition by comparing the quality of their diets with traditional shoppers.
Qualitative Research on Food Purchasing Patterns Mail-based quantitative questionnaires can only produce data within the limits of the questions and answers offered. A qualitative study will therefore be conducted to gather in-depth information. A subsample of respondents to the mailed food environment questionnaire will be asked whether they are willing to host a researcher for a short period to accompany them on their usual shopping trips. From among those who respond positively, a random selection of six participants from each region of Thailand (enough to achieve information saturation; Guest et al., 2006) will be selected to participate in a brief study consisting of “accompanied shopping trip(s)” (Jackson et al., 2006), providing an opportunity to discuss their activities. These qualitative insights on influences on food provisioning and consumption behavior will help to flesh out the findings from the quantitative study, allowing us to understand in a deeper manner how Thai food culture is being experienced by modern Thais and how values and personal preferences are formed, which is information that is difficult to derive quantitatively. Observing actual shopping behavior as it occurs will help us to understand the various factors that influence food purchasing decisions beyond the economic and enable us to understand the values associated with various retail formats including cultural predilections and preferences.
CONCLUSIONS There are few existing studies of the links between food environments, food retail options, and health outcomes in developing countries. Existing studies in such settings often describe the situation from an economic perspective, rather than considering impacts on food culture and nutrition. Most studies have been
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conducted in developed Western countries that have fundamentally different food retail sectors from countries such as Thailand, where the modernizing of food retailing and the globalization of diets are much more recent. The qualitative and quantitative information that the current study produces will be valuable in helping determine to what extent changes in Thai food retailing are producing positive and negative impacts on the diets of Thai consumers, and also how these impacts are being experienced differentially depending on socioeconomic status, gender, area of residence, and other relevant factors. Our use of the existing TCS gives us access to an extensive database of information on the group being studied and the benefit of a long running research partnership with a strong multidisciplinary team of Thai and Australian researchers. Resulting information will potentially be of use to Thai policy makers who are currently considering approaches to addressing the rapid rise in obesity and diet-related disease in Thailand. Current approaches are primarily focusing on individual behavior modification through public education campaigns on diet and exercise and improved food nutrition labeling. These approaches have experienced some past success in Western countries. By the late 1990s, however, it was becoming clear that a combination of medical intervention and consumer education on risky eating behaviors was not enough. A new approach to addressing consumption-related disease is now being adopted by many national and international bodies, which focuses on the broader “obesogenic” environment (Chopra, 2002). Quantifying and qualifying the role of different food retail formats in fostering an obesogenic environment in Thailand will assist in developing policies that support the access of Thai consumers to affordable healthy food options and help in identifying ways in which upstream and downstream factors influence food provisioning and dietary choice.
REFERENCES Aekplakorn, W., Hogan, M.C., Chongsuvivatwong, V., Tatsanavivat, P., Chariyalertsak, S., Boonthum, A., Tiptaradol, S., Lim, S.S., 2007. Trends in Obesity and Associations with Education and Urban or Rural Residence in Thailand. Obesity 15, 3113–3121. Burns, C., Inglis, A., 2006. The relationships between the availability of healthy and fast food and neighbourhood level socio-economic deprivation: a case study from Melbourne, Victoria. Obesity Reviews 7, 39. Chopra, M., 2002. “Globalisation and food: implications for the promotion of healthy diets. Globalisation, diets and non-communicable disease”. World Health Organization, Geneva. Cummins, S., Macintyre, S., 2006. Food environments and obesity—neighbourhood or nation? International Journal of Epidemiology 35, 100–104. Drenowski, A., Popkin, B.M., 1997. The nutrition transition: new trends in the global diet. Nutrition Reviews 55, 31–43. ESCAP, 2008. “Improving vital statistics and cause of death statistics: The experience of Thailand”. Economic and Social Commission for Asia and the Pacific, Bangkok. Food and Agriculture Organization, 2006. Dietary energy consumption of countries. FAO, Rome.
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Ford, P.B., Dzewaltowski, D.A., 2008. Disparities in obesity prevalence due to variation in the retail food environment: three testable hypotheses. Nutrition Reviews 66, 216–228. Guest, G., Bunce, A., Johnson, L., 2006. How many interviews are enough? An experiment with data saturation and variability. Field Methods 18, 59–82. Hattersley, L., Dixon, J., 2010. Supermarkets, food systems and Public Health: facing the challenges. In: Lawrence, G., Lyons, K., Wallington, T. (Eds.), Food security, nutrition and sustainability, Earthscan, London. Hawkes, C., 2008. Dietary implications of supermarket development: a global perspective. Development Policy Review 26, 657–692. Jackson, P., Perez del Aguila, R., Clarke, I., Hallsworth, A., De Kervenoael, R., Kirkup, M., 2006. Retail restructuring and consumer choice 2. Understanding consumer choice at the household level. Environment and Planning A 38, 47–67. Jaibun, K., 2006. Markets and ways of life: an intital investigation into research on markets and the Thai way of life. In: Chaisingkanon, S. (Ed.), Markets in life and life in markets, Centre for the Study of the Humanities, Bangkok. Joint WHO/FAO Expert Consultation, 2003. “Diet, nutrition and the prevention of chronic diseases.” Report of a joint WHO/FAO expert consultation. WHO Technical report series 916, 34–38. Kelly, M., Banwell, C., Dixon, J., Seubsman, S., Yiengprugsawan, V., Sleigh, A., 2010a. Nutrition transition, food retailing and health equity in Thailand. Australasian Epidemiologist 17, 4–7. Kelly, M., Strazdins, L., Dellora, T., Khamman, S., Seubsman, S., Sleigh, A., 2010b. Thailand’s work and health transition. International Labour Review 149, 373–386. Kosulwat, V., 2002. The nutrition and health transition in Thailand. Public Health Nutrition 5, 183–189. Lake, A., Townshend, T., 2006. Obesogenic environments: exploring the built and food environments. The Journal of the Royal Society for the Promotion of Health 126, 262–267. Minten, B., Reardon, T., 2008. Food Prices, Quality, and Quality’s Pricing in Supermarkets versus Traditional Markets in Developing Countries. Applied Economic Perspectives and Policy 30, 480–490. Nielsen, A.C, 2006. “Asia Pacific Retail and Shopper Trends”. Available at: (accessed March 2012). Satheannoppakao, W., Aekplakorn, W., Pradipasen, M., 2009. Fruit and vegetable consumption and its recommended intake associated with sociodemographic factors: Thailand National Health Examination Survey III. Public Health Nutrition 12, 2192–2198. Schaffner, D., Bokal, B., Fink, S., Rawls, K., Scweiger, J., 2005. Food retail-price comparison in Thailand. Journal of Food Distribution Research 36, 167–171. Shannon, R., 2009. The transformation of food retailing in Thailand 1997-2007. Asia Pacific Business Review 15, 79–92. Sleigh, A., Seubsman, S., Bain, C., and the TCS team., 2008. Cohort profile: the Thai cohort of 87,134 Open University students. International Journal of Epidemiology 37, 266–272. Vandergeest, P., 2006. “Natural markets: remaking food and agriculture in Southeast Asia”. Paper presented at the 2006 Annual Meeting of the Association of American Geographers, March 7–11, Chicago, IL. Warr, P., 2005. “Thailand: Beyond the crisis”. Routledge, Oxon. Webster, D., 2005. Urbanization: new drivers, new outcomes. In: Warr, P. (Ed.), Thailand Beyond the Crisis, Routledge, Oxon. Wilbulpolprasert, S. (Ed.), 2008. “Thailand Health Profile 2005–2007”. Ministry of Public Health, Bangkok. World Bank, 2011. Thailand Now an Upper Middle Income Economy. Available at: < http:// go.worldbank.org/OQV5D81040> (accessed March 2012).
Thai Food Culture in Transition: A Mixed Methods Study on the Role of Food Retailing Matthew Kelly, Cathy Banwell, Jane Dixon, Sam-ang Seubsman, and Adrian Sleigh The Australian National University, Canberra, Australia
INTRODUCTION In the modern world, urbanization, industrialization, and technological change have transformed food systems, affecting food production, processing, distribution, and retailing. A new globalized food environment has been created with transnational food corporations increasingly controlling all four of these aspects of the food system. Accompanying the changes have been profound changes in diet for much of the world’s population. Traditional diets, particularly in urban areas, are being replaced by diets higher in fats, salts, sugar, and animal products and often with lower intakes of fresh fruits and vegetables—a nutrition transition. Such fundamental changes to the food system, along with increasing food availability and diversity, have helped countries worldwide reduce their levels of malnutrition and produce healthier populations in the short term. But in recent decades countries around the world, even the poorest countries, have begun to experience an epidemic of obesity and diet-related disease (Drenowski and Popkin, 1997; Chopra, 2002). Thailand is a country with a strong food culture that is intimately connected to local agriculture and retail markets, which provide affordable sources of healthy fresh foods. It is important in this context to examine ways in which changes to this food culture may impact the health status of the Thai people. The ways in which local food cultures and diets react to these upstream influences in the global food system are complex and difficult to characterize. Teasing apart the positive and negative influences of a modernizing food system in developing country contexts is particularly problematic. However, the task is researchable and in this chapter we describe one approach adopted by a contemporary study in Thailand. This research assesses the interaction between the When Culture Impacts Health. http://dx.doi.org/10.1016/B978-0-12-415921-1.00027-0 Copyright © 2013 Elsevier Inc. All rights reserved.
319
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rapid modernization of food retailing in Thailand, Thai food culture and food preferences, and nutrition and health outcomes for Thai people in a context of rapidly rising obesity and diet-related diseases. To accomplish this, building on an overarching longitudinal study of the health-risk transition in Thailand (The Thai Cohort Study; TCS), an innovative mix of quantitative and qualitative methods is employed, as detailed below in the section Thai Food Culture Transition Study.
THAI TRANSITIONS Economic Growth, Poverty Reduction, and Health Transitions Thailand is a Southeast Asian country that has achieved a rapid and fundamental transformational economic growth and development over the past four decades. This has been achieved from a very low economic base; after World War II Thailand was considered one of the world’s poorest countries and had not been observed to have experienced substantive economic growth for a century before this time. Since the 1960s, however, and accelerating in the 1980s, industrial development, as well as the commercialization of agriculture, resulted in 40 years of GDP growth (Warr, 2005). Thailand is now an upper middle income country with an annual GDP per capita of $4600 (World Bank, 2011). Economic growth in Thailand has occurred in a period of globalization and has involved profound social, cultural, and lifestyle changes for the Thai population. In 1960 over 80% of the Thai workforce was agricultural, and by the late 2000s this figure had fallen to around 35% (Kelly et al., 2010b). The changes in employment have also been accompanied by a process of urbanization; nearly half of all Thais now live in urban areas (Webster, 2005). These workforce changes and moves toward more modern urban lifestyles have repercussions for the health behaviors and nutrition profiles of Thai people.
Health and Nutrition Transitions in Thailand In Thailand the major health challenges of poverty—malnutrition, high mortality, and infectious disease—are being replaced by increased longevity, lower mortality, and an increasing prevalence of chronic disease. Between 1964 and 2006 Thai life expectancy increased from 56 to 70 for males and from 62 to 78 for females; the maternal mortality ratio fell from 374.3 to 9.8 per 100,000 live births and the infant mortality rate from 49 to 21 per 1000 live births (Wilbulpolprasert, 2008). However, recent decades have seen increases in cardiovascular disorders, diabetes, obesity, cancers, and traffic injuries. Eight of the top ten causes of death in Thailand can now be related to modern lifestyles (ESCAP, 2008). An important factor in this change in health profile is the rapid change in the diet of the Thai population. Traditional Thai diets can be considered to be protective against chronic diseases, being rich in cereals, legumes, and fresh
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fruit, vegetables, and herbs, with the majority of protein coming from fish. Urbanization and modernization have meant an increasing demand for both more convenient foods and more modern foods, which are more processed and higher in fats, animal proteins, and sugars (Kosulwat, 2002). Indeed while per capita sugar consumption in Thailand was estimated at about 7 kg/year by 1983, this figure was 33.2 kg by 2006 (Wilbulpolprasert, 2008) and between 1969 and 2003 the estimated intake of kilocalories in Thailand increased from 2110 to 2400 (Food and Agriculture Organization, 2006). In addition to increases in the amount of fat and animal protein consumed, just as concerning may be decreases in fresh fruit and vegetable consumption, with only around one-quarter of adult Thais meeting recommended intakes (Satheannoppakao et al., 2009). Through this period severe malnutrition has been virtually eliminated in Thailand while in the last 20 years obesity has rapidly developed as a new problem with prevalence growing four times in the last two decades. By 2009 obesity (body mass index ≥ 25) affected 40.7% of women and 28.4% of men. This is now an important public health concern in Thailand (Kosulwat, 2002; Aekplakorn et al., 2007; Wilbulpolprasert, 2008). In addition to obesity, related health problems of diabetes, gallbladder disease, and some cancers are expected to become significant problems for the Thai population in coming years.
Changes in the Food Retailing Sector in Thailand In Thailand the fresh market (talad sot) has for centuries been a center of Thai communities. Marketplaces are part of the ritual, symbolic, and cultural life of Thai people and function as repositories of local food culture and ingredients, regionally and nationally. Importantly, markets in Thailand also function as social centers maintaining social capital for Thai communities and a source of livelihood for large numbers of poorer Thais, especially women, who predominate as stall holders in fresh markets (Jaibun, 2006). In recent decades these traditional formats have been joined by modern food retailing outlets including convenience stores (especially 7-11 stores), supermarkets, and hypermarkets. This process began in the 1980s with the opening of the first supermarkets in Bangkok. Retail change accelerated after the 1997 Asian Financial Crisis and resulting deregulation of foreign investment in food retailing with transnational food corporations (TFCs) including Tesco and Carrefour increasing their store numbers, store sizes, and spreading the reach of modern food retailing into provincial centers outside Bangkok for the first time (Kelly et al., 2010a). Since 1997 the number of modern food retail outlets in Thailand has increased from 1290 to 6654 with the largest growth occurring at the two ends of the food retail spectrum in hypermarkets and convenience stores. Perhaps even more striking is the growth of market share of modern food retail, which was only around 5% in 1980 but grew to nearly 50% by 2006 (AC Nielsen, 2006; Shannon, 2009).
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As supermarkets control more of the food supply and diet-related diseases escalate it is important to consider the links between supermarkets and nutrition outcomes. Supermarkets respond to consumer demand to some extent (in Western countries they are starting to respond to health concerns), but they also create consumer preference (Hawkes, 2008). Supermarkets also have differing influences on nutrition in developing and already developed countries. In most Western developed countries supermarkets are an essential source of dietary diversity and affordable fresh foods. They achieve this position through their economies of scale and vertical supply chain efficiencies including subcontracting farmers to grow food directly for them. In developing countries, however, supermarkets may have a more ambiguous effect on public health. Supermarkets often first concentrate on the processed, packaged foods that they can deliver cheaply and where they receive the highest profit margin, allowing aggressive price discounts and promotions. The processed packaged foods offered through modern retail outlets are also often new novel foods that attract customers; however, these are often the very foods associated with negative outcomes of the nutrition transition (Hawkes, 2008; Hattersley and Dixon, 2010). At the international level, studies, including a joint World Health Organization/ Food and Agriculture Organization (WHO/FAO) expert consultation, implicate the spread of food outlets selling energy-dense foods in population weight gain (Joint WHO/FAO Expert Consultation, 2003; Burns and Inglis, 2006). The increasing market share of modern retail in Thailand now is beginning to impact traditional food retail outlets. Consequently, making obesogenic foods more available and affordable as described above may also make affordable fresh healthy foods more expensive and harder to access. Prices for fresh fruits and vegetables have also been shown to be consistently lower at traditional fresh markets in Thailand than in modern retail formats (Schaffner et al., 2005; Vandergeest, 2006). Thai hypermarkets sell processed products 12% cheaper and fresh foods 10% cheaper than traditional retailers (Minten and Reardon, 2008). In Thailand public health policy responses to the rapidly growing problem of diet-related chronic disease are well under way. Programs target physical activity, healthy body size, and appropriate diet particularly for school-age Thais. However, economic change, foreign investment laws, and international trade agreements mean that the Thai food environment is now fundamentally linked to the globalized trade in food and modern retail outlets that now control around half of the Thai food retail sector. It is important therefore for Thailand to understand, in a more holistic manner, the factors influencing nutritional outcomes for its people. There have been few studies to date that investigate how changes in the food environment, and particularly changes in the food retailing sector, impact population nutrition in developing countries. Here we discuss a collaborative study conducted by the Australian National University and Sukhothai Thammathirat Open University (STOU) in Bangkok, which tackles this topic.
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THAI FOOD CULTURE TRANSITION STUDY Research Question The aim of the collaborative food culture transition study is to understand how changes in the food system in Thailand, particularly in food retailing and provisioning behavior, interact with changes in diet and health outcomes. The objective is to analyze the interaction between the food environment in Thailand and individual- and household-level food provisioning behavior and links between this food provisioning and health and nutritional outcomes. The research question posed to answer this objective was what effect has the rapid growth in modern food retailing in Thailand had on individual food provisioning behavior and nutritional outcomes? We hypothesize that persons who mainly shop at modern food retailers will make distinctive food choices and these will be reflected in their nutritional outcomes.
Difficulties in Measuring Food Environments and Connecting with Health Outcomes Measuring the influence of environmental factors on health is complex. The physical design of a person’s environment, the socioeconomic structure, or even the dominant culture can all influence how an individual interacts with his or her environment and the health implications of that interaction (Lake and Townshend, 2006). These observations also apply to individuals’ food environments. The influence on health outcomes of supermarket presence depends on the range of goods sold at the supermarket, the relative prices of food types, and the mix of food retail outlets that are available within that food environment. Importantly, although studies have been carried out on the relationship between food environments and health, very few have been able to establish a causative relationship, that is, low availability of fresh foods in poorer areas may be due to low demand from those societal groups rather than low supply causing unhealthy diets (Cummins and Macintyre, 2006). What is clear, however, is that individual health behaviors including food intake are influenced by many factors at multiple levels, and frameworks now exist for empirically describing food environments with factors including availability, accessibility, and relative pricing of different food types all contributing to the obesogenicity of a given food environment (Ford and Dzewaltowski, 2008).
Methodology for Thai Food Culture Transition Study The Thai setting is significantly different from those described in much of the existing literature on food environments, food retailing, and nutrition. Indeed, there are very few examples of this type of study in developing nations where the modernization of food retailing is more recent and traditional food retail outlets persist and perhaps a greater variety of food sources are available. In
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the study described here we attempt to address this issue of the links between food retail environment, food provisioning choices, and nutritional outcomes in Thailand. Rather than attempting, as the studies discussed above, to measure objectively the constitution of particular food environments, we have chosen to use people’s own perceptions of what constitutes their local food environment and what food retail choices they have available to them and to link those perceptions to these individuals’ food shopping and dietary patterns. The Thai food culture transition study adopts a mixed quantitative and qualitative approach and connects to a long running study of health transitions in Thailand, the TCS. The TCS involves researchers based at the Australian National University in Canberra and STOU in Bangkok. The study involves a large multidisciplinary team consisting of epidemiologists, anthropologists, sociologists, demographers, and nutritionists in both Australia and Thailand who are bringing their combined expertise to bear on understanding the changes that are occurring in the health of the Thai population. The varied expertise involved in the team allows a unique analysis of the sociocultural as well as medical determinants of these health transitions. The team has been conducting joint research for nearly eight years and has produced much new information with nearly 60 publications so far addressing varied aspects of the health status of the Thai population. In 2005 the TCS sent a 20-page questionnaire to all 200,000 registered STOU students. Completed questionnaires were received from 87,134 people who then formed the baseline cohort for the study. Topics covered in the baseline questionnaire included sociodemographic and economic details, height and weight, injury and disease history, food and physical activity, tobacco and alcohol use, and transport behavior. In 2009 a four-year follow-up was conducted with a response rate of around 70% (60,000 respondents). The follow-up questionnaire covered broadly similar topics to the baseline. The members of the TCS have a similar geographic and demographic distribution to the general Thai population but are somewhat more urbanized and more highly educated. Urbanization and tertiary education are important mediators in the adoption of modern ideas and behaviors and thus this Thai Cohort will be an ideal group in which to study the effects of the transitions under way in Thailand, perhaps indicating future trajectories in the general Thai population (Sleigh et al., 2008).
Quantitative Study The quantitative part of the research on food culture transition will utilize data derived from the TCS. A subsample of 3,500 members of the Thai Cohort living in the four distinct regions of Thailand and Bangkok also will be sent a supplementary questionnaire covering various aspects of their food environment and food provisioning behavior. The questions asked are divided into the following sections: A. Personal information on the respondent: household size, rural/urban residence, household income, and body size (height and weight). B. Local food environment of respondent: mix of stores available now and in the past and relative accessibility of different food store types.
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C. Food shopping behavior: frequency of visiting different food store types, types of food purchased at each store, time and money spent on food shopping. D. Food consumption behavior of respondent: frequency of eating certain types of foods, fruit and vegetable consumption, and a 24-hour food diary. Data derived from these supplementary questionnaires will then be linked to the other information already provided by respondents in the 2005 and 2009 whole cohort questionnaires and informative associations analyzed. Information from these previous questionnaires will include sociodemographic information, physical and mental health indicators (including disease history and self-rated health), health risk behaviors (including smoking and alcohol), and family history. It will then be possible to characterize respondents as using modern, traditional, or mixed venues and describe these groups in terms of socioeconomic status, urban rural residence, demographic characteristics, health indicators, and importantly, terms of dietary differences. Implied will be the assessment of whether shoppers who favor modern food retail outlets have progressed further along the nutrition transition by comparing the quality of their diets with traditional shoppers.
Qualitative Research on Food Purchasing Patterns Mail-based quantitative questionnaires can only produce data within the limits of the questions and answers offered. A qualitative study will therefore be conducted to gather in-depth information. A subsample of respondents to the mailed food environment questionnaire will be asked whether they are willing to host a researcher for a short period to accompany them on their usual shopping trips. From among those who respond positively, a random selection of six participants from each region of Thailand (enough to achieve information saturation; Guest et al., 2006) will be selected to participate in a brief study consisting of “accompanied shopping trip(s)” (Jackson et al., 2006), providing an opportunity to discuss their activities. These qualitative insights on influences on food provisioning and consumption behavior will help to flesh out the findings from the quantitative study, allowing us to understand in a deeper manner how Thai food culture is being experienced by modern Thais and how values and personal preferences are formed, which is information that is difficult to derive quantitatively. Observing actual shopping behavior as it occurs will help us to understand the various factors that influence food purchasing decisions beyond the economic and enable us to understand the values associated with various retail formats including cultural predilections and preferences.
CONCLUSIONS There are few existing studies of the links between food environments, food retail options, and health outcomes in developing countries. Existing studies in such settings often describe the situation from an economic perspective, rather than considering impacts on food culture and nutrition. Most studies have been
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conducted in developed Western countries that have fundamentally different food retail sectors from countries such as Thailand, where the modernizing of food retailing and the globalization of diets are much more recent. The qualitative and quantitative information that the current study produces will be valuable in helping determine to what extent changes in Thai food retailing are producing positive and negative impacts on the diets of Thai consumers, and also how these impacts are being experienced differentially depending on socioeconomic status, gender, area of residence, and other relevant factors. Our use of the existing TCS gives us access to an extensive database of information on the group being studied and the benefit of a long running research partnership with a strong multidisciplinary team of Thai and Australian researchers. Resulting information will potentially be of use to Thai policy makers who are currently considering approaches to addressing the rapid rise in obesity and diet-related disease in Thailand. Current approaches are primarily focusing on individual behavior modification through public education campaigns on diet and exercise and improved food nutrition labeling. These approaches have experienced some past success in Western countries. By the late 1990s, however, it was becoming clear that a combination of medical intervention and consumer education on risky eating behaviors was not enough. A new approach to addressing consumption-related disease is now being adopted by many national and international bodies, which focuses on the broader “obesogenic” environment (Chopra, 2002). Quantifying and qualifying the role of different food retail formats in fostering an obesogenic environment in Thailand will assist in developing policies that support the access of Thai consumers to affordable healthy food options and help in identifying ways in which upstream and downstream factors influence food provisioning and dietary choice.
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