Economic transition and household food

consumption: A study of Bulgaria

from 1985 to 2002

Ludmila Ivanova a, Plamen Dimitrov a, Dora Ovcharova a,Jocilyn Dellava b, Daniel J. Hoffman b,*

a National Center of Public Health Protection, Sofia, Bulgariab Department of Nutritional Sciences, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA

Received 8 August 2006; received in revised form 9 August 2006; accepted 9 August 2006

Abstract

Major economic transitions typically entail changes in the availability of and purchasing power for

different types of foods leading to long-term changes in the composition of the diet. Bulgaria, a former

Eastern Bloc country, underwent a difficult and protracted transition from a centralized to market economy

with acute economic crises and a much slower recovery of income levels than in Poland, the Czech

Republic, and Hungary. Using annual data from the Bulgarian National Household Survey, we study

changes in the reported consumption of major foods (excluding alcoholic drinks) and their constituent

macronutrients from 1985 to 2002, examining also the differences in dietary patterns between the period

prior to and following the transition. The consumption of most major food items decreased, resulting in a fall

in per capita energy consumption of 429 kcal/day (1.80 MJ/d), following the economic transition of 1991.

As expected, the consumption of foods that were more expensive per unit of energy decreased greater than

cheaper foods, �34% for animal products and �19% for visible fats, but only �10% for carbohydrates.

These changes are related to the changes in income and market prices as well as the general negative trend in

economic growth and hyperinflation in the mid-1990s. Thus, Bulgaria experienced a decrease in food

consumption without significant changes in the dietary pattern following the economic transition of 1991.

The fact that part of this decline may be attributed to continued economic challenges suggests that future

transitions in the diet may be expected as economic development proceeds.

# 2006 Elsevier B.V. All rights reserved.

JEL classification : I1

Keywords: Economic transition; Diet; Agriculture; Food policy; Chronic diseases; Bulgaria; Food consumption;

Nutrition

http://www.elsevier.com/locate/ehb

Economics and Human Biology 4 (2006) 383–397

* Correspondence to: 26 Nichol Avenue, New Brunswick, NJ 08901, USA. Tel.: +1 732 932 6568; fax: +1 732 932 6522.

E-mail address: dhoffman@aesop.rutgers.edu (D.J. Hoffman).

1570-677X/$ – see front matter # 2006 Elsevier B.V. All rights reserved.

doi:10.1016/j.ehb.2006.08.001

1. Introduction

Dietary changes associated with major economic changes have been studied in many

countries (Jahns et al., 2003; Lipoeto et al., 2004). The majority of these studies have focused on

the nutritional changes that follow improved economic growth stimulated by economic

development (Holmboe-Ottesen, 2000; Popkin, 2002). However, there is limited information

available on nutritional changes following either drastic economic transitions or acute economic

crises, outside of wartime. Historically, significant economic crises have actually resulted in

moderate health benefits as the ability to purchase foods associated with chronic diseases (e.g.

animal products) was diminished and was accompanied by a decline in diet-related diseases

(e.g. cardiovascular disease and stroke) (Strom and Jensen, 1951). Such economic changes can be

one of the more immediate factors that have long-term effects on diet and health since they

directly affect a country’s ability to produce food, foster agricultural production, and enhance

economic growth. Moreover, maintaining a healthy level of physiological capital is key to

promoting economic health and sustained development (Fogel, 2004). Thus, it is of interest to

study economic disruptions and crises and their affect on diet in transitional economies.

Specifically, changes from a centrally planned to a market economy, such as that experienced

by Bulgaria after 1991, involve radical changes affecting food prices, including changes to

producer and consumer subsidies and taxes. Also, when there is a severe downturn in a nation’s

economy, the ability to purchase foods that are more expensive per unit of dietary energy

decreases (FAO, 2004b). These factors interact and impinge upon a population’s ability to obtain

a healthful diet. In addition, the percent of health care financing by the government decreased

from 100% in 1989 to less than 50% in the 1990s (Koulaksazov, 2003) creating the potential for

long-term health problems if services are reduced to citizens without private health insurance.

High levels of illness and premature death from vascular diseases characterized Bulgaria in the

pre- and post-transition period and this high level of morbidity and mortality from chronic

diseases may impair prospects for economic recovery (McKee and Suhrcke, 2005). Therefore, it

is essential to study such changes and their effect on food intake as diet has been shown to be a

key factor that promotes health and prevents disease.

Countries that were once part of the former Council for Mutual Economic Assistance

(COMECON) have reported a complex set of social, governmental, and economic transitions

following a dramatic shift in geopolitical structure. Relative to nutrient intake, following the

transition from a centralized to market economy, agricultural and economic reforms and

development began to rapidly unfold in most of these countries. As would be expected, some

countries are reporting a generalized inadequate intake of foods and diet (Parizkova, 2000).

However, most countries appear to be experiencing greater food security with an overall increase

in food intake since 1990 (Dofkova et al., 2001; Kowrygo et al., 1999; Parizkova, 2000). Bulgaria

is unique among former COMECON countries for several reasons. Agricultural production had

thrived before the collapse of COMECON as a result of exporting many foodstuffs to Russia and

other parts of the Soviet Union (US Library of Congress, 2005). In turn, Bulgaria had access to

low-cost energy and raw materials from the Soviet Union. This financial advantage allowed

Bulgaria to subsidize several industries and food products, but these subsidies began to decrease

following 1991; the loss of subsidies in Bulgaria was perhaps even more severe than in other

former COMECON countries (World Bank, 2001). Bulgaria was unable to maintain this structure

of agribusiness, while moving from a centralized to a market economy in 1991 and eliminating

governmental price fixing. Perhaps, the most important factor that makes Bulgaria unique among

former COMECON members is that Bulgaria’s transition was slow and plagued by debt,

L. Ivanova et al. / Economics and Human Biology 4 (2006) 383–397384

corruption, and hyperinflation (World Bank, 2001). Thus, Bulgaria’s transition had many effects

on agricultural production and marketing, demographics (e.g. increased population of retirees

and emigration of younger persons), income, economic growth and stability, and diet.

In addition to the structural changes Bulgaria has experienced since 1991, Bulgaria has

undergone a series of economic crises that prompted several changes to the economic structure. For

example, in the mid-1990s, Bulgaria’s economy rapidly contracted and in some years inflation

exceeded 2000% (IME, 1999). Aside from these economic problems, the United Nations’ (UN)

sanctions against Iraq and Serbia in 1992, as well as the Kosovar Civil War in 1999, reduced foreign

demand of domestically produced goods, causing further harm to the economy (IME, 1999). The

economic changes that Bulgaria has experienced in the past 15 years, beginning with a radical

change in their economic system, to a period of economic contraction, followed by a rapid increase

in inflation and the accompanying economic recovery, all create a novel backdrop against which the

dietary changes experienced by the Bulgarian people can be studied, especially as they move into a

period of real development with economic and structural progress. As Bulgaria is poised to enter the

European Union, it is unclear how its people fared nutritionally during the last 15 years of economic

transition following the fall of the Soviet Union. Therefore, the objective of this paper is to describe

the changes in the Bulgarian diet following the shift from centralized to market economy and

following the economic crises of the 1990s.

2. Data and methods

We examine dietary changes in Bulgaria from 1985 to 2002. Data studied has been derived

from the Bulgarian National Household Budget Survey that has been conducted using surveying

practices and procedures established by the Bulgarian National Statistical Institute (NSI, 2003).

Briefly, two stages of random sampling were employed to generate a geographically

representative sample of Bulgaria: first, random sampling in the census districts was conducted;

second, individual households with one or more persons were randomly selected for the

administration of the survey. Proportions were used to create the selection blocks from which

households were chosen; households were not chosen based on the number of members residing

in the household and participation was voluntary. Due to voluntary participation, replacements

were made to achieve the desired sample sizes. The sample size of each survey varied from 6000

households in 1995–1997 to 3000 households in 1997, 1998, 1999, and 2002. The average

household size was constant for each of the years surveyed. Different households were selected

for each year, except for the years 1995–1997. Participants were required to keep a diary of all

sources of income and expenditure including food and non-food products, food produced at

home, number of ‘‘days of absence,’’ number of people consuming meals in each household, and

household changes. Interviewers went to each household twice a month for 1 year for each annual

survey.

Yearly totals were calculated using weighted means based on the monthly data. Following

1999, household expenditures were formatted to meet EUROSTAT requirements and

Classification of Individual Consumption by Purpose (COICOP) classifications and years

1995–1998 were reformatted to meet this standard. Dietary consumption was based on the

reported per capita daily caloric consumption of each food item analyzed. The caloric equivalent

of reported household food consumption, derived form reported purchase and consumption

patterns of each household, was calculated using the Bulgarian database for commonly

consumed foods. This database is maintained by the National Center for Public Health Protection

and is updated as new foods are introduced into the country. The macronutrient composition of

L. Ivanova et al. / Economics and Human Biology 4 (2006) 383–397 385

the diet was calculated to reflect the proportion of the diet that is composed of fat, protein, and

carbohydrates.1 Consumption of foods and nutrients was calculated per capita by dividing the

calculated household consumption by the number of individuals reported to be residing in the

household surveyed.

Individual food items selected for analysis included bread, flour, rice, meat, meat products, eggs,

milk, yogurt, white cheese, fresh fruit, fresh vegetables, potatoes, oil, butter, margarine, lard, and

sugar. These items were grouped as follows: grain and grain products (i.e. bread, flour, and rice),

meat and dairy (i.e. meat, meat products, eggs, milk, yogurt, and white cheese), vegetables and

fruits (i.e. fruit, fresh vegetables, and potatoes), fats and sugar (i.e. oil, butter, margarine, lard, and

sugar). For the purpose of caloric calculations, poultry, beef, veal, lamb, mutton, goat, pork, and

poultry were included in the meat category as these were the only meat items for which complete

data were available. Only major dietary items with complete data available for each year were

analyzed; items lacking complete data for each year were excluded to preserve consistency.2

To estimate the energy consumption and percent of macronutrients of the diet, the conversion

factors noted earlier were used to estimate, from the grams of protein, fat, or carbohydrate in

particular food items. This allowed for the calculation of kilocalories per gram of each food item

and the percent of macronutrients in the diet. The data were calculated annually and by the two

periods, pre-transition (1985–1990) and transition (1991–2002).3 Statistical significance was set

at a p-value less than 0.05 and all statistical analyses were conducted using SPSS for Windows

12.0 (SPSS Inc., Chicago, IL, USA).

3. Results

The energy consumption in Bulgaria was decreased by 429 kcal/day/capita lower ( p < 0.05)

in the transition period compared to the pre-transition era (Table 1). Moreover, the consumption

L. Ivanova et al. / Economics and Human Biology 4 (2006) 383–397386

Table 1

Differences in per capita daily energy consumption and percent of calories as macronutrient between the pre-transition

(1985–1990) and transition period (1991–2002) (mean � S.D.)

Pre-transition Transition Difference

Total calories 2623 � 71 2194 � 180 �429

Carbohydrates (%) 48 51 3

Fats and sugar (%) 38 36 �2

Protein (%) 13 13 0

Note: Macronutrients are carbohydrates, fat, and protein.

1 The total caloric content of any one food is calculated by the mass of specific macronutrients contained in that food

(e.g. fat, protein, or carbohydrates). Standard conversions between grams of macronutrients to calories from macro-

nutrients was changed from 9.3, 4.3, and 4.3 kcal/g for fat, carbohydrates, and protein respectively to 9, 4, and 4 kcal/g to

make conversion between grams and calories simpler after 1989.2 Prior to 1995, margarine intake was included in the ‘‘oil’’ group, but following 1995 it was listed as an individual food

item and thus it was included in analysis. Alcohol was not included in the analyses of reported household food

consumption for two reasons. First, reported alcohol consumption accounted for less than 2–3% of calculated energy

consumption and is generally restricted to consumption by adult males and not the overall household. Second, reported

alcohol consumption did not change appreciably during the time period studied (from approximately 2.9% of household

energy consumption in 1985 to 1.8% in 2002).3 Years were grouped as such since the actual governmental changes associated with the dismantling of the Soviet

Union did not end until 1991.

of all major food items decreased following the economic transition (Table 2). However, there

were no significant changes in the macronutrient composition between these two periods.

Particularly large decreases were reported for meat, milk, yogurt, commercially prepared bread,

oil, butter, and sugar. In addition, there was a significant change in the percent contribution of the

different food groups to the total caloric intake: consumption of meat and dairy products

decreased (24% to 19%), grain products increased (48% to 54%) while other products had no

appreciable change.

Longitudinal analyses of the data showed that there was a significant decrease in the

consumption of almost all foods studied, except for flour, rice, lard, and potatoes, from 1985 to 2002

(Fig. 1). The overall reported consumption of lard decreased, but there was a period in the early part

of the transition during which the consumption actually increased (Fig. 1). The overall consumption

of fruits and vegetables did not change (Fig. 1). The consumption of meat and meat products

declined from 1985 to 2002, but the overall consumption of eggs was relatively stable (Fig. 1).

The pattern of energy consumption was parallel to the energy supply as estimated by the Food

and Agriculture Organization of the UN (FAO, 2004a) (Fig. 2). In terms of economic changes, the

L. Ivanova et al. / Economics and Human Biology 4 (2006) 383–397 387

Table 2

Differences in per capita daily energy consumption (kcal) of selected food products between the pre-transition (1985–

1990) and transition period (1991–2002) (mean � S.D.)

Food category Pre-transition Transition Change Relative contribution to

daily caloric intake (%)

Pre Post

Meat and dairy products

Meat 198 � 52 110 � 7 �88

Meat products 110 � 8 95 � 5 �15

Eggs 29 � 1 24 � 1 �5

Milk 92 � 5 62 � 2 �30

Yogurt 106 � 4 46 � 3 �60

Cheese 91 � 3 79 � 3 �12

Total 624 � 63 416 � 71 �208 24 19

Grains and grain products

Bread 1095 � 37 1000 � 18 �95

Flour 120 � 6 118 � 5 �2

Rice 54 � 3 51 � 2 �3

Sugar 132 � 16 96 � 9 �36

Total 1401 � 24 1265 � 95 �136 48 54

Fruits and vegetables

Vegetables 42 � 1 44 � 3 2

Potatoes 62 � 5 62 � 3 0

Fresh fruit 53 � 2 35 � 5 �18

Total 158 � 5 142 � 8 �16 6 6

Fat products

Oil 373 � 13 309 � 23 �64

Butter 44 � 1 17 � 10 �27

Lard 24 � 3 29 � 11 5

Margarine 0 � 0 16 � 15 16

Total 441 � 12 371 � 26 �70 17 17

Gross Domestic Product (GDP at purchasing power parity in real US dollars) declined

significantly following the fall of Communism and remained weak until after the economic crisis

of 1997. Following the crisis, the Bulgarian Lev was pegged to the Deutschmark (later to the

Euro) and has shown modest recovery since that time. Results from regression analyses (Table 3)

confirmed that caloric intake was not affected significantly by changes in the GNP. At the same

time, producer prices for foods increased slightly following the economic change of 1991, but

increased more rapidly during the period of hyperinflation, only to return to lower prices when

L. Ivanova et al. / Economics and Human Biology 4 (2006) 383–397388

Fig. 1. Longitudinal changes in dietary consumption of selected foods from 1985 to 2002 in Bulgaria. Source: Bulgarian

National Statistical Institute, Sofia, Bulgaria.

Table 3

Multiple linear regression analyses to determine the relationship between gross national product, economic transition, and

energy consumption in Bulgaria

Variable Coefficient Standard error p-Value

Constant 5.892 1.693 0.003

ln GNP 0.287 0.227 0.226

Transition �0.125 0.470 0.018

Total caloric intake as the outcome variable and log of GNP and economic transition (0: pre-transition and 1: post-transition)

as the independent variables, adjusted R2 = 0.50.

the economy stabilized (FAO, 2005). These changes in food prices paralleled the reported dietary

intake (Fig. 3), suggesting that food prices may be a significant factor in the decreased energy

intake of Bulgarians since 1989.

4. Discussion

The transition from a centralized to market economy in the countries of Eastern Europe has

spurred many economic crises, including near total collapse of some economies, episodes of

hyperinflation, devaluation of local currency, and the introduction of ‘‘shock’’ economic policies

(Marangos, 2002; Sachs, 1994, 2004). The Baltic countries, Poland, Slovenia, and the Czech

Republic have experienced relative success following their transition. While Romania, Bulgaria,

and some parts of former Yugoslavia, have met with greater challenges and have not experienced

the same degree of success. These economic crises have resulted in many changes in

demographic structure as well as in agricultural policies and production, all of which influence

the consumption of food in adequate quantities. Nutrition is a key part of forming a healthy

individual’s biological well being, essential to human capital, health, and long-term economic

development (Fogel and Costa, 1997). Therefore, it is important to understand how dietary

patterns and nutrition are influenced by significant changes in the Bulgarian economy.

In Bulgaria, the estimated consumption of energy from foods decreased by 429 kcal/day/capita

between the two periods analyzed. This was accompanied by a decreased consumption of meat,

bread, milk and yogurt, oil and butter, and sugar. We also observed that the dietary pattern shifted

slightly as the consumption of expensive foods, such as meats and dairy products, decreased while

that of cheaper grain products increased. While there are several distinct socio-economic factors

that could precipitate these dietary changes, it is absolutely necessary to preface any such

discussions with some comments on methodological factors that could bias the aggregated data

studied.

L. Ivanova et al. / Economics and Human Biology 4 (2006) 383–397 389

Fig. 2. Longitudinal changes in energy consumption in Bulgaria relative to estimated caloric supply and gross national

product. Source: Bulgarian National Statistical Institute, Sofia, Bulgaria.

For reported food consumption, there is always some degree of bias given the fact that people

are asked to recount their purchasing patterns and are free to provide or not provide information

related to their habits and income. For example, there was a relatively large non-response rate to

each of the budget surveys, although non-responders were replaced with households of similar

size in the same cluster. However, it is highly unlikely that the use of substitutes could account for

the changes reported above. The database of food composition is another potential source of bias.

Such databases are updated regularly to stay accurate with respect to the macronutrient content of

available foods. However, introduction of bias from the addition of new foods in the database

would most likely be random and not systematic. Finally, another source of potential bias rests in

the nature of aggregated data such as those we used in this study. Aggregated data do not allow for

stratification by income or education and limit our ability to look beyond the national averages

reported for the households surveyed. Still, these issues are common to any analysis of national

L. Ivanova et al. / Economics and Human Biology 4 (2006) 383–397390

Fig. 3. Reported per capita energy consumption from the Bulgarian Household Surveys and changes in (a) Food Price and

(b) Consumer Price Indexes from 1990–2002. Source: Bulgarian National Statistical Institute, Sofia, Bulgaria.

budget surveys and threaten only the generalizability of the data, not the conclusions that can be

drawn from surveys of randomly selected households.

4.1. Economics and diet in transitional countries

Changes in diet, such as those experienced by the Bulgarians, are intimately linked to its

economic and agricultural structure of a state. Simply put, food is needed to maintain health and

when food prices increased more rapidly than income, food security is threatened. In Bulgaria,

the average real per capita household income decreased by more than 1000% in the early 1990s

while the consumer price index increased by more than 2500% (Mishev et al., 2005). While there

was a major decrease in the reported energy consumption, there was only a modest shift in the

dietary pattern consumed by Bulgarians between the pre-transition and transition periods,

reflected by a shift from more expensive animal products to less expensive grain products. The

cost of food is a key factor in food selection and food purchasing and can often be more powerful

than personal taste or product preference (Pomerleau et al., 2002). To overcome either cost

increases or fluctuations, many households in Eastern Europe still maintain small agricultural

plots. These small plots provide an opportunity for households to grow food for personal

consumption and can help mitigate changes in market price or relative income. Since much of

what is grown for personal consumption are fruits and vegetables, use of these plots may

contribute to the stability of consumption patterns of these items. Many countries promote private

gardening and consumption of food items from family farms and gardens is very important

(Pomerleau et al., 2002). This may explain, in part, the reason that there was not a consistent

decline in fruit and vegetable intake among Bulgarians similar to what was found for other foods.

As reflected in many macroeconomic indicators, Bulgaria has experienced profound changes

in its economic structure. The growth rate was �9.1% in 1990, but the rate increased during the

early 1990s (WHO, 2000). Since 1997 Bulgaria has experienced consistent growth. At the same

time, unemployment has increased from 1.5% in 1990 to 18% in 2000 (Kolev, 2005; NSI, 2000).

The determination as to exactly how these changes influence agricultural production,

distribution, and diet of the Bulgarian people is beyond the scope of this paper. Yet, a broad

discussion regarding factors that are intimately related to household practices, and ultimately

diet, is warranted to fully explore how the transition may have influenced diet since 1990.

Household income, inflation, and unemployment play significant roles in food purchases and

consumption. Throughout the transition, Bulgaria experienced decreased real income and

increased inflation, exceeding 2000% per annum in 1997 (IME, 1999). As household income fell

and relative prices of food increased, food purchases and caloric consumption decreased (Fig. 3a).

In addition, with the rise of inflation, there was a concomitant decrease in reported food purchasing

and consumption (Fig. 3b), especially for more expensive foods. The proportion of income spent on

food items decreased in the latter part of the 1990s. In 1995, 49% of income was spent on food items,

but this proportion increased during the economic crises to 55% in 1997 and later decreased to

below its initial level to 45% in 1999 (Fig. 4) (NSI, 2003). Unemployment, a considerable problem

in Bulgaria following the fall of Communism, may also influence household income, although it has

been suggested that unemployment and retirement do not necessarily do so as newly unemployed

persons may receive income from the informal sector (Dimova et al., 2004). Nonetheless, changes

in unemployment are most likely going to influence a household’s ability to purchase quality food

items, especially during periods of economic crisis or transition.

Socio-demographic changes also influence the national diet and may even affect the energy

requirements. When young adults from Bulgaria emigrate, they leave behind a society that is

L. Ivanova et al. / Economics and Human Biology 4 (2006) 383–397 391

composed of children and older persons (Georgieva et al., 2002; Rangelova, 2003), both of whom

have lower energy requirements compared to persons between the ages of 20 and 30 years. This

shift could influence the structure of dietary demand, reflected by a decrease in reported energy

consumption, without a change in actual food patterns. In addition, there has been a decreased

birth rate from 39/1000 in the 1980s to 8.8/1000 in 2002. Furthermore, the index of aging

(number of people aged 65 years and over per 100 youths under age 15 years) increased from 29.2

in 1960 to 116.4 in 2002, reflecting a larger proportion of older than younger Bulgarians.

Unemployment even has the potential to influence energy requirements since an unemployed

individual is more likely to have a lower energy requirement compared to an employed

individual, accommodating a decreased energy intake. Combined, these changes have some

potential to contribute to a decreased energy requirement of the nation. This would explain why

the macronutrient composition (percent consumption of carbohydrate, protein, and fat) of the diet

did not change, despite changes in the dietary pattern, accompanied by a decreased reported

energy consumption following the transition. While any one of these factors could influence

individual household size, the loss of some individuals through migration would not influence the

aggregated data on household consumption.

4.2. Changes in agricultural production and policy influence food intake

The national policies established to promote agriculture often affect health and diet. In

Bulgaria, one set of policies that directly influenced both access to and production of agricultural

L. Ivanova et al. / Economics and Human Biology 4 (2006) 383–397392

Fig. 4. Proportion of reported household income spent on food and non-alcoholic beverages in Bulgaria from 1995 to

2002. Source: Bulgarian National Statistical Institute, Sofia, Bulgaria.

products was agricultural collectivization. By the late 1950s, 92% of the arable land was

collectivized. Near the end of the Communist era, as size restrictions were relaxed, personal

plots accounted for much of the agricultural output and even urban families began

establishing such plots. Following the transition, collective properties were sold or returned to

families in an attempt to restore family farms (Montiel, 1998). Unfortunately, local producers

faced difficulties finding export markets for agricultural products, but producers have also

been forced to compete with imports, which are often sold at lower prices than locally

produced goods. Thus, the shift from a centralized to market economy, with the

accompanying increase in family farms, most likely protected some individuals from

decreased food availability, but the overall result appears to have been a decline in production

and distribution, creating a considerable proplexus to the agricultural sector. This is illustrated

by the example of changes in two commodities that were found to have decreased in terms of

intake, grain and meat.

Grain production, such as wheat, corn, and barley, is a particularly difficult commodity

given its vulnerability to inclement weather. Thus, it was especially harmful to the Bulgarian

grain production when, following the transition, an initiative was undertaken to increase

the grain supply. However, much of the grain produced was used as animal feed. This

shift added a stress to the grain supply by creating a cycle in which domestic grain production

increased without an increase in available grain for human consumption. Thus, a gap in grain

production was created and resulted in an increased need for imported grain products.

This gap did not influence all grain products since the use of flour remained stable

from 1985 to 2002, but bread (most probably commercially prepared) consumption did

decline.

Similar to grain, livestock production underwent significant changes after 1991. Prior to the

transition, livestock consumption by the Bulgarian people in the pre-transitional period was

higher than dividing the transitional period. In addition, meat consumption was possible for

Bulgarians in part because of state subsidies for meat products, despite low real income (USDA

ERS, 2004). These subsidies reduced the price gaps between production and consumption and

may account for the high consumption of meat and animal products in the 1980s. Following the

transition, agricultural production decreased in general and large decreases in livestock

production were also reported (USDA ERS, 2004). In 1991, a reduction in feed rations for

animals was initiated, after which meat became scarce and expensive, especially in the urban

areas (LOC, 2005). The cumulative effect of these numerous and often overlapping policy

changes was an overall decrease in meat consumption. However, some minimal protein intake

was possible, most likely through less costly preserved meats and the common practice of

keeping livestock, even in peri-urban areas.

Finally, the elimination of governmental price fixing of food items in 1991 resulted in

increased food prices. Generally, all other factors remaining equal, such as income or

unemployment, increased food prices may result in decreased consumption of more expensive

foods. An intervention study in China found that an increase in the price of pork products,

designed to promote a lower fat intake, had essentially no effect on fat intake of higher income

persons, but had a deleterious effect on protein intake of lower income persons (Guo et al., 1999).

Thus, the differences in price elasticity for the same food between different income groups meant

little or no change for one and potentially severe consequences for the other. However, in

Bulgaria, other governmental policies worked to improve agriculture and food security. Thus,

some forces may have prompted a decreased intake while others may have protected the diet in

quality, but not in quantity.

L. Ivanova et al. / Economics and Human Biology 4 (2006) 383–397 393

4.3. Association between diet and chronic diseases in countries undergoing an economic

transition

Since the primary purpose of any discussion of diet and economy is the overall health or

physiological capital of a nation, it is necessary to describe changes in health following the

transition in Bulgaria. While a critical view of disease patterns in transitional countries suggests that

the health effects of development vary between gender and across age groups, with almost no effect

on chronic disease patterns for elderly persons (Salomon and Murray, 2002), we restrict our

discussion here to diseases most associated with diet, cardiovascular disease and heart disease.

The dietary changes we observed for Bulgaria are similar to many, but not all, countries that are

former COMECON nations. Briefly, there was a decreased energy consumption among 7 of the 21

former COMECON nations (e.g. Moldova, Ukraine, Uzbekistan, Tajikistan, Serbia-Montenegro,

Kazakhstan, and Hungary), but the decrease ranged from 200 to 500 kcal per capita. When we

consider countries that have experienced similar changes as Bulgaria, the general trend varies

depending upon the nutritional status prior to economic growth immediately following the

transition. For example, a survey of adolescents in various countries of Central and Eastern Europe

found that those from countries with a higher GDP consumed diets of poor quality (high in fat and

sugar, low in fruit and vegetables) compared to those from countries with a lower GDP (Parizkova,

2000). In Hungary, immediately following the transition, the intake of animal fats and protein

remained higher than nutritional recommendations, while the intake of micronutrients bordered on

deficiencies (Biro et al., 1996). A comparison of mortality rates due to cardiovascular disease in

Eastern Europe revealed a moderate decrease following 1994 and suggested that this decline may

have been due to a combination of changes in both diet and cardiovascular disease treatment

(Kesteloot et al., 2006). Poland serves as a unique model for this observation since it is not only

experiencing a decreased prevalence of chronic diseases, but has attributed some of this decline to

the decreased intake of animal protein as well as an increased intake of polyunsaturated fats, such as

rapeseed oil (Zatonski and Willett, 2005).

In Bulgaria, mortality from most chronic diseases, such as cancer and circulatory diseases,

have increased in the past few decades (WHO, 2005). In terms of diet-related diseases, the

mortality rate from ischemic heart disease for all persons decreased from 246 deaths (per

100,000 persons/year) in 1985 to 197 deaths in 2002 (WHO, 2005). Deaths from cerebrovascular

diseases, such as stroke, decreased from 254 deaths in 1985 to 1999 deaths in 2002 (WHO, 2005).

The relationship between diet and diet-related chronic diseases is complicated by concomitant

changes in demographics, physical activity, even changes in specific types of nutrients consumed

(e.g. a replacement of saturated fat with polyunsaturated fats or omega-3 fatty acids), all of which

are important, but beyond the scope of this paper. Nonetheless, it appears that as Bulgaria

continues to develop, we may anticipate a rise in the intake of processed foods, prompting an

even further increased prevalence of diet-related chronic diseases.

With respect to an anthropometric measures of nutritional status, the use of BMI is a generally

useful indictor of inadequate (BMI < 18.0) or excess energy intake (BMI > 30.0). Other

countries in Eastern Europe undergoing the nutrition transition report that BMI has increased

since the beginning of the economic transition. For example, the BMI of young men in Poland did

not change during the early period of the economic transition, but the BMI of all adults did

increase between 1995 and 2001 (Koziel et al., 2004). In Russia, the prevalence of obesity

(BMI > 30) has increased from 13% to 16% among adults during their period of transition (Jahns

et al., 2003). In the case of Bulgaria, only a few studies have reported BMI. The mean BMI of

men and women living in Sofia and Veliko Tournovo in the late 1990s was estimated as 26.2 and

L. Ivanova et al. / Economics and Human Biology 4 (2006) 383–397394

25.8 for men, and 27.0 and 26.8 for women (Georgieva, 2001; Vasilevski et al., 1998). A semi-

randomized survey of 1000 adults in Sofia (preliminary data from a study on retail sites and diet

collected between 2004 and 2005) suggest that the mean BMI for adults is 24.6, 25.30 for men

and 24.05 for women (Hoffman et al., 2006). Unfortunately, we have not found data on BMI in

the 1980s to which these values could be compared.

For most countries that have experienced an economic transition, the direction has been one of

increased development and sustained economic growth with accompanying increases in foreign

trade. The epidemiological change that accompanies such a transition is characterized by

increased urbanization, changes in diets from traditional to more processed foods, increased

intake of fat and sugar, and a shift in disease prevalence from communicable to non-

communicable diseases (Kim et al., 2000; Popkin, 2001; Vorster et al., 2005; WHO, 1998). This

concept has come under scrutiny given that the changes in disease prevalence associated with

development may not necessarily increase, especially when advance statistical methods are

applied to refined morbidity data (Salomon and Murray, 2002). Still, given the overwhelming

data from developing countries that support the concept that development fosters chronic disease

development, Bulgaria, based on our analyses, does not appear to be experiencing a new

‘‘nutrition transition’’. Simply, mortality from diet-related chronic diseases was already high in

the 1970s and the Bulgarian diet has remained relatively stable in terms of macronutrient

composition, but with lower caloric intake, following the economic transition. At the same time,

this is an important time in which to both study and report the diet in Bulgaria as the economy

becomes stabilized and economic growth improves. While Bulgaria may have stabilized in terms

of the decreased energy intake, they may be at a nutritional nadir, with the next step being one

towards an increased intake of processed foods.

5. Conclusion

The major finding of this study is that in Bulgaria, following the shift from a centralized to

market economy, the reported food and energy consumption decreased by 427 kcal/day/capita.

However, this decline is probably not of sufficient magnitude to affect the weight or BMI of the

Bulgarian population. Furthermore, this decline was accompanied by subtle shifts in the dietary

pattern, but no significant changes in the macronutrient composition of the diet. In contrast to the

increased consumption of high fat and high calorie foods that has occurred in other transitional

countries (Popkin, 2001, 2002), such changes have not occurred in Bulgaria. Still, some caution

has to be used since we analyzed aggregated data that did not allow for a stratified analysis by

household income or region. In fact, it is highly likely that stratifying the data by income group

would make the changes in dietary intake appear more negative than what they are for the middle

and lower income groups, assuming that high income groups would be less likely to decrease

food intake during periods of economic crises. Nonetheless, the economic changes experienced

by Bulgaria coincide with decreased reported food consumption, suggesting a close relationship

between the unstable economic background and nutritional health during the past 15 years.

Acknowledgements

The work conducted for this paper was accomplished through a cooperative agreement

between Rutgers University and the National Center of Public Health Protection Bulgaria. We are

also indebted to the citizens of Bulgaria who have been unwavering in their willingness to

respond to each annual survey. We would also like to thank the Government of Bulgaria for

L. Ivanova et al. / Economics and Human Biology 4 (2006) 383–397 395

making the data utilized available through public dissemination (National Statistical Institute of

Bulgaria, 2, P. Volov Str., 1038 Sofia, Bulgaria). Finally, we are thankful for the economic and

statistical advice provided by Ira Gang, Department of Economics, Rutgers University and David

Colin, DevTech Systems Inc. This work was supported in part by a USDA—Foreign Agriculture

Service Cooperative Agreement BU-14.

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