obesity reviews
doi: 10.1111/obr.12193
Public Health
Symposium report: the prevention of obesity and NCDs: challenges and opportunities for governments Tim Lobstein and Hannah Brinsden
World Obesity Federation (formerly the
Summary
International Association for the Study of
This paper is written as a briefing document with the aim of providing support to policy-makers and government officials tackling obesity and related noncommunicable diseases. It is based on a symposium Obesity and noncommunicable diseases: Learning from international experiences1 convened by the International Association for the Study of Obesity (now the World Obesity Federation) and its policy section, the International Obesity TaskForce (now World Obesity – Policy and Prevention). The symposium discussed a wide range of proposals to tackle the consumption of unhealthy food products, including interventions in the market through fiscal policies and marketing restrictions, measures to strengthen public health legislation and measures to limit agri-food company lobbying activities. It recognized the need for government leadership and action in order to reduce preventable deaths while improving economic performance and identified a need for governments to take a systems wide approach to tackling obesity and to work with civil society, especially to monitor the drivers of disease and to hold all stakeholders accountable for progress.
Obesity), London, UK
Received 29 January 2014; revised 8 April 2014; accepted 23 April 2014
Address for correspondence: Dr T Lobstein World Obesity Federation, Charles Darwin House, 12 Roger Street, London WC1N 6BQ, UK. E-mail: [email protected]
Keywords: Civil society, government, non-communicable disease, policy, prevention. obesity reviews (2014) 15, 630–639
Introduction The major non-communicable diseases (NCDs) – cancer, cardiovascular disease, diabetes and chronic pulmonary 1
The symposium was held under Chatham House rules at the New York
Academy of Medicine, 23–24 September 2013. Financial support for this conference was received from the Aetna Foundation (see Acknowledgements). Participants included senior members of multilateral and national government agencies, representatives of international non-governmental organizations working in public health and consumer protection, public health research experts and policy analysts. Participants reflected experience in Europe, India, Thailand, Australia, New Zealand, Brazil, Mexico, Canada and the USA.
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disease – now account for more than 36 million deaths every year worldwide (65% of all deaths), of which the majority occur in low- and middle-income countries, where almost a quarter of deaths are in people under age 60 years (1). By 2030, NCDs are expected to cause four times as many deaths as the combined figure for infectious diseases, and maternal, perinatal and malnutritionrelated conditions (2). Tobacco, alcohol, poor diets and sedentary behaviour lie behind much of the disease burden. The rapid rise in obesity prevalence worldwide indicates that diet and lack of physical activity are replacing tobacco as the leading cause of preventable disease (3). The disease burden from obesity-related conditions is already putting health services under stress (4,5). Besides © 2014 The Authors obesity reviews © 2014 World Obesity
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the significant health consequences, obesity and NCDs pose a major economic burden to countries through lower productivity, reduced earning capacity and increased household costs (6). Such burdens on society and individuals are not inevitable. Positive health behaviour depends on healthpromoting environments: in the present case, these include the protection and promotion of food supplies for optimum nutrition, opportunities for plentiful physical activity and adequate education and training to establish healthy diet and activity patterns. These health-promoting environments are shaped by policies at local, national and international levels and are influenced by market forces and the activities of commercial operators (7). This paper explores some of the challenges and opportunities that governments face when creating health promoting policies and it makes recommendations for the next steps that need to be taken to tackle obesity and NCDs. It considers policy issues linked to food environments and diet, with learnings from other areas such as tobacco and alcohol control.
Government commitments to action At the 66th World Health Assembly in May 2013, member states resolved to reduce NCD premature mortality by 25% by the year 2025 (8). This resolution is an important step forward for the reduction of preventable deaths from NCDs globally and follows a commitment made in 2011 in a High Level Meeting of the United Nations General Assembly, which issued a Political Declaration on the Prevention and Control of NCDs (9). In 2013, the World Health Assembly adopted a Global action plan for the prevention and control of noncommunicable diseases 2013–2020 (10) and an NCD Global Monitoring Framework (11), which focuses on a series of targets and indicators to reduce the prevalence of NCDs and their risk factors. The Assembly approved nine targets: to halt the rise of obesity and diabetes, reduce high blood pressure by 25%, reduce physical inactivity by 10%, reduce the harmful use of alcohol by 10%, reduce tobacco use by 30% and reduce salt/sodium intake by 30%. To support member states in their strategies to tackle NCDs, the World Health Organization (WHO) has issued a number of publications related to NCDs, obesity and diet including: A set of Recommendations on the Marketing of foods and non-alcoholic beverages to children (12); Population based intervention for childhood obesity prevention (13); Global recommendations on physical activity and health (14); a Global Strategy to reduce the harmful consumption of alcohol (15); and the International Code of Marketing of Breastmilk Substitutes (16). © 2014 The Authors obesity reviews © 2014 World Obesity
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In September 2014, the United Nations General Assembly is scheduled to receive reports on the progress made by member states and the WHO towards meeting the commitments made at the 2011 High Level Meeting.
Challenges to health promotion policies Progress towards NCD reduction is hampered by factors that are commonly experienced in public health: (i) difficulties providing robust evidence on the likely effectiveness of policies before they have been introduced; (ii) competition for resources between public health preventive services and other government-provided services; (iii) advocacy from commercial interests that promote the consumption of products liable to harm health; and (iv) opposition to market restrictions from government departments responsible for the promotion of free market activity and economic growth. The problem of evidence generation is familiar in public health. The development of sophisticated modelling techniques alongside examples of effective policy implementation can help to resolve the issue. Economic modelling showing the costs of preventative action and the comparable costs of failing to take action can help to identify cost-effective interventions (17,18). In open market economies, companies have a general duty to obtain maximum shareholder return through the creation and promotion of their products, and food companies are no exception. Reductions in the relative price of energy-dense commodities such as oils, fats, sugars and starches, combined with competitive promotion of products made from these commodities are likely to encourage high levels of consumption (19), which poses a severe problem for public health proponents seeking to reduce consumption, particularly of highly processed and highly promoted products such as soft drinks and snack foods (20,21). The conflicting interests of commerce and public health in relation to tobacco consumption have been well documented, but it is now increasingly evident that similar conflicts have developed in relation to the consumption of alcohol and food (22,23). Lessons from past advocacy movements for health and equity indicate: • Business interests can gain more influence than public health interests in the policy-making process due to their economic power (24). • Policies that call for interventions in the operation of markets can face particular resistance, with requirements for proof of market failure needed to justify action (25). • Strong interests can develop in maintaining the status quo, however inefficient or unfair, putting a high burden of proof on the advocates for change (26,27).
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• Industry lobbying power is significant and can undermine public health. In 2012, the US alcohol industry employed 256 lobbyists, the tobacco industry employed 174 lobbyists and the food and beverage industry employed 327 lobbyists to influence the 553 members of the US Congress (28). • Public health promoters need to use the media, make data politically relevant, challenge the opposition and produce consensus statements (29). • Community action is vital in order to increase the political will of legislators to challenge business freedoms and intervene in market practices (30). In food supplies, the greatest profit is often gained from processed and long shelf-life products that disproportionately contribute to NCDs and obesity (31). While commercial operators accept the need to ensure that their products are safe and reliable, they have no specific need to be interested in the cumulative nutritional impact of their products. Increasingly ‘Big Food’ is being accused of undermining public health moves to prevent chronic disease (32), and the WHO Director General, Dr Margaret Chan, has warned . . . It is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda, and Big Alcohol. . . . Let me remind you. Not one single country has managed to turn around its obesity epidemic in all age groups. This is not a failure of individual will-power. This is a failure of political will to take on big business. (33) Even in situations where the influence of commercial interests is not apparent, a prevailing ideology in favour of economic growth and open market development can inhibit policy-makers from proposing stronger public health intervention and increased consumer protection (34–36). There is a need for government authorities and civil society organizations to recognize these conflicts and develop procedures that properly manage them, in order to be able to implement policies that protect and promote better health. Commercial operators may seek to engage in ‘public– private partnerships’ with government and civil society. Although interaction and cooperation with the commercial sector can be important for service delivery, health policies need to be developed in policy arenas that are not unduly influenced by commercial interests (37). Potential conflicts of interest need to be managed appropriately, and while full transparency of any such relationship is necessary, it may not be sufficient to prevent undue commercial influence (38). It is important to recognize the main drivers of business practices include a company’s responsibility to provide increased returns to its stakeholders, its need to generate consumer demand, its need to respond to commodity prices
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and competitors’ marketing activities and its need to promote itself in the media, protect itself in the law courts, and lobby for favourable regulatory regimes (23). If properly implemented and monitored, agreements reached voluntarily – i.e. without recourse to statutory regulation – might be effective for implementing policies, although we know of no evidence to show that they are cheaper or more effective than compulsory approaches (39). Indeed, in the case of marketing of foods and beverages to children, there is increasing evidence that the voluntary initiatives pledged by industry bodies in the last 8 years are failing to protect children and that stronger measures are needed (40). Voluntary agreements are unlikely to be effective unless they include substantial disincentives for non-participation and sanctions for non-compliance. Furthermore, there is a danger that the offer of voluntary activities may undermine progress by delaying or preventing more effective regulatory measures, and therefore national authorities should establish at the outset a set of clear targets and timelines, with a clear commitment to introducing statutory regulation if the voluntary measures show signs of failure (41). In this sense, the measures are ‘co-regulatory’ rather than voluntary, as they are led by government, using government-set criteria for achieving the policy goals (Box 1).
Box 1 The Public Health Responsibility Deal (England) An example of a voluntary public–private partnership has been operating for several years in England, where the Department of Health’s ‘Public Health Responsibility Deal’ coordinates a series of voluntary industry commitments and pledges on food, alcohol, physical activity and healthy workplaces, and includes civil society organizations who largely play a watchdog role in the process. Introducing the Responsibility Deal, the government stated its belief that this approach would ‘secure more progress, more quickly, with less cost than legislation’ (86). Under the commitments for food, some progress has been made, for instance with the introduction of smaller portion sizes available for soft drinks and confectionery. Experience with public–private partnerships suggest that such schemes need strong monitoring and evaluation (87), with clearly agreed definitions and areas of action, independent standardssetting with sanctions or targets (88). Civil society organizations have been cautious to offer support to the Responsibility Deal, especially around proposals regarding alcohol consumption, with most preferring to call for regulatory measures (89,90).
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Framing the strategy Systems thinking Experience in the field of public health suggests that the most cost-effective initiatives are likely to be population wide and use integrated, multidisciplinary, comprehensive and sustainable approaches, involving a wide variety of complementary actions that address the individual, community, the environment, and society at large (17,42). Behaviour is strongly influenced by social norms and immediate environments, and in order to achieve sustained changes in behaviour, it is necessary to make sustained changes in social and physical environments (43) (Box 2). Furthermore, food-related selection behaviour is influenced by subconscious, precognitive stimuli (44), so that the provision of information about healthy choices may be ineffective if there is no change to these primary stimuli. The provision of information about healthy choices is less effective for individuals who have difficulty gaining access to the means to achieve healthy behaviour – such as locally available low-cost fruit and vegetable supplies, or local, safe recreation facilities (45). Health education strategies will also need to be complemented with practical measures to support health behaviour in order to avoid a widening of inequalities in health outcomes. A ‘systems approach’ to tackling NCDs and obesity means the creation of health-promoting environments – social, economic and policy environments as well as physical environments – and it means the involvement of key actors, including different government departments, in the systems that create these environments, such as the media, educators, the food industry, healthcare providers, leisure and entertainment companies, transport providers and urban planners (46). When using the term ‘the food industry’, we refer to a wide range of enterprises, some of which contribute to providing foods that are recommended for increased consumption in national guidelines, and some of which promote products that are not recommended for
Box 2 Integrating policies for health ‘Obesity prevention interventions should be supported by policies at all levels of government – national, regional and local. National policies can create supportive environments; regional policies can facilitate pooling of resources; and local tailoring of interventions results in more effective targeted interventions. Global (intergovernmental) support for obesity prevention can help to address transnational environmental factors, such as creating a healthier food supply’. (p. 20) World Health Organization (91)
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increased consumption. A systems approach needs to recognize the differences, and at community level to build stronger food supply systems to encourage improved dietary intakes.
Promoting nutrition security It is important to recognize that many commonalities exist between the dietary drivers and solutions available for overweight and obesity and those for malnutrition. The term ‘nutrition security’ may be used to refer to a wider dimension than the usual term ‘food security’: whereas food security concerns the assured supply, availability and affordability of adequate food to make a healthy diet possible, nutrition security embraces food security and also the factors that promote and protect the consumption of a healthy diet, in accordance with recommended food-based dietary guidelines (47). Such consumption may be jeopardized by lack of facilities, skills or knowledge, or by persuasive messages and inducements to consume unhealthy products. Population-based strategies to improve food security and to promote societal norms and standards, and restrict marketing practices that undermine healthy choices, will enhance nutrition security. Policies to ensure nutrition security should therefore focus on the creation of healthier environments for all children, improving food and nutrition security and promoting healthy feeding practices for mothers and infants, promoting healthy diets and physical activity practices for children of all ages. It also focuses on the protection of health through restrictions on the promotion of products that undermine optimum health behaviour, as shown through actions in the realm of tobacco control, alcohol marketing and the promotion of breast-milk substitutes (7). By looking at consumption as well as supply, nutrition security takes into account cross-cutting issues such as life course phases, social inequalities and under-nutrition. For children, policies to ensure optimum growth and development need to focus on ensuring a supply of healthful foods and ensuring that consumption is promoted and protected fully from competing interests. Nutrition security for an infant includes the nutrition security of the mother before and during pregnancy, appropriate weight gain in pregnancy, the protection of exclusive breastfeeding for the first 6 months, and appropriate complementary feeding (48) thereafter. Similarly, physical activity security implies the supply and use of the optimum environments for active behaviour (green spaces, safe play, active transport facilities, widely available, affordable and accessible to all) and ensuring the favourable determinants of their use, including cultural practices, social norms, education and skills, and information, and protection from inducements to increase sedentary behaviour, for example through the promotion of
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sedentary games or entertainments, or other incentives for prolonged screen-watching. As with nutrition security, there is a need for government authorities at national and sub-national levels to recognize their role in the protection and promotion of healthy physical activity (49).
Working with civil society Civil society organizations (used here as a collective term for non-profit organizations undertaking voluntary, noncommercial activities in the public interest) are important stakeholders, representing public health and consumer protection, health promotion and health delivery, and acting to uphold and influence social norms and strengthen community organization. Such organizations can act as watchdogs, monitoring and holding to account the actions of commercial and governmental sectors, and stimulating action and change at local and national policy levels. The history of the struggle to draft and implement the International Code of Marketing of Breast-milk Substitutes, for example, shows how effective advocacy emerged through the monitoring and challenging of commercial activity (50). This Code, and the Framework Convention on Tobacco Control, were built despite challenges from corporate interest, and could not have been developed through stakeholder consensus, or trust or partnership with commercial bodies, and this is likely to continue to be the case where there are significant commercial and economic interests at stake. A key role of civil society is to challenge the market dominance and power discussed above and can be particularly important in low- and middle-income countries where ‘Big Food’ has only recently entered the market. The role of civil society in these circumstances is increasingly recognized by public health funding agencies, where it is seen as a valuable contributor to the development of public awareness and the need for change through political action. This is exemplified by the support of Bloomberg Philanthropies for community activity and advocacy to tackle obesity in Mexico (see Box 3). An alliance of civil society organizations and skilled researchers can help to fill the evidence gaps to support specific policy proposals, including the policies that will emerge as the WHO NCD and obesity action plans are defined operationally. The WHO’s monitoring proposals for NCDs concern prevalence and outcomes of disease, and the provision of treatment, but touch only lightly on the factors that influence population health. Although recognizing that a continuing programme of health surveillance is needed, little is suggested for the regular monitoring of the key environmental influences on health behaviour, especially the food environment and the environment for physical activity and sedentary behaviour. A programme for monitoring food environments is being developed by INFORMAS, a global NGO-academic
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Box 3 Bloomberg uses philanthropic support to promote change through community action Bloomberg Philanthropies has launched an Obesity Prevention Program to strengthen community advocacy and popular awareness-raising (92). The Foundation has provided a $10 m 3-year programme of support for obesity prevention in Mexico and the funds are being used to promote population-wide policies including: • Banning junk food and sugary beverage advertising to children; • Raising taxes on sugar-sweetened beverages; • Promoting healthy public sector food policies; • Introducing front-of-package nutrition labels; and • Developing obesity prevention advertising campaigns. The programme has included subway advertising campaigns in Mexico City depicting the negative effects of obesity, TV ads calling for a tax on soft drinks, media stories in popular newspapers and in social media. It has also included support for policy-relevant research, e.g. into children’s exposure to commercials, the foods and beverages available in schools and the national economic damage caused by obesity. Within the first year of the Bloomberg-supported programme, the Mexican government moved to introduce an 8% tax on ‘junk’ food and a 1 peso per litre tax on soft drinks (93).
network (see Box 4) and a similar network for physical activity could be formed. Such developments need support from national and local governments, and the results need to be fed into government policy-making.
Government leadership If member states are to be effective in reducing the burden of NCDs and meet their obesity targets agreed through the World Health Assembly, then they need to take action to create health-promoting environments and ensure nutrition security for all. This includes building the case for intervention, so that public health has a stronger voice in crossgovernment strategic planning. It means encouraging advocacy and developing social marketing campaigns to increase public support for population-wide interventions, and it means making a series of interventions in the marketplace to reduce over-consumption and protect consumer health. 1. Strengthen the case for action • Monitor and predict national productivity losses and health costs, accumulated throughout the life course from the burden of NCDs, and assess the © 2014 The Authors obesity reviews © 2014 World Obesity
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Box 4 INFORMAS: Monitoring food environments INFORMAS – the International Network for Food and Obesity/NCDs Research, Monitoring and Action Support – is a global network of researchers and NGOs that aims to monitor and benchmark policies and actions to create healthy food environments. The project is concerned initially with monitoring food environments as important determinants of dietary choices. Examples of specific benchmarking approaches are shown here: Module Composition
Examples of information sources Food environments Comparison sites; crowd sourcing of label data Retailers’ websites; crowd sourcing; image search engines
Examples of indicators
Nutrient profiles; levels of salt, sugar and fat in key foods Labelling Proposition of foods with health and nutritional claims that are healthy; presence of nutrition information panels Provision Crowd sourcing; suppliers’ databases Food quality; adherence to standards; availability; affordability Promotion Spot-surveys; social media probes; purchased Usage, impacts and exposure of children to data; site hits; Facebook friends; tweets unhealthy food advertisements Prices Comparison sites; household budget surveys; ‘healthy’ vs. ‘current’ diets; affordability by commercial databases socioeconomic status SES); price trends Retail GPS data; food outlet lists; Google Street Outlet density; shelf space; checkout View; in-store sampling displays Trade and investment Trade data; cross-border agreements; Trade trends; inward investment; domestic stockbroker advisories protection Food policies and actions Public Sector Policy text analysis; key interviews; Infrastructure (leadership, governance and departmental budgets funding); impact (standards, regulations and health assessments) Private Sector Text analysis; key interviews; consumer Access to Nutrition Index (ATNI); plus and market surveys; investor forecasts indicators of industry influence on policies Source: INFORMAS, a global network for monitoring food environments (55)
economic case for taking action. Examples: OECD (51,52), UK (53) and Thailand (54). • Monitor progress and change in relation to the drivers of obesity/food environments. Examples INFORMAS (55), Canada (56) and Brazil (57). 2. Develop cross-departmental action plans embracing a broad range of initiatives at multiple levels of intervention • Establish interdepartmental taskforces to coordinate government strategies to tackle NCDs, considering all aspects of food supplies and nutrition security, the physical environment and secure physical activity. Examples: Australia (58), USA (59) and Taiwan (60). • Review relevant policies and evidence for their effectiveness and cost-effectiveness. Example: WHO (61,62) and Australia (63). • Review policy success and failures in related areas of public health promotion and protection, and © 2014 The Authors obesity reviews © 2014 World Obesity
interventions to achieve behaviour change. Examples: WHO (64) and UK (43,65). • Involve public health and civil society organizations in developing strategies and action plans, and providing evidence of good practices. Example: WHO (66,67) and WCRF (68). • Develop a systems-based analysis of opportunities for intervention at multiple levels. Example: Victoria, Australia (69) and West Africa (70). 3. Establish guidelines and standards for protecting nutrition security • Monitor and strengthen standards for commercial practices that threaten nutrition and physical activity security. Examples UK (71), Korea (72) and USA (73). • Monitor and strengthen standards for the provision of food in state-controlled institutions. Chile (74) and South Africa (75).
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• Support the construction of operational tools including nutrient profiling schemes, food formulation standards, food environment indicators and health impact assessments. 4. Use government purchasing power to build healthier consumption patterns • Support the inclusion of health and nutrition criteria for awarding national and local government supply contracts. Examples: UK (76) and Brazil (77). • Use school and hospital food policies as beacons of good practice in the community. Example: New York City (78). 5. Strengthen public health legislation in order to increase competence for interventions • Review and strengthen public health legislation in order to permit and to require interventions, including market interventions, for public protection. Example: British Columbia (79) and Victoria (80). 6. Use multilateral negotiation opportunities to strengthen national health programmes • Negotiate better health protection through crossborder agreements on marketing. Example: Keyhole (81) and WHO Europe (82). 7. Encourage behaviour change and a shift in cultural norms • Use social marketing to encourage changes in cultural norms and to build public acceptability for interventions Examples: UK (83,84). • Disseminate examples of good practice from other countries. Example: Bellagio review (85) and WCRF (68). 8. Strengthen ministry of health leadership • Ministries of Health (or whichever ministries are responsible for nutrition security and obesity prevention) need to demonstrate a strong business case for public health action, especially fiscal action such as taxes and subsidies to influence purchasing patterns, and market interventions on advertising, prices and labelling. • Ministries can demonstrate their obligations to follow international charters (e.g. for child rights) and agreements (e.g. for tobacco) and recommendations from authorities such as WHO. 9. Gather support and counter resistance • Ministries can show support from nongovernmental organizations, including health and consumer advocacy groups, pro-family and child interest groups (e.g. churches, charities) and campaigns by parents/mothers’ networks. • Ministries can counter resistance from commercial interests by making more transparent the role and activities of commercial lobbyists and political donors and supporting measures to manage conflicts of
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interest and to prevent commercial interests prevailing over public interests. 10. Establish accountability agencies • Establish independent agencies that can monitor and report publicly on policy development, implementation and progress towards targets. • Extend accountability for health impact to other sectors, including the commercial operators and their federal bodies, non-governmental organizations and the media.
Conflict of interest statement The authors declare that they have no conflicts of interest.
Acknowledgements The symposium that led to this paper, and the production of this paper itself, was assisted by financial support from the Aetna Foundation, a national foundation based in Hartford, Connecticut, USA, that supports projects to promote wellness, health and access to high-quality care for everyone. The views presented here are those of the authors and not necessarily those of the Aetna Foundation, its directors, officers or staff. We also wish to acknowledge the valuable comments and suggestions received on previous drafts from the Scientific Advisory Council of the then International Obesity TaskForce. Hannah Brinsden is in receipt of a study grant from the UK Coronary Prevention Group.
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doi: 10.1111/obr.12193
Public Health
Symposium report: the prevention of obesity and NCDs: challenges and opportunities for governments Tim Lobstein and Hannah Brinsden
World Obesity Federation (formerly the
Summary
International Association for the Study of
This paper is written as a briefing document with the aim of providing support to policy-makers and government officials tackling obesity and related noncommunicable diseases. It is based on a symposium Obesity and noncommunicable diseases: Learning from international experiences1 convened by the International Association for the Study of Obesity (now the World Obesity Federation) and its policy section, the International Obesity TaskForce (now World Obesity – Policy and Prevention). The symposium discussed a wide range of proposals to tackle the consumption of unhealthy food products, including interventions in the market through fiscal policies and marketing restrictions, measures to strengthen public health legislation and measures to limit agri-food company lobbying activities. It recognized the need for government leadership and action in order to reduce preventable deaths while improving economic performance and identified a need for governments to take a systems wide approach to tackling obesity and to work with civil society, especially to monitor the drivers of disease and to hold all stakeholders accountable for progress.
Obesity), London, UK
Received 29 January 2014; revised 8 April 2014; accepted 23 April 2014
Address for correspondence: Dr T Lobstein World Obesity Federation, Charles Darwin House, 12 Roger Street, London WC1N 6BQ, UK. E-mail: [email protected]
Keywords: Civil society, government, non-communicable disease, policy, prevention. obesity reviews (2014) 15, 630–639
Introduction The major non-communicable diseases (NCDs) – cancer, cardiovascular disease, diabetes and chronic pulmonary 1
The symposium was held under Chatham House rules at the New York
Academy of Medicine, 23–24 September 2013. Financial support for this conference was received from the Aetna Foundation (see Acknowledgements). Participants included senior members of multilateral and national government agencies, representatives of international non-governmental organizations working in public health and consumer protection, public health research experts and policy analysts. Participants reflected experience in Europe, India, Thailand, Australia, New Zealand, Brazil, Mexico, Canada and the USA.
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disease – now account for more than 36 million deaths every year worldwide (65% of all deaths), of which the majority occur in low- and middle-income countries, where almost a quarter of deaths are in people under age 60 years (1). By 2030, NCDs are expected to cause four times as many deaths as the combined figure for infectious diseases, and maternal, perinatal and malnutritionrelated conditions (2). Tobacco, alcohol, poor diets and sedentary behaviour lie behind much of the disease burden. The rapid rise in obesity prevalence worldwide indicates that diet and lack of physical activity are replacing tobacco as the leading cause of preventable disease (3). The disease burden from obesity-related conditions is already putting health services under stress (4,5). Besides © 2014 The Authors obesity reviews © 2014 World Obesity
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the significant health consequences, obesity and NCDs pose a major economic burden to countries through lower productivity, reduced earning capacity and increased household costs (6). Such burdens on society and individuals are not inevitable. Positive health behaviour depends on healthpromoting environments: in the present case, these include the protection and promotion of food supplies for optimum nutrition, opportunities for plentiful physical activity and adequate education and training to establish healthy diet and activity patterns. These health-promoting environments are shaped by policies at local, national and international levels and are influenced by market forces and the activities of commercial operators (7). This paper explores some of the challenges and opportunities that governments face when creating health promoting policies and it makes recommendations for the next steps that need to be taken to tackle obesity and NCDs. It considers policy issues linked to food environments and diet, with learnings from other areas such as tobacco and alcohol control.
Government commitments to action At the 66th World Health Assembly in May 2013, member states resolved to reduce NCD premature mortality by 25% by the year 2025 (8). This resolution is an important step forward for the reduction of preventable deaths from NCDs globally and follows a commitment made in 2011 in a High Level Meeting of the United Nations General Assembly, which issued a Political Declaration on the Prevention and Control of NCDs (9). In 2013, the World Health Assembly adopted a Global action plan for the prevention and control of noncommunicable diseases 2013–2020 (10) and an NCD Global Monitoring Framework (11), which focuses on a series of targets and indicators to reduce the prevalence of NCDs and their risk factors. The Assembly approved nine targets: to halt the rise of obesity and diabetes, reduce high blood pressure by 25%, reduce physical inactivity by 10%, reduce the harmful use of alcohol by 10%, reduce tobacco use by 30% and reduce salt/sodium intake by 30%. To support member states in their strategies to tackle NCDs, the World Health Organization (WHO) has issued a number of publications related to NCDs, obesity and diet including: A set of Recommendations on the Marketing of foods and non-alcoholic beverages to children (12); Population based intervention for childhood obesity prevention (13); Global recommendations on physical activity and health (14); a Global Strategy to reduce the harmful consumption of alcohol (15); and the International Code of Marketing of Breastmilk Substitutes (16). © 2014 The Authors obesity reviews © 2014 World Obesity
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In September 2014, the United Nations General Assembly is scheduled to receive reports on the progress made by member states and the WHO towards meeting the commitments made at the 2011 High Level Meeting.
Challenges to health promotion policies Progress towards NCD reduction is hampered by factors that are commonly experienced in public health: (i) difficulties providing robust evidence on the likely effectiveness of policies before they have been introduced; (ii) competition for resources between public health preventive services and other government-provided services; (iii) advocacy from commercial interests that promote the consumption of products liable to harm health; and (iv) opposition to market restrictions from government departments responsible for the promotion of free market activity and economic growth. The problem of evidence generation is familiar in public health. The development of sophisticated modelling techniques alongside examples of effective policy implementation can help to resolve the issue. Economic modelling showing the costs of preventative action and the comparable costs of failing to take action can help to identify cost-effective interventions (17,18). In open market economies, companies have a general duty to obtain maximum shareholder return through the creation and promotion of their products, and food companies are no exception. Reductions in the relative price of energy-dense commodities such as oils, fats, sugars and starches, combined with competitive promotion of products made from these commodities are likely to encourage high levels of consumption (19), which poses a severe problem for public health proponents seeking to reduce consumption, particularly of highly processed and highly promoted products such as soft drinks and snack foods (20,21). The conflicting interests of commerce and public health in relation to tobacco consumption have been well documented, but it is now increasingly evident that similar conflicts have developed in relation to the consumption of alcohol and food (22,23). Lessons from past advocacy movements for health and equity indicate: • Business interests can gain more influence than public health interests in the policy-making process due to their economic power (24). • Policies that call for interventions in the operation of markets can face particular resistance, with requirements for proof of market failure needed to justify action (25). • Strong interests can develop in maintaining the status quo, however inefficient or unfair, putting a high burden of proof on the advocates for change (26,27).
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• Industry lobbying power is significant and can undermine public health. In 2012, the US alcohol industry employed 256 lobbyists, the tobacco industry employed 174 lobbyists and the food and beverage industry employed 327 lobbyists to influence the 553 members of the US Congress (28). • Public health promoters need to use the media, make data politically relevant, challenge the opposition and produce consensus statements (29). • Community action is vital in order to increase the political will of legislators to challenge business freedoms and intervene in market practices (30). In food supplies, the greatest profit is often gained from processed and long shelf-life products that disproportionately contribute to NCDs and obesity (31). While commercial operators accept the need to ensure that their products are safe and reliable, they have no specific need to be interested in the cumulative nutritional impact of their products. Increasingly ‘Big Food’ is being accused of undermining public health moves to prevent chronic disease (32), and the WHO Director General, Dr Margaret Chan, has warned . . . It is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda, and Big Alcohol. . . . Let me remind you. Not one single country has managed to turn around its obesity epidemic in all age groups. This is not a failure of individual will-power. This is a failure of political will to take on big business. (33) Even in situations where the influence of commercial interests is not apparent, a prevailing ideology in favour of economic growth and open market development can inhibit policy-makers from proposing stronger public health intervention and increased consumer protection (34–36). There is a need for government authorities and civil society organizations to recognize these conflicts and develop procedures that properly manage them, in order to be able to implement policies that protect and promote better health. Commercial operators may seek to engage in ‘public– private partnerships’ with government and civil society. Although interaction and cooperation with the commercial sector can be important for service delivery, health policies need to be developed in policy arenas that are not unduly influenced by commercial interests (37). Potential conflicts of interest need to be managed appropriately, and while full transparency of any such relationship is necessary, it may not be sufficient to prevent undue commercial influence (38). It is important to recognize the main drivers of business practices include a company’s responsibility to provide increased returns to its stakeholders, its need to generate consumer demand, its need to respond to commodity prices
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and competitors’ marketing activities and its need to promote itself in the media, protect itself in the law courts, and lobby for favourable regulatory regimes (23). If properly implemented and monitored, agreements reached voluntarily – i.e. without recourse to statutory regulation – might be effective for implementing policies, although we know of no evidence to show that they are cheaper or more effective than compulsory approaches (39). Indeed, in the case of marketing of foods and beverages to children, there is increasing evidence that the voluntary initiatives pledged by industry bodies in the last 8 years are failing to protect children and that stronger measures are needed (40). Voluntary agreements are unlikely to be effective unless they include substantial disincentives for non-participation and sanctions for non-compliance. Furthermore, there is a danger that the offer of voluntary activities may undermine progress by delaying or preventing more effective regulatory measures, and therefore national authorities should establish at the outset a set of clear targets and timelines, with a clear commitment to introducing statutory regulation if the voluntary measures show signs of failure (41). In this sense, the measures are ‘co-regulatory’ rather than voluntary, as they are led by government, using government-set criteria for achieving the policy goals (Box 1).
Box 1 The Public Health Responsibility Deal (England) An example of a voluntary public–private partnership has been operating for several years in England, where the Department of Health’s ‘Public Health Responsibility Deal’ coordinates a series of voluntary industry commitments and pledges on food, alcohol, physical activity and healthy workplaces, and includes civil society organizations who largely play a watchdog role in the process. Introducing the Responsibility Deal, the government stated its belief that this approach would ‘secure more progress, more quickly, with less cost than legislation’ (86). Under the commitments for food, some progress has been made, for instance with the introduction of smaller portion sizes available for soft drinks and confectionery. Experience with public–private partnerships suggest that such schemes need strong monitoring and evaluation (87), with clearly agreed definitions and areas of action, independent standardssetting with sanctions or targets (88). Civil society organizations have been cautious to offer support to the Responsibility Deal, especially around proposals regarding alcohol consumption, with most preferring to call for regulatory measures (89,90).
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Framing the strategy Systems thinking Experience in the field of public health suggests that the most cost-effective initiatives are likely to be population wide and use integrated, multidisciplinary, comprehensive and sustainable approaches, involving a wide variety of complementary actions that address the individual, community, the environment, and society at large (17,42). Behaviour is strongly influenced by social norms and immediate environments, and in order to achieve sustained changes in behaviour, it is necessary to make sustained changes in social and physical environments (43) (Box 2). Furthermore, food-related selection behaviour is influenced by subconscious, precognitive stimuli (44), so that the provision of information about healthy choices may be ineffective if there is no change to these primary stimuli. The provision of information about healthy choices is less effective for individuals who have difficulty gaining access to the means to achieve healthy behaviour – such as locally available low-cost fruit and vegetable supplies, or local, safe recreation facilities (45). Health education strategies will also need to be complemented with practical measures to support health behaviour in order to avoid a widening of inequalities in health outcomes. A ‘systems approach’ to tackling NCDs and obesity means the creation of health-promoting environments – social, economic and policy environments as well as physical environments – and it means the involvement of key actors, including different government departments, in the systems that create these environments, such as the media, educators, the food industry, healthcare providers, leisure and entertainment companies, transport providers and urban planners (46). When using the term ‘the food industry’, we refer to a wide range of enterprises, some of which contribute to providing foods that are recommended for increased consumption in national guidelines, and some of which promote products that are not recommended for
Box 2 Integrating policies for health ‘Obesity prevention interventions should be supported by policies at all levels of government – national, regional and local. National policies can create supportive environments; regional policies can facilitate pooling of resources; and local tailoring of interventions results in more effective targeted interventions. Global (intergovernmental) support for obesity prevention can help to address transnational environmental factors, such as creating a healthier food supply’. (p. 20) World Health Organization (91)
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increased consumption. A systems approach needs to recognize the differences, and at community level to build stronger food supply systems to encourage improved dietary intakes.
Promoting nutrition security It is important to recognize that many commonalities exist between the dietary drivers and solutions available for overweight and obesity and those for malnutrition. The term ‘nutrition security’ may be used to refer to a wider dimension than the usual term ‘food security’: whereas food security concerns the assured supply, availability and affordability of adequate food to make a healthy diet possible, nutrition security embraces food security and also the factors that promote and protect the consumption of a healthy diet, in accordance with recommended food-based dietary guidelines (47). Such consumption may be jeopardized by lack of facilities, skills or knowledge, or by persuasive messages and inducements to consume unhealthy products. Population-based strategies to improve food security and to promote societal norms and standards, and restrict marketing practices that undermine healthy choices, will enhance nutrition security. Policies to ensure nutrition security should therefore focus on the creation of healthier environments for all children, improving food and nutrition security and promoting healthy feeding practices for mothers and infants, promoting healthy diets and physical activity practices for children of all ages. It also focuses on the protection of health through restrictions on the promotion of products that undermine optimum health behaviour, as shown through actions in the realm of tobacco control, alcohol marketing and the promotion of breast-milk substitutes (7). By looking at consumption as well as supply, nutrition security takes into account cross-cutting issues such as life course phases, social inequalities and under-nutrition. For children, policies to ensure optimum growth and development need to focus on ensuring a supply of healthful foods and ensuring that consumption is promoted and protected fully from competing interests. Nutrition security for an infant includes the nutrition security of the mother before and during pregnancy, appropriate weight gain in pregnancy, the protection of exclusive breastfeeding for the first 6 months, and appropriate complementary feeding (48) thereafter. Similarly, physical activity security implies the supply and use of the optimum environments for active behaviour (green spaces, safe play, active transport facilities, widely available, affordable and accessible to all) and ensuring the favourable determinants of their use, including cultural practices, social norms, education and skills, and information, and protection from inducements to increase sedentary behaviour, for example through the promotion of
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sedentary games or entertainments, or other incentives for prolonged screen-watching. As with nutrition security, there is a need for government authorities at national and sub-national levels to recognize their role in the protection and promotion of healthy physical activity (49).
Working with civil society Civil society organizations (used here as a collective term for non-profit organizations undertaking voluntary, noncommercial activities in the public interest) are important stakeholders, representing public health and consumer protection, health promotion and health delivery, and acting to uphold and influence social norms and strengthen community organization. Such organizations can act as watchdogs, monitoring and holding to account the actions of commercial and governmental sectors, and stimulating action and change at local and national policy levels. The history of the struggle to draft and implement the International Code of Marketing of Breast-milk Substitutes, for example, shows how effective advocacy emerged through the monitoring and challenging of commercial activity (50). This Code, and the Framework Convention on Tobacco Control, were built despite challenges from corporate interest, and could not have been developed through stakeholder consensus, or trust or partnership with commercial bodies, and this is likely to continue to be the case where there are significant commercial and economic interests at stake. A key role of civil society is to challenge the market dominance and power discussed above and can be particularly important in low- and middle-income countries where ‘Big Food’ has only recently entered the market. The role of civil society in these circumstances is increasingly recognized by public health funding agencies, where it is seen as a valuable contributor to the development of public awareness and the need for change through political action. This is exemplified by the support of Bloomberg Philanthropies for community activity and advocacy to tackle obesity in Mexico (see Box 3). An alliance of civil society organizations and skilled researchers can help to fill the evidence gaps to support specific policy proposals, including the policies that will emerge as the WHO NCD and obesity action plans are defined operationally. The WHO’s monitoring proposals for NCDs concern prevalence and outcomes of disease, and the provision of treatment, but touch only lightly on the factors that influence population health. Although recognizing that a continuing programme of health surveillance is needed, little is suggested for the regular monitoring of the key environmental influences on health behaviour, especially the food environment and the environment for physical activity and sedentary behaviour. A programme for monitoring food environments is being developed by INFORMAS, a global NGO-academic
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Box 3 Bloomberg uses philanthropic support to promote change through community action Bloomberg Philanthropies has launched an Obesity Prevention Program to strengthen community advocacy and popular awareness-raising (92). The Foundation has provided a $10 m 3-year programme of support for obesity prevention in Mexico and the funds are being used to promote population-wide policies including: • Banning junk food and sugary beverage advertising to children; • Raising taxes on sugar-sweetened beverages; • Promoting healthy public sector food policies; • Introducing front-of-package nutrition labels; and • Developing obesity prevention advertising campaigns. The programme has included subway advertising campaigns in Mexico City depicting the negative effects of obesity, TV ads calling for a tax on soft drinks, media stories in popular newspapers and in social media. It has also included support for policy-relevant research, e.g. into children’s exposure to commercials, the foods and beverages available in schools and the national economic damage caused by obesity. Within the first year of the Bloomberg-supported programme, the Mexican government moved to introduce an 8% tax on ‘junk’ food and a 1 peso per litre tax on soft drinks (93).
network (see Box 4) and a similar network for physical activity could be formed. Such developments need support from national and local governments, and the results need to be fed into government policy-making.
Government leadership If member states are to be effective in reducing the burden of NCDs and meet their obesity targets agreed through the World Health Assembly, then they need to take action to create health-promoting environments and ensure nutrition security for all. This includes building the case for intervention, so that public health has a stronger voice in crossgovernment strategic planning. It means encouraging advocacy and developing social marketing campaigns to increase public support for population-wide interventions, and it means making a series of interventions in the marketplace to reduce over-consumption and protect consumer health. 1. Strengthen the case for action • Monitor and predict national productivity losses and health costs, accumulated throughout the life course from the burden of NCDs, and assess the © 2014 The Authors obesity reviews © 2014 World Obesity
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Box 4 INFORMAS: Monitoring food environments INFORMAS – the International Network for Food and Obesity/NCDs Research, Monitoring and Action Support – is a global network of researchers and NGOs that aims to monitor and benchmark policies and actions to create healthy food environments. The project is concerned initially with monitoring food environments as important determinants of dietary choices. Examples of specific benchmarking approaches are shown here: Module Composition
Examples of information sources Food environments Comparison sites; crowd sourcing of label data Retailers’ websites; crowd sourcing; image search engines
Examples of indicators
Nutrient profiles; levels of salt, sugar and fat in key foods Labelling Proposition of foods with health and nutritional claims that are healthy; presence of nutrition information panels Provision Crowd sourcing; suppliers’ databases Food quality; adherence to standards; availability; affordability Promotion Spot-surveys; social media probes; purchased Usage, impacts and exposure of children to data; site hits; Facebook friends; tweets unhealthy food advertisements Prices Comparison sites; household budget surveys; ‘healthy’ vs. ‘current’ diets; affordability by commercial databases socioeconomic status SES); price trends Retail GPS data; food outlet lists; Google Street Outlet density; shelf space; checkout View; in-store sampling displays Trade and investment Trade data; cross-border agreements; Trade trends; inward investment; domestic stockbroker advisories protection Food policies and actions Public Sector Policy text analysis; key interviews; Infrastructure (leadership, governance and departmental budgets funding); impact (standards, regulations and health assessments) Private Sector Text analysis; key interviews; consumer Access to Nutrition Index (ATNI); plus and market surveys; investor forecasts indicators of industry influence on policies Source: INFORMAS, a global network for monitoring food environments (55)
economic case for taking action. Examples: OECD (51,52), UK (53) and Thailand (54). • Monitor progress and change in relation to the drivers of obesity/food environments. Examples INFORMAS (55), Canada (56) and Brazil (57). 2. Develop cross-departmental action plans embracing a broad range of initiatives at multiple levels of intervention • Establish interdepartmental taskforces to coordinate government strategies to tackle NCDs, considering all aspects of food supplies and nutrition security, the physical environment and secure physical activity. Examples: Australia (58), USA (59) and Taiwan (60). • Review relevant policies and evidence for their effectiveness and cost-effectiveness. Example: WHO (61,62) and Australia (63). • Review policy success and failures in related areas of public health promotion and protection, and © 2014 The Authors obesity reviews © 2014 World Obesity
interventions to achieve behaviour change. Examples: WHO (64) and UK (43,65). • Involve public health and civil society organizations in developing strategies and action plans, and providing evidence of good practices. Example: WHO (66,67) and WCRF (68). • Develop a systems-based analysis of opportunities for intervention at multiple levels. Example: Victoria, Australia (69) and West Africa (70). 3. Establish guidelines and standards for protecting nutrition security • Monitor and strengthen standards for commercial practices that threaten nutrition and physical activity security. Examples UK (71), Korea (72) and USA (73). • Monitor and strengthen standards for the provision of food in state-controlled institutions. Chile (74) and South Africa (75).
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• Support the construction of operational tools including nutrient profiling schemes, food formulation standards, food environment indicators and health impact assessments. 4. Use government purchasing power to build healthier consumption patterns • Support the inclusion of health and nutrition criteria for awarding national and local government supply contracts. Examples: UK (76) and Brazil (77). • Use school and hospital food policies as beacons of good practice in the community. Example: New York City (78). 5. Strengthen public health legislation in order to increase competence for interventions • Review and strengthen public health legislation in order to permit and to require interventions, including market interventions, for public protection. Example: British Columbia (79) and Victoria (80). 6. Use multilateral negotiation opportunities to strengthen national health programmes • Negotiate better health protection through crossborder agreements on marketing. Example: Keyhole (81) and WHO Europe (82). 7. Encourage behaviour change and a shift in cultural norms • Use social marketing to encourage changes in cultural norms and to build public acceptability for interventions Examples: UK (83,84). • Disseminate examples of good practice from other countries. Example: Bellagio review (85) and WCRF (68). 8. Strengthen ministry of health leadership • Ministries of Health (or whichever ministries are responsible for nutrition security and obesity prevention) need to demonstrate a strong business case for public health action, especially fiscal action such as taxes and subsidies to influence purchasing patterns, and market interventions on advertising, prices and labelling. • Ministries can demonstrate their obligations to follow international charters (e.g. for child rights) and agreements (e.g. for tobacco) and recommendations from authorities such as WHO. 9. Gather support and counter resistance • Ministries can show support from nongovernmental organizations, including health and consumer advocacy groups, pro-family and child interest groups (e.g. churches, charities) and campaigns by parents/mothers’ networks. • Ministries can counter resistance from commercial interests by making more transparent the role and activities of commercial lobbyists and political donors and supporting measures to manage conflicts of
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interest and to prevent commercial interests prevailing over public interests. 10. Establish accountability agencies • Establish independent agencies that can monitor and report publicly on policy development, implementation and progress towards targets. • Extend accountability for health impact to other sectors, including the commercial operators and their federal bodies, non-governmental organizations and the media.
Conflict of interest statement The authors declare that they have no conflicts of interest.
Acknowledgements The symposium that led to this paper, and the production of this paper itself, was assisted by financial support from the Aetna Foundation, a national foundation based in Hartford, Connecticut, USA, that supports projects to promote wellness, health and access to high-quality care for everyone. The views presented here are those of the authors and not necessarily those of the Aetna Foundation, its directors, officers or staff. We also wish to acknowledge the valuable comments and suggestions received on previous drafts from the Scientific Advisory Council of the then International Obesity TaskForce. Hannah Brinsden is in receipt of a study grant from the UK Coronary Prevention Group.
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