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The double burden of malnutrition

The Commercial Determinants of Health (CDoH) have been defined as “the systems, practices, and pathways through which commercial actors drive health and equity, both in a positive and negative way”.[1] The CDoH have impact on health in diverse ways, as the example of nutrition policy below indicates. 

In 2013, Carlos Monteiro, Professor of Nutrition and Public Health at the University of Sao Paulo, gave a presentation at a World Health Organization (WHO) meeting on the escalating obesity epidemic in the European Region.[2] In this presentation, he clearly outlined how the increasing consumption of Ultra Processed Foods (UPFs) (e.g. soft-drinks, frozen or chilled ready-meals, snacks, etc.) has led to a veritable explosion of Non-Communicable Diseases (NCDs), such as type 2 diabetes and cardiovascular disease. This happened in the two decades after the fall of the Berlin Wall, when Europe opened its boarders and markets to Central and Eastern European Countries. This enabled Western transnational food and beverage corporations to infiltrate the continent and pollute the landscapes with their supermarkets and distribution centres that thrive on cheap human labour. In short: liberalised economic globalisation, Santa Claus and Coca-Cola had won. The American dream, including its hamburgers and donuts, was to become tangible for all. Emblematic of this market expansion was an infamous 1997 television commercial featuring Michael Gorbachev, former President of the Soviet-Union, promoting Pizza Hut![3]

As early as 2013, the WHO had recognised the harmful side-effects on health of all the unregulated practices of industries involved in ‘Big Food’, ‘Big Soda’ and ‘Big Alcohol’. Since market power readily translates into political power, few governments have since prioritized health over big business.[4] In 2023, these phenomena are known as the CDoH.¹ It has become a global pathology driving disease and death as the availability of UPF has now deeply penetrated even the middle and lower-income strata across the globe. Amazingly, only four commercial products (tobacco, alcohol, UPF and fossil fuels) account for one-third of annual deaths worldwide.[5] Global obesity has almost tripled since 1975; 39% (1.9 billion) of adults aged 18 years and older were overweight and 13% obese in 2016.[6] 39 million children below the age of 5  are overweight, as are 340 million children and adolescents between the ages of 5 and 19.⁶ At the same time, more than 900,000 people worldwide live in famine-like conditions.[7] This double burden of malnutrition is a form of injustice that, like the ecological crises, is unfolding across the globe like a slow-motion disaster.

The Commercial Determinants of Health

Commercial enterprises are diverse and do not operate in isolation. They are an actor alongside other actors, including governments, who would have the potential to shape the regulatory systems that currently enable commercially driven health harms so that this is no longer possible. However, instead of using regulatory mechanisms, regulation and taxation is too often limited by governments, which helps to further expand neoliberal globalisation, a form of market fundamentalism or free market ideology.⁷ Major corporations achieve this, amongst other strategies, by creating international public private policy initiatives and multi-stakeholder approaches, which generally accommodate corporate business interests. An example of this is the ‘Scaling Up Nutrition’ (SUN) movement, which includes the food industry, thereby legitimising a voluntary partnership model and potential conflicts of interest over more stringent government regulations.[8] Corporate interference in policymaking further includes legal threats, media campaigns, policy capture and delaying, undermining and circumvention techniques.[9]        

The CDoH lens is a direct response of international Public Health science, practice and activists to the framing by commercial companies that food consumption and healthy food behaviour are individual choices.[10] This framing shifts responsibility from those producing unhealthy products and more importantly, from those setting the regulatory framework conditions for businesses. A major question is then what kind of collaborative ideas and alliances could challenge this conglomerate of powerful commercial entities that have captured (inter-)national politics that ought to protect Public Health? Can we imagine an alternative set of strategies to counter this development and to further a pro-‘Public Health Playbook’ for businesses?[11]

Counteracting the negative impacts of the CDoH

To this end, we could learn from longstanding, somewhat neglected efforts by activists, feminists and critical scholars since the late 1970s to counter the influence of companies like Nestlé. Among other critical practices, Nestlé has marketed (and still does) breast milk substitutes, such as infant formula as an alternative to regular breastfeeding. The International Baby Food Action Network (IBFAN), an international coalition of advocacy groups, has been campaigning for over 40 years for the right of mothers to breastfeed their babies, free from misleading commercial pressure and deceptive claims by the baby food industry.[12] IBFAN urges countries to implement the WHO International Code of Marketing of Breast-milk Substitutes, adopted in 1981.[13] They have used methods such as targeted popular campaigning and advocacy efforts with government diplomats in the UN for stricter regulations. They also sought to link their cause to a broader social and health movement by harnessing the power of legal advice and strategic litigation, health education and the promotion of grassroots ownership.¹² IBFAN’s successes indicate that it takes a dedicated independent coalition with a long-term strategy and stamina, as well as solid funding that is free from conflict of interest, to confront corporate interference in politics.

Recent research has shown how Ultra-Processed Food Industry (UPFI) actors actively use various methods to shape WHO’s NCD policymaking in accordance with their interests.[14] These include intensive lobbying by UPFI actors in WHO Member States, co-opting civil society, hiring former WHO employees, and actively challenging or undermining unfavourable scientific information.¹⁴ Similarly, industry actors have been found to undermine political efforts to restrict UPF advertising on Transport of London facilities e.g. by exaggerating potential costs and underplaying potential benefits of the policy.[15]    

Over the last decade, the global public health community has faced, and is facing, several crises including the lack of prevention, preparedness and response to pandemic risks and the impacts of the climate emergency, biodiversity loss and ecological degradation. These crises, including its corporate capture in the form of global public private initiatives as possible solutions, has delayed and distracted governments from taking actions on the CDoH. Cynically, one could say that commercial entities in the Food, Alcohol and Fossil industry benefit, at least on the short term, from governments having to focus on other, seemingly more urgent issues. Nevertheless, the double burden of malnutrition is nothing but another symptom of an economic system that is not delivering on its intended purpose, as it has enabled unsustainable economic growth that does not account for environmental or health harms. Actions on the CDoH should hence be considered part of a broader rethinking of (global) political governance of the economic system, with the aim of pushing back on profit orientation and centring health and equity as the system’s primary purpose.[16] Post- or degrowth economic models which are based on regenerative and distributive principles to meet the needs of all people within the means of the living planet, will be crucial to achieving these goals. Such a wellbeing-oriented approach is now also being promoted by WHO.[17]

The devil is in the details

But the devil will be in the details, depending on the design of policies intended to promote a wellbeing approach as furthered by governments and international institutions. In essence, considerable shifts in trade rules and international taxation agreements are required. At the moment, these benefit the interests of investors and global companies over public interests.¹⁶ It would also be necessary to establish more stringent international regulatory frameworks, for instance a UN convention on minimising the harmful impacts of commercial food and drink products.¹⁶ More concretely, governments, citizens group and business would have to engage in alternative forms of business models, such as local cooperative food systems models.

 Moreover, a public investment model for food and water companies, subsidised by governments, whereby ecological and social aims are rewarded, and profit margins by shareholders are minimised, but fair, is possible. In Australia, India and Brazil there have been decent experiences with such ‘public-public’ initiatives as they are known. It requires a united health, social, ecological and labour movement that demands, via a political and citizen mobilisation process, governments and companies to profoundly change their practices. History teaches us that such mobilisation is required to enforce transformative change given the political and financial power of commercial actors.¹⁶ It requires public health actors to form coalitions, in order to be protected against industry threats while monitoring and exposing corporate activities, debunking its arguments.¹⁰ The decade long campaign by Foodwatch around the Nutri-Score, a consumer-friendly nutritional label lobbied against by UPFI for 18 years, shows what kind of dedicated and persistent effort has been required to attain a mandatory European nutrition label.[18]    

Limits to the consumption and production of harmful products

At the core of matters, it is needed to limit the consumption and production of unhealthy foodstuff and other harmful CoDH, such as sweetened and alcoholic drinks. This necessitates at the more structural level, at least in high income countries, limiting current directions of economic growth and engaging with post-growth policy proposals in the industrialised health, food and agricultural domain.¹⁷ This confirms the need for  massive investments across the globe in diversified, small-scale, non-commercial, eco-friendly farming. Peasants must be represented in decision-making and global health actors can engage in international solidarity on building food sovereignty.[19] At the basis of this drive for increased food and health sovereignty is an ethics of sufficiency and ‘limitarianism’. This promotes the idea that in the world as it is, as well as in the nearby future, no-one should have (or consume), more than what is needed to lead a healthy, fulfilled life.[20] In the medical and public health field this translates to ‘First, Do No Harm’ as a principal value in intervening in societies or patients.[21] The CDoH are a key global public health challenge, and possibility for concrete action, in the coming decade to engage with. We need to limit the harms inflicted on people and planet by the CDoH in a globalised market economy by regulating the food environment and creating the conditions for a healthy nutritional dietary landscape.

Remco van de Pas, Katharina Wabnitz, Centre for Planetary Health Policy

[1] Gilmore, A. B., Fabbri, A., Baum, F., Bertscher, A., Bondy, K., Chang, H. J., … & Thow, A. M. (2023). Defining and conceptualising the commercial determinants of health. The Lancet, 401(10383), 1194-1213.

[2] https://www.slideshare.net/who_europe/specific-policies-to-tackle-dietrelated-ncd-in-europe

[3] https://foreignpolicy.com/2019/11/28/mikhail-gorbachev-pizza-hut-ad-thanksgiving-miracle/

[4] https://www.who.int/director-general/speeches/detail/who-director-general-addresses-health-promotion-conference

[5] Gilmore, A. B., Fabbri, A., Baum, F., Bertscher, A., Bondy, K., Chang, H. J., … & Thow, A. M. (2023). Defining and conceptualising the commercial determinants of health. The Lancet, 401(10383), 1194-1213.

[6] https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

[7] https://www.wfp.org/global-hunger-crisis

[8] Lie, A. L. (2021). ‘We are not a partnership’–constructing and contesting legitimacy of global public–private partnerships: the Scaling Up Nutrition (SUN) Movement. Globalizations, 18(2), 237-255. https://doi.org/10.1080/14747731.2020.1770038

[9] https://www.babymilkaction.org/

[10] https://phmovement.org/wp-content/uploads/2023/03/GHW6-chapter-C3.pdf 

[11] Lacy-Nichols, J., Marten, R., Crosbie, E., & Moodie, R. (2022). The public health playbook: ideas for challenging the corporate playbook. The Lancet Global Health.

[12] Sterken, E. (2021). IBFAN News Brief: Breastfeeding Protection and Tackling Malnutrition in the Time of COVID. https://journals.sagepub.com/doi/pdf/10.1177/08903344211017024 

[13] https://www.who.int/publications/i/item/9241541601

[14] Lauber, K., Rutter, H., & Gilmore, A. (2021). Big Food and the World Health Organization: A qualitative study of corporate political activity in global-level non-communicable disease policy. BMJ Global Health, 6(6), [e005216]. https://doi.org/10.1136/bmjgh-2021-005216

[15] Lauber, K., Hunt, D., Gilmore, A.B., Rutter, H., 2021. Corporate political activity in the context of unhealthy food advertising restrictions across Transport for London: A qualitative case study. PLOS Medicine 18, e1003695.. https://doi.org/10.1371/journal.pmed.1003695

[16] Friel, S., Collin, J., Daube, M., Depoux, A., Freudenberg, N., Gilmore, A. B., … & Mialon, M. (2023). Commercial determinants of health: future directions. The Lancet, 401(10383), 1229-1240.

[17] https://www.who.int/publications/m/item/achieving-well-being

[18] https://www.foodwatch.org/en/news/2022/nutri-score-in-the-eu-18-years-of-food-lobbying/

[19] https://viacampesina.org/en/

[20] Robeyns, I. (2022). Why limitarianism?. Journal of Political Philosophy, 30(2), 249-270. https://doi.org/10.1111/jopp.12275

[21] Sokol, D. K. (2013). “First do no harm” revisited. Bmj, 347. https://doi.org/10.1136/bmj.f6426