Obesity: the challenge for the food industry

Tim Lobstein, Policy Director for the World Obesity Federation, looks at the increasing trends to regulate the food market.

Introduction

In June this year the UK Government announced the second instalment of its childhood obesity plan, setting a target to halve obesity rates by 2030 and suggesting a range of measures it was minded to explore, including extending the fiscal policies it has already introduced and adding further market interventions to influence consumer choice. What does this mean for food producers, caterers and retailers?

Extending the range of sugary products subjected to a levy, restricting the promotion of products at supermarket check-outs, limiting the retail ‘special offers’ and restricting broadcast advertising before a 9pm watershed are all being mooted,

and are in addition to moves by Public Health England to require reformulation of products and restrictions on portion sizes. Such measures may not appeal to the directors of food and beverage companies, whose products are deemed too high in sugar, salt or fat, but they will surely not be surprised by these moves.

The public have been urged to limit their consumption of calorie-rich foods for several decades, but the lack of effect of this message has led to a shift in  focus from consumer to producer. Writing in the online trade journal in 2011, Caroline Scott- Thomas summarised the problem food manufacturers face in the emerging obesity crisis with the challenging headline ‘Eat Less’: A difficult message for industry[1]. Soon afterwards, Andrew Lansley’s Responsibility Deal was launched, including a Calorie Reduction pledge in which five billion calories (kcal) would be voluntarily removed from the UK population’s daily diet^[2].

The public have been urged to limit their consumption of calorie-rich foods for several decades, but the lack of effect of this message has led to a shift in focus from consumer to producer.

Whilst producers were now the focus of attention for changing the food supply, public health advocates feared that putting responsibility for improving the nation’s diet in the hands of the same companies that were causing the problem was like asking a burglar to install your door locks. The food industry surely had an interest in promoting over consumption, not just for the sales of the products on the day but for the continued excess consumption that arises as a consequence: the average UK adult gained just over 10kg (about 15% of their initial bodyweight) between 1984 and 2010, and this additional mass has to be supplied with nutrients and energy. Even if no further weight gain occurs, the average adult’s intake of calories must be 10-15% greater in 2010 than 25 years earlier, with a corresponding increase in the national food and beverage market.

Worldwide obesity prevalence levels have shot up, with over 12% of all adults globally – some 670 million – now classified as obese.

This ‘walking investment’ that benefited the food supply chain was particularly worrying in the case of children, where rapid increases in the average child’s bodyweight occurred in the 1990s and early 2000s. The persistence of obesity from childhood through to adulthood means that an early ‘investment’ in encouraging excess calorie consumption creates a lifetime of returns through increased food consumption.

The results of excess calorie consumption, combined with decreased calorie expenditure, are clear to see. Worldwide obesity prevalence levels have shot up, with over 12% of all adults globally – some 670m – now classified as obese (see Figure 1). The figure approaches 30% of all adults in the Americas. In the USA, almost 40% of all adults are obese and a further 30% are overweight i.e. fewer than one third of Americans are a healthy weight.

As a result of this rising epidemic and the inadequacy of health education messages, the conceptual framing and the language used to describe the causes of obesity has begun to change. Through much of the 1980s and 1990s there was a prevailing narrative of personal responsibility and lifestyle choices. Health promotion literature encouraged people to ‘look after yourself’ (the title of a UK government campaign) and this has persisted in the social marketing campaigns, such as Change 4 Life. However, a gradual change of emphasis has emerged with greater awareness among policy-makers of the role of the environmental cues that shape food choices and dietary behaviour, including price, availability and promotional marketing. The UK’s Food Standards Agency recognised that the formulation of processed foods was largely outside consumer control, and that the wrapping and packaging of processed food meant that consumers lost direct sight of the product and instead relied on a label conveying marketing messages; therefore both subjects were legitimate concerns for regulators. The language of ‘consumer choice’ became a language of nudges, inducements and ‘choice architecture’ signalling an awareness of the role of the environment in shaping behaviour. The phrase ‘obesogenic environment’ – meaning a physical, economic and social environment that promotes behaviour leading to a gain in bodyweight – became common currency.

Further changes to the conceptualisation and language of obesity have ensued. While there has long been a recognition that lower socio-economic groups tend to suffer greater ill-health and shorter life expectancy, the phrase ‘social determinants’ of health has focused attention on the stark gradients in health within quite small areas and further emphasised the environmental (including social, cultural and economic environments) factors that raise the risk of obesity. The clearest illustration of this can be seen in the remarkable data collected in the National Child Measurement Programme, which finds a virtually linear increase in obesity risk in parallel with an increase in the local area deprivation index used in the surveys. This is not a small-scale sample survey: virtually every child in England is measured at the two age points shown (see Figure 2).

A greater challenge to the food and beverage industry, however, is an increasing reference to the ‘commercial determinants of health’^[3]. This specifically identifies the prevailing drivers, which operate in the food supply chain as the primary force shaping the food environment.

This includes the trends to mass production, use of additives for long-shelf life, promotional marketing in all its forms and the overall drive to increase consumption. The phrase was recently proposed in a draft declaration of the United Nations meeting on the prevention of non-communicable disease, held in Uruguay in October 2017: ‘We call on WHO to consider establishing a commission to address the commercial determinants of health that have a bearing on the prevention and control of NCDs’^[5].

The final document did not include this paragraph. Consultation responses from the commercial stakeholders had challenged the wording, and in particular the need to consider the broader determinants, especially the need to address the ‘political determinants of health’^[6]. This correctly raises issues of the governance of health and commerce, and the political tradecraft, which negotiates the balance of freedoms and protections between public goods and private enterprise.

Recognising that both private sector and public sector policies are influential in determining the obesogenicity of environments, a research network called INFORMAS (International Network for Food and Obesity Research, Monitoring and Action Support) led by the University of Auckland has launched a series of modules to monitor food environments and to evaluate the policy commitments of governments and the actions of private sector stakeholders^[7]. Two of the modules form part of an ‘accountability framework’ designed to hold to account governments and businesses whose policies shape the food environment^[8].

It is notable that governments around the world have become increasingly willing to consider regulatory interventions, especially interventions that have a low cost to public finances and a level of public support. Restrictions on the promotional marketing of fatty and sugary foods to children, taxation of sugary drinks or snack foods, requirements for front-of-pack symbols warning of high fat or sugar content, and displays of nutrition information in fast food outlets, have been adopted by several countries and are increasingly recommended and implemented in policy statements by national and international public health bodies (see Table 1).

Traditionally, food policy was a governmental concern when food supplies failed, due to natural disasters, wars or rampant poverty. Now, though, most of the world’s population lives in countries where overweight and obesity kill more people than underweight. While the prevalence of childhood stunting remains unacceptably high, it has nearly halved in the last two decades as childhood overweight and obesity have doubled^[9]. Under-nourishment continues to affect large numbers, but now it substantially overlaps with problems of excess bodyweight – not just in the same country, or even the same community, but within the family and even the same person. Poorly nourished mothers are more likely to have children that develop overweight and obesity. Poor nourishment in childhood leads to a combination of stunting and adiposity, particularly abdominal adiposity in adulthood.