Can we leave industry to lead efforts to improve population health? YesBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2279 (Published 17 April 2013) Cite this as: BMJ 2013;346:f2279
In the past century, the food industry has provided a sustainable source of nutritious, safe, and affordable foods that support physical and intellectual development and foster intergenerational improvements in health and economic development.1 Undernutrition has fallen considerably worldwide.2 In the past two decades, however, high body mass index has risen in ranking from 11th to 6th place out of the 20 leading risk factors for disease burden, as measured by the percentage of global disability adjusted life years.3
The causes of obesity are complex, and no one approach can tackle them all. Despite government initiatives and regulations, the problem persists in industrialised and developing countries. Voluntary action in the private sector, specifically by the food and drinks industry, can complement public policies and is, in some cases, more effective than government restrictions. Regulation and litigation may be viewed as simplistic approaches, especially in countries where most food produced is beyond the regulatory reach of governments, while hindering innovation.
Industry led efforts to improve the nutritional quality of products have accelerated in the past decade, often in the absence or in advance of regulations. Such voluntary action harnesses competitive market forces, stimulates research, and fosters alliances that drive industry-wide change.
The following are motivating factors: progressive chief executives simply know it is the right thing to do; investors increasingly reward companies that consider health as part of broader sustainability4; and consumer demand for healthy foods is rising.5 An industry that has relied on a business model that favours product quantity over quality is beginning to see better nutrition, not more calories, as a strategic goal.
Voluntary efforts by food companies (that often are a precursor to government regulations) to tackle obesity include more investment in research and development aimed at calorie reduction for new and reformulated products; less marketing of the most energy dense, nutrient poor products (such as sugary drinks) to children; and labelling to inform consumers about innovative community based programmes with the potential to reduce childhood obesity, such as the EPODE International Network (Together, Let’s Prevent Childhood Obesity), a public-private consortium from the scientific and policy communities. There is also large scale experimentation with subsidies for healthy foods. Subsidies offered by retailers and insurers to increase consumption create incentives for food companies to reformulate to meet healthy food criteria.6
The focus has been to reduce childhood obesity, which represents the best opportunity to lower lifetime risk. The combined effect of public and industry-led initiatives is likely to have been responsible for the recent decline in childhood obesity in parts of the United States.7
The past decade has seen industry led partnerships such as that between the American Beverage Association and Alliance for a Healthier Generation, which has reduced calories in beverages shipped to US schools by 88% since 2006,8 and the International Food and Beverage Alliance, which committed in 2008 to support the World Health Organization’s global strategy on diet, physical activity, and health through product development and reformulation; nutrition information, responsible advertising, and programmes to increase awareness of healthy diets and activity.9 In 2011, the National Restaurant Association launched Kids LiveWell, an alliance of family friendly restaurants across the US that offer and promote children’s menu items that meet scientifically verified nutritional criteria.
The Healthy Weight Commitment Foundation, a US partnership to combat childhood obesity whose members include food and drink makers and supermarket chains, has pledged to remove 1.5 trillion calories from the marketplace by 2015.10
These commitments are being evaluated by the Robert Wood Johnson Foundation. “An independent evaluation of this type has never before been undertaken, and its implications for tracking how industry formulates and packages its products are unprecedented,” according to Barry Popkin, University of North Carolina Food Research Program and one of the authors of a study establishing the analytic framework for assessing changes in the US food stream.11
Initiatives by individual companies can encourage others to highlight their efforts to improve the overall nutritional profile of their products. As examples, PepsiCo pledged to eliminate the direct sale of full calorie drinks to all schools worldwide and is well on the way to achieving this, and Unilever announced plans to cut salt content in 22 000 products as its contribution to meeting WHO’s recommended 5 g maximum daily intake.
Doing the right thing turns out to be good for business. A Hudson Institute study of chain restaurants found that “between 2006 and 2011 lower-calorie foods and beverages were the key growth engine,” and concluded, “Increasing lower-calorie menu portfolios can help quick-service and sit-down restaurant chains improve the key performance metrics demanded by their shareholders and Wall Street, while at the same time providing lower-calorie foods and beverages for families and children.”12
Voluntary action by consumers is also important. Food choices have deep links to cultural, social, and historical norms, as well as childhood habits. Current research suggests the efficacy of simple interventions that nudge people into healthy choices.13 14 15 Using incentives to encourage healthy eating (and reduce consumption of unhealthy foods) has shown promise in shifting diets in a large population16 and is evidence of the type of innovation possible through voluntary actions.
Overall, the food system needs an approach that draws on the power of markets through smarter incentives for food companies to change products and marketing practices, subsidies for healthy food, disincentives for supersizing portions, increased physical activity, and rewards for health professionals and teachers who promote healthy eating and activity. All must be supported by continual communication and social marketing focused on key health messages. Market led solutions, when combined with public policies, will make healthy choices the default option.
Cite this as: BMJ 2013;346:f2279
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I am a paid employee of The Vitality Group, a private health and wellness company, and subsidiary of Discovery Holdings, South Africa; I serve as a paid advisory member of the PepsiCo Scientific Advisory Board; and I am an unpaid adviser to the Clinton Global Initiative and the National Institute for Health’s Fogarty International Center.
Read Klim McPherson’s side of the debate at doi:10.1136/bmj.f2426.
Provenance and peer review: Not commissioned; not externally peer reviewed.