The prevention of obesity and NCDs: challenges and opportunities for governments

HEALTH-PROMOTING POLICIES: THE CHALLENGE

Despite these resolutions and the publications supporting strategic planning for NCD reduction, progress is hampered by factors which are commonly experienced in public health. These factors include (a) difficulties providing robust evidence on the likely effectiveness of policies before they have been introduced, (b) competition for resources between public health preventive services and other government-provided services, and (c) conflicting advocacy from commercial interests which promote the consumption of products liable to harm health, and non-health government departments which prioritise 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 identify cost-effective interventions. 

In open market economies, companies fulfil their duty to obtain maximum shareholder return by promoting their products aggressively. Their collective actions encourage over-consumption. This poses a severe problem for public health proponents seeking to reduce consumption of specific products. 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 exist in relation to the consumption of alcohol and food.14  15

Lessons from tobacco and alcohol indicate: 

• Business interests can gain more influence than public health interests in the policy making process due to their economic power and their anticipated support for the status quo.16 
• Changing the status quo can face significant resistance from policy makers, who put the burden of proof on the advocates for change. 
• Industry lobbying power is significant and undermines public health. In 2012 the US alcohol industry employed 256 lobbyists, the tobacco industry 174 lobbyists, and the food and beverage industry 327 lobbyists to influence the 553 members of the US Congress.17 
• Public health promoters need to use the media, make data politically relevant, challenge the opposition and produce consensus statements. 
• Community action is vital in order to increase the political will of legislators to challenge business freedoms / practices and to implement the necessary policies. 
• In food supplies, the greatest profit is often gained from processed and long shelf-life products which disproportionately contribute to NCDs and obesity.18 

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,19 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.”20

Even in situations where the influence of commercial interests is not apparent, the prevailing ideology in favour of economic growth and open market development can lead policy-makers to resist proposals for stronger public health intervention and increased consumer protection. There is a need for governments and civil society to recognise these conflicts and develop procedures which properly manage them, in order to be able to implement policies which protect and promote better health. 

Commercial operators may seek to engage in ‘public-private partnerships’ with government and civil society, if the activities – such as physical activity initiatives – do not threaten their markets. While 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. Potential conflicts of interest of this nature need to be managed appropriately to ensure that the public’s interest is protected. Full transparency of any such relationship is essential. It is important to recognise the main drivers of business practices include a company’s responsibility to provide increased returns to its stakeholders, including investors who seek short-term gain, its need to generate consumer demand, its need to respond to commodity prices 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.

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Graham