The WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases (NCDs) 2013–201 was adopted at the 66th World Health Assembly in May, 2013. The accompanying NCD Global Monitoring Framework2 includes specific targets to halt the rise in obesity and type 2 diabetes in adults and adolescents. Although targets of no increase might sound modest, they are probably the most formidable of the WHO targets because no country has yet achieved them. These targets will not be achieved without improvements in food environments at local, national, and transnational levels because obesogenic food environments are the underlying drivers of the obesity epidemic.3 Food environments encompass the collective physical, economic, policy, and sociocultural surroundings, opportunities, and conditions that affect people's food and beverage choices and nutritional status.4
This Series paper focuses on the strengthening of accountability mechanisms that will create healthy food policies and environments. Strategies to improve physical activity were reviewed by Kohl and colleagues5 in the 2012 Lancet Series about physical activity. The paper by Roberto and colleagues,6 introducing this second Lancet Series about obesity, outlines several key reasons for the poor global progress on obesity prevention. Chiefly, the processed-food industry has been very successful in blocking governmental and societal efforts to implement food policies for obesity prevention.7, 8, 9, 10 There is broad agreement, as noted by Gortmaker and colleagues11 in the first Lancet Series about obesity, that government-led policies and regulations, such as restrictions on unhealthy-food marketing to children, interpretive front-of-pack labelling, healthy food policies in schools and the public sector, and taxes on unhealthy products, such as sugar-sweetened beverages, are needed. These policies are of high priority and are included in the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–201 for several reasons: the policies are cost effective, feasible, and have population-wide effects; the policies reduce nutrition inequalities by improving benefits to more disadvantaged populations; once established, the policies are sustainable; the policies support other societal objectives, such as protecting children from exploitation and enabling consumers to make informed food choices; and regulations carry the strongest accountability levers.
The poor progress in the reduction of obesity requires explanation. Deregulation and the shift of health responsibilities to the individual are core narratives in the present dominant climate of neoliberal politics and economics.12 The food industry's initiatives to reduce obesity have centred around the establishment of voluntary marketing codes and product reformulation, promotion of physical activity and community-based initiatives, and provision of information for consumers about the nutritional benefits of their food products through health and nutrition claims.13 Debate persists about whether the responsibility of taking action lies with the individual (the food industry offering more consumer choices) or with society (the government providing societal leadership). What those actions should entail is another matter of debate. Hard approaches involve government regulatory and fiscal interventions, whereas soft approaches involve educational and industry voluntary codes.14 In view of the substantial political power of the processed-food industry, government approaches to obesity prevention largely favour industry's preferences for a focus on individual responsibilities and soft approaches. These approaches, which are close to business-as-usual, are perpetuating the conditions that drive obesity.
Key messages
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Major improvements are needed in the healthiness of food environments if the global targets of halting the rise in obesity and type 2 diabetes are to be met
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The proposed four step accountability framework aims to ensure progress towards achievement of the WHO obesity and diabetes targets, which are to take the account (through independent assessment and benchmarking of progress), share the account (through communication of the evidence of progress), hold to account (to ensure accomplishments are acknowledged and non-compliance or poor performance is sanctioned), and respond to the account (through system-wide improvements to policies and actions)
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Although governments probably need improved regulatory mechanisms to ensure private sector accountability, several non-regulatory mechanisms (eg, quasiregulatory, political, market-based, and public and private communications) are underutilised; these mechanisms will help to strengthen the difficult step of holding private sector to account for performance
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The process of food policy development needs increased protection from the vested interests of the processed-food industry
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Where food systems are not yet highly dependent on transnational food corporations, efforts should concentrate on preservation and strengthening of national food sovereignty and agro-food-biodiversity and prevention of food systems from becoming highly dominated by big food corporations
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Civil society will need to increase its role substantially to independently monitor progress and create a large demand for changes to food environments
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Global and national food systems need to create sustainable diets, which are not only secure and economically viable, but also promote health, equity, and environmental sustainability; prominent features of the UN's Post-2015 Development Agenda should be global goals to reduce obesity and NCDs and achieve sustainable diets as climate change threatens to inflict major damage to global food systems
In this Series paper, we investigate these viewpoints and propose a wider perspective on how governments, the private sector, and civil society can be linked within an accountability framework to ensure progress on improving the healthiness of food policies and environments. We also examine a number of quasiregulatory approaches that could be the first steps towards breaking the impasse between the regulatory and deregulatory positions.