Elsevier

The Lancet

Volume 385, Issue 9986, 20–26 June 2015, Pages 2534-2545
The Lancet

Series
Strengthening of accountability systems to create healthy food environments and reduce global obesity

https://doi.org/10.1016/S0140-6736(14)61747-5Get rights and content

Summary

To achieve WHO's target to halt the rise in obesity and diabetes, dramatic actions are needed to improve the healthiness of food environments. Substantial debate surrounds who is responsible for delivering effective actions and what, specifically, these actions should entail. Arguments are often reduced to a debate between individual and collective responsibilities, and between hard regulatory or fiscal interventions and soft voluntary, education-based approaches. Genuine progress lies beyond the impasse of these entrenched dichotomies. We argue for a strengthening of accountability systems across all actors to substantially improve performance on obesity reduction. In view of the industry opposition and government reluctance to regulate for healthier food environments, quasiregulatory approaches might achieve progress. A four step accountability framework (take the account, share the account, hold to account, and respond to the account) is proposed. The framework identifies multiple levers for change, including quasiregulatory and other approaches that involve government-specified and government-monitored progress of private sector performance, government procurement mechanisms, improved transparency, monitoring of actions, and management of conflicts of interest. Strengthened accountability systems would support government leadership and stewardship, constrain the influence of private sector actors with major conflicts of interest on public policy development, and reinforce the engagement of civil society in creating demand for healthy food environments and in monitoring progress towards obesity action objectives.

Introduction

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

  • 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

  • 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)

  • 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

  • The process of food policy development needs increased protection from the vested interests of the processed-food industry

  • 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

  • Civil society will need to increase its role substantially to independently monitor progress and create a large demand for changes to food environments

  • 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.

Section snippets

Absence of appropriate accountability mechanisms

The 2011 UN high-level meeting on NCDs15 and WHO's 2004 Global Strategy on Diet, Physical Activity, and Health16 encouraged a multisectoral response, including voluntary partnerships among public, private, and civil society stakeholders as a core strategy to reduce obesity rates.17, 18 Many national governments, as well as the transnational processed-food corporations, have made such partnerships a central feature of their response to obesity. Although many different interactions with the wide

Accountability and governance of food systems

Whereas responsibility refers to the obligations to be fulfilled by one actor, accountability involves one actor answering to another actor, the account holder, who is empowered with the authority to assess how well the former fulfils obligations to achieve specific goals.24 Accountability also involves recognition of achievements and enforcement of performance through the application of sanctions for poor performance or non-compliance. As such, accountability is ultimately about governance and

An accountability framework to create healthy food environments

An accountability framework to improve the healthiness of food environments has been proposed by Kraak and colleagues,24 following a comprehensive review of 15 interdisciplinary conceptual frameworks for institutional accountability. One example of an institutional accountability framework was developed by the Commission on Information and Accountability for Women's and Children's Health (“Monitor, Review, and Act” three step framework).37 Another accountability framework was developed by the

Illustrations of accountability of national approaches to food policy

Two approaches to improving the healthiness of food environments are illustrated using the four step accountability framework (figure): the Public Health Responsibility Deal Food Network in England32, 79, 80 (panel 2) and the National Food and Nutrition Security System in Brazil (panel 3). Voluntarism is the key feature of the Responsibility Deal in England. Here the government's position is to encourage but not require food industry actors to implement pledges to improve food environments. By

Implications for obesity-prevention policies

The determinants of obesity and the solutions to prevent it are complex. However, the debates have, to some degree, become entrenched in simple dichotomies: individual versus environmental causes, hard versus soft approaches to action, supply versus demand for consumption of unhealthy food products, government regulation versus industry voluntary codes, top-down versus bottom-up drivers for change, evidence-based versus lobby-responsive policy making, importance of diet versus physical

References (92)

  • R Bonita et al.

    Country actions to meet UN commitments on non-communicable diseases: a stepwise approach

    Lancet

    (2013)
  • R Beaglehole et al.

    Independent global accountability for NCDs

    Lancet

    (2013)
  • SS Lim et al.

    A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010

    Lancet

    (2012)
  • R Beaglehole et al.

    NCD Countdown 2025: accountability for the 25 × 25 NCD mortality reduction target

    Lancet

    (2014)
  • D Gleeson et al.

    Emerging threats to public health from regional trade agreements

    Lancet

    (2013)
  • AM Thow et al.

    Trade and food policy: case studies from three Pacific Island countries

    Food Policy

    (2010)
  • B Reeve et al.

    ‘Legislative scaffolding’: a new approach to prevention

    Aust N Z J Public Health

    (2013)
  • MEE Petticrew et al.

    The public health responsibility deal: how should such a complex public health policy be assessed?

    Lancet

    (2012)
  • R Horton et al.

    From public to planetary health: a manifesto

    Lancet

    (2014)
  • Global Action Plan for the Prevention and Control of Noncommunicable diseases 2013–2020

    (2013)
  • Comprehensive global monitoring framework, including 25 indicators and a set of nine voluntary targets for the prevention and control of noncommunicable diseases

    (2013)
  • B Swinburn et al.

    INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support): overview and key principles

    Obes Rev

    (2013)
  • CA Roberto et al.

    Patchy progress on obesity prevention: emerging examples, entrenched barriers, and new thinking

    Lancet

    (2015)
  • D Stuckler et al.

    Manufacturing epidemics: the role of global producers in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco

    PLoS Med

    (2012)
  • BM Popkin

    Bellagio Declaration 2013: countering Big Food's undermining of healthy food policies

    Obes Rev

    (2013)
  • PLoS Medicine series on Big Food: the food industry is ripe for scrutiny

    PLoS Med

    (2012)
  • J Clarke

    Dissolving the public realm? The logics and limits of neo-liberalism

    J Soc Policy

    (2004)
  • E Alexander et al.

    Major multinational food and beverage companies and informal sector contributions to global food consumption: implications for nutrition policy

    Global Health

    (2011)
  • Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases

    (2011)
  • Global strategy on diet, physical activity and health

    (2004)
  • Partnerships. Agenda item 18.1, 21 May

    (2010)
  • VI Kraak et al.

    Balancing the benefits and risks of public-private partnerships to address the global double burden of malnutrition

    Public Health Nutr

    (2012)
  • LL Sharma et al.

    The food industry and self-regulation: standards to promote success and to avoid public health failures

    Am J Public Health

    (2010)
  • M Bovens

    Analysing and assessing accountability: a conceptual framework

    Eur Law J

    (2007)
  • M Chan

    WHO Director-General addresses health promotion conference

  • VI Kraak et al.

    An accountability framework to promote healthy food environments

    Public Health Nutr

    (2014)
  • S Rochlin et al.

    Making partnerships accountable for delivering development

    (2008)
  • EU Igumbor et al.

    “Big food,” the consumer food environment, health, and the policy response in South Africa

    PLoS Med

    (2012)
  • CA Monteiro et al.

    The impact of transnational “big food” companies on the South: a view from Brazil

    PLoS Med

    (2012)
  • C Jönsson et al.

    Transnational actors in global governance patterns, explanations, and implications

    (2010)
  • R Dodgson et al.

    Global health governance: a conceptual review. Discussion paper no. 1

    (2002)
  • B McGrady

    Trade and public health: the WTO, tobacco, alcohol, and diet

    (2011)
  • Public Health Responsibility Deal. Sign up and pledge to improve public health in England

    (2012)
  • Food and beverage manufacturers pledging to reduce annual calories by 1·5 trillion by 2015

  • T Elliott et al.

    A systematic interim assessment of the Australian Government's Food and Health Dialogue

    Med J Aust

    (2014)
  • Keeping promises, measuring results: commission on information and accountability for women's and children's health

    (2011)
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