Non-communicable disease governance in the era of the sustainable development goals: a qualitative analysis of food industry framing in WHO consultations

The complex nature of obesity and related NCDs was invoked to dismiss regulatory approaches as too simplistic. The German Food Federation (BLL), for example, expressed the view that “regulatory measures like marketing restrictions are not suitable to solve the complex issue of NCDs” [72]. Diet was framed as too complex for the regulation of specific products such as SSBs to be effective or appropriate, drawing attention to non-dietary factors such as a lack of physical activity. Promoting a “holistic” [73‐77] approach to dietary public health policy instead, such arguments were employed to make the case that all products, including those considered unhealthy, play a role in people’s diets. This placed the blame for unhealthy diets as well as the responsibility for a “balanced” [73, 78, 79] lifestyle on the individual, justifying the food industry’s promotion of individual- rather than population-level interventions. In framing the issue as complex, respondents also fed into the narrative of partnership approaches as the way forward, USCIB, for example, claims that “[g]iven the complex nature of nutrition and health, making progress on NCDs will require partnerships to be formed between policymakers and non-state actors with lines of communication remaining open” [63].

In opposing regulatory approaches, respondents framed regulation as inappropriate or unnecessary by arguing that existing (regulatory or other) measures were sufficient, the current voluntary actions have achieved positive results; and where an intervention was necessary, non-statutory, self- or co-regulation would be preferable or should at least have “its place in the policy mix” [80]. FIA and IFBA, for example, highlight self-regulation as “cost-effective”, “measurable”, “flexible”, and able to “quickly respond to societal concerns” [81, 82]. The legitimacy of non-statutory approaches was emphasised by invoking WHO’s previous guidance, with FIA for example pointing out that “self-regulation has formally been recognised as a means of implementing the policy objective of reducing the impact on children of the marketing of foods high in fat, sugar and salt in the 2010 WHO recommendations” [60, 81]. Further marketing restrictions were also opposed by one German [72, 83] and one Brazilian [84] respondent on the basis that sufficient regulation was already in place at country level. In a similar vein, a frequent argument against COI safeguards maintained that sufficient protections existed, often directly invoking the WHO’s Framework of Engagement with Non-State Actors (FENSA, [85]) [64‐66], even though the proposed safeguards focused on member state management of COI whereas FENSA is an internal WHO guide [53].

Respondents employed a partnership framing to convey a need for industry participation to adequately tackle NCDs and maintain that food industry actors have a right to participate. Portraying themselves as a part of the solution, food industry actors invoked the urgency of collaboration in order to tackle the NCD challenge. Highlighting the imbalance between available and required public resources to prevent and treat NCDs, respondents argued that the food industry is needed to fill such gaps: “Given the importance of tackling NCDs and the limited technical expertise and resources available in many countries, public-private engagement will be extremely important to better address the challenges of NCDs” [86].

A partnership framing and the use of language around ‘multistakeholder’ and ‘multisectoral’ approaches were also used to position the food industry as a legitimate policy actor with the right to participate. The idea of a shared purpose between industry and the public sector was employed to paint a picture of the industry as a partner, rather than an opponent or a bystander, in NCD policy. To highlight the food industry as a vital stakeholder, respondents emphasised its economic importance [59, 63, 87] and positioned it as a bridge between government and consumers, arguing that “businesses in the food sector have the closest direct relationships with consumers through their day to day food and diet choices” [88]. Ostensibly successful previous collaboration with governments and international organisations, as well as ongoing voluntary commitments, were cited to demonstrate that the food industry deserves a strong role going forward. Invoking the food industry’s “long and successful history of engaging on nutrition and health issues at national, regional, and global levels”, GMA added that “key public health initiatives, such as the development of salt reduction strategies, could not have been achieved without constructive engagement between health authorities and our industry” [59]. Respondents also explicitly differentiated the food industry from other sectors whose products are perceived as more harmful, such as alcohol and tobacco. In particular, food industry actors heavily protested any comparison or association with the widely denormalised tobacco industry, considering it “inappropriate for the WHO to compare the food and beverage industry to industries excluded from engagement with the WHO” [64, 65]. In a similar vein, respondents opposed the use of the term ‘health-harming’ on the basis that it would inappropriately equate their products with alcohol and tobacco. One respondent stated that although “high-fat, sugar and salt products should be consumed in a balanced manner, it would not be appropriate to classify such products as “health-harming”, presumably in the same category as tobacco products or alcohol beverages” [84]. While acknowledging a perceived risk from private sector engagement in some cases, COI was widely downplayed as manageable through disclosure and the notion of excluding actors due to COI was dismissed as “unfair” [64, 65].

Respondents questioned whether regulatory policies would have the intended benefit for public health and argued that they may have unintended negative effects. Food industry actors claimed that regulatory policies would not work, either because they are too narrowly focused (see ‘Complexity’) or because, as seen particularly in the context of SSB taxation, they would not have the desired effect of decreasing consumption of the target product or nutrient [74]. Conversely, the same respondents also warned against devastating impacts of SSB taxation on businesses, employment, the economy, or low-income groups. ICBA, for example, justified its opposition to SSB taxation by maintaining that “history has also shown that these types of tax initiatives are regressive, and are unlikely to actually affect obesity rates and thus non-communicable diseases” [74]. Closely linked to the partnership framing discussed above, food industry actors argued that the proposed COI safeguards may undermine efforts to reduce NCDs by, for example, depriving “member states of the knowledge, expertise, and resources of the private sector and put at risk programs that are helping member states achieve their own public health objectives” [64]. A number of respondents, for example GMA and USCIB in two near-identical submissions, explicitly presented non-engagement with industry as a threat to NCD policy, arguing that “it is essential that WHO support government engagement with private sector, including by helping governments understand missed opportunities and assess risk of not engaging” [59, 63].

A central element to commercial actors’ arguments was evidence, including the principle of evidence-based policymaking. Regulatory policies were contested with claims that the evidence base is either insufficient in quantity or quality, or contraindicative (closely linked to ‘Unintended consequences’). Respondents questioned the evidence base underlying regulation, BLL for example asserted that “[a]dvertising plays – if it all – a minor role in influencing food choices (…). This has been shown in practice and scientific studies” [72] and ICBA questioned the link between SSBs and obesity, stating that “the overall weight of the scientific evidence on sugar and/or sugar-sweetened beverages show that they do not have a unique effect on body weight beyond their contribution to total calorie intake” [74]. An apparent lack of evidence was often put forward to justify delaying policy action. IFBA, for example, claimed that “further work is needed to assess the impact as well as the implementation approaches of fiscal measures before these are recommended” [79] and GMA argued that “there are significant evidence gaps in understanding how label format impacts consumer behaviour” [73]. The distinction between healthy and unhealthy foods itself, and the use of associated terms such as processed and health-harming was contested with claims that there is a lack of evidence supporting them. Widely pledging their support for evidence-based policymaking in principle, food industry actors also portrayed industry engagement as an important part of it, arguing, for example, that “[p]rivate sector engagement is, and has been, a key contributor to evidence-based policymaking at the WHO” [86]. More specifically, multiple submissions argued that evidence-based policymaking demands the consideration and inclusion of all evidence, including the industry’s own.

The concept of good governance was invoked throughout the consultation responses, using the indeterminate but ubiquitous term to advocate a very specific approach to decision-making – a significant role for the private sector and emphasis on minimising the economic impact of health policies. Despite rhetorical alignment with accountable and transparent policymaking, respondents framed COI safeguards as incoherent with, or even “antithetical” [64] to, good governance. A number of US-based BAs explicitly made reference to “good regulatory practice”, which, according to USCIB, includes “transparent stakeholder consultation, cost/benefit analysis, and assessment of alternatives to regulation” [89]. Such arguments were closely tied to the promotion of economic impact assessment.

Furthermore, policy coherence, within the WHO and with the wider UN system, was emphasised by respondents in support of their positions and preferred governance approaches. The SDGs as well as the WHO’s own FENSA and publications on NCD policy were invoked to oppose COI safeguards in nutrition policy. FIA, for example, expressed its concern that the proposed safeguards “perhaps contradict the spirit of FENSA, as well as the WHO’s Global Strategy for the prevention and control of non-communicable diseases 2013-2020, the 2011 UN Political Declaration on NCDS, and the UN’s Sustainable Development Goals, specifically SDG 17” [66]. Correspondingly, industry engagement was positioned as essential for increasing policy coherence. The concept, often invoked with the aim of improving the alignment of other policy agendas with health, was reframed by Engaging America’s Global Leadership (EAGL) [90] as going “in both directions”, meaning that health ministries should also align their approaches with other policy areas such as “economic growth and development” [90].

Submissions questioned the political legitimacy of the WHO regarding its role within the UN system, its internal coherence, and issues of national sovereignty. Closely related to arguments around policy coherence mentioned above but instead conveying a sense of the WHO’s NCD agenda being subordinate to the wider UN’s Sustainable Development Agenda, the WHO’s restricted room for action was highlighted. The WHO Department of Nutrition’s attempts at developing guidance for addressing and managing COI in nutrition policy were framed as out of step with other WHO policies, the SDGs and the overall multistakeholder approach prominent within the UN system. Citing SDG 17 directly in several cases, respondents interpreted the Sustainable Development agenda as an imperative for partnership, suggesting that the WHO must comply with this approach. Similarly, the WHO was portrayed as an agency with a narrow focus and capability. For example, its expertise and authority on issues such as fiscal policy was questioned by actors opposing SSB taxation: “Offering such policy advice in a field – economics and fiscal policy – far from WHO’s expertise is not in our opinion a prudent course of action” [71, 91].

Respondents also emphasised national primacy in decision-making, arguing that questions such as whether to engage with industry in policymaking should not be answered by the WHO, but left to Member States. Correspondingly, and despite their non-binding nature, proposed COI safeguards were portrayed as potentially infringing on national sovereignty, and contravening Member States’ legal obligations: “Member States must observe their own legal and normative obligations to free and open governance to deliver regulations that meet public policy objectives” [92]. The US-based ICBA [93] and GMA [94] explicitly referred to protections for commercial speech as the potentially conflicting policy area. Furthermore, the primary responsibility and authority for tackling NCDs was attributed to national governments, implying that the WHO has a limited role to play. Emphasising that NCD policy should be driven by national priorities, respondents advocated flexible and non-restrictive, namely weaker, recommendations.