Recently, Cancer Council NSW published a study finding that food industry self-regulation in Australia has not been effective in reducing children’s exposure to unhealthy food marketing. Australian children still see, on average, three advertisements for unhealthy foods and beverages during each hour of prime time television they watch. This figure remains unchanged despite the Australian food industry introducing two voluntary codes on food marketing to children in 2009.
I undertook an in-depth analysis of the terms and conditions of the two food industry codes on marketing to children. I also analyzed the processes of administration, monitoring, enforcement and review established by the self-regulatory scheme.
My analysis drew on the code documents themselves, monitoring reports from the food industry, existing independent research, and a sample of advertising complaint determinations from the Advertising Standards Board. I also considered the revisions made to the codes in 2014 (following an independent review of the scheme), and asked whether these revisions make the codes more likely to protect children from exposure to unhealthy food marketing.
My key finding is that the substantive terms and conditions of the codes contain a series of loopholes which leave food companies with a variety of techniques they can use to market unhealthy products to children. These loopholes include:
A weak definition of “media directed primarily to children” which excludes general audience programs that are popular with children
A weak definition of “advertising directed to children,” made weaker still by the Advertising Standards Board’s interpretive approach; and
The exclusion from the codes of key promotional techniques such as company-owned characters (e.g., Ronald McDonald), brand advertising, product line advertising, and product packaging and labelling.
The processes used to administer and enforce the codes also contain a series of flaws, undermining the codes’ efficacy, transparency and accountability. These include:
A lack of consultation with, or participation by, external stakeholders in the development of the codes, e.g., consumer or child representatives, government, or public health groups;
A lack of independent, systematic monitoring of the codes; and
The limited availability of enforcement mechanisms for non-compliance.
These loopholes and limitations help to explain why food industry self-regulation has not been effective in improving children’s food marketing environment. Further, the revisions to the codes made in 2014 appear to have done little to improve the self-regulatory scheme, and are unlikely to lead to lead to reductions in children’s exposure to unhealthy food marketing.
My article sets out a “responsive” or step-wise approach for strengthening regulation of food marketing to children, by closing off the loopholes in the substantive terms and conditions of the codes, and strengthening regulatory processes, including monitoring and enforcement. Most importantly, I argue, regulation of food marketing to children needs strong government leadership and an approach to protecting children from unhealthy food marketing that doesn’t just rely on voluntary food industry action. There are a range of regulatory options available, even if government is unwilling to introduce new statutory controls on food marketing to children.
The Grattan Institute report estimates that such a tax would reduce the consumption of sugary drinks by about 15% and generate up to half a billion dollars that could help to pay for a broad array of obesity-related programs.
Imagine! A public health policy that fights obesity, diabetes and tooth decay AND generates revenue.
The National Party hate the idea. Deputy Prime Minister and Leader of the Nationals, Barnaby Joyce told reporters:
“If you want to deal with being overweight, here’s a rough suggestion: stop eating so much, and do a bit of exercise. There’s two bits of handy advice and you get that for free. The National Party will not be supporting a sugar tax”.
Well that’s what he said.
But here’s what I heard: “We know that obesity and diabetes are out of control. But we have ideological objections to being part of the solution”.
The same day that Minister Joyce shared these thoughts with reporters, the Australian Food and Grocery Council issued a press release saying that it was seeking a “constructive response to obesity”.
“Obesity is a serious and complex public health issue with no single cause or quick-fix solution”, explained the AFGC, but “it is not beneficial to blame or tax a single component of the diet”.
With most complex issues, you start somewhere. You come up with evidence-informed policies and you try them out. You rigorously evaluate their performance, and learn by doing.
But not with obesity. “Complexity” is the new enemy of action. Since the causes of obesity are complex, every “single” policy advanced in response can be dismissed as a dangerously simplistic solution to a complex problem.
Welcome to obesity, the problem we’re not allowed to start to fix.
Except with personal responsibility, of course.
Personal responsibility…the answer to obesity, traffic accidents, terrorism, Zika virus, perhaps everything?
In a limited sense, Barnaby Joyce is right.
The only cure for personal obesity is personal responsibility.
But personal responsibility has turned out to be a spectacularly poor solution to “societal obesity”.
By societal obesity, I am referring to the trend towards overweight and obesity that has arisen over the past few decades and now affects the majority of adult men and women (and more than one in four children).
Since each of us is an individual, and because we live in a culture that prizes individual autonomy, it’s easy to fall into the trap of believing that individual effort, personal motivation, is the solution to the world’s ills.
But just as the global epidemics of obesity and diabetes were not caused by a catastrophic, global melt-down in personal responsibility, personal responsibility is equally unlikely to provide the magic solution.
That’s where public policies come in.
Governments know all this, but with the exception of tobacco control, they seem reluctant to apply their knowledge in the area of preventive health.
The fact is, from road traffic accidents to terrorism, smart governments:
acknowledge the complexity of the factors that contribute to societal problems;
They acknowledge that multiple interventions are needed, in many settings;
They acknowledge that possible solutions need to be trialled now, under conditions of uncertainty, instead of handing the problem to future generations.
They monitor the actions they take, because healthy public policy is a dynamic, ongoing process; and finally
They give a damn. Meaning that they recognise they are accountable to the community for helping to solve difficult, societal problems, and for the performance of the public policies they administer.
Imagine if Australia’s government took that approach with obesity.
The debate about a sugary drinks tax is here to stay: it will never go away
A tax on sugary drinks will get National Party politicians in trouble with sugar producers, and Liberal Party politicians in trouble with big food.
Despite batting it away, a tax on sugary drinks is on the public agenda, and it’s here to stay. I don’t see the sugary drinks industry winning on this issue indefinitely.
Partly because Australian health researchers will keep it on the agenda.
It will come back, and back. Especially as evidence of its success accumulates overseas.
One conversation worth having is how revenues from a sugary drinks tax might support agricultural producers in rural Australia, helping to cushion them from the adverse effects (if any) of the tax and creating incentives for the production of a sustainable and healthy food supply.
In the meantime, Australian health advocates need to broaden their base.
Advocacy for public policy action on obesity needs to become more closely integrated with advocacy on food security. And advocacy in both areas needs to be linked more closely to action on reducing health inequalities.
But enough about all that. You really came here for Barnaby, didn’t you?
The UK tax on soft drink and Jamie Oliver’s call to action
TodayBritain announced that from 2017 it would levy a tax on soft drinks containing more than five grams of sugar per 100 millilitres, as part of efforts to contain rising levels of childhood obesity. The announcement prompted Jamie Oliver to post a video on Facebook encouraging other governments to follow suit, and telling Australia and other countries to “pull your finger out” on soft drink taxes.
Should Australia introduce a sugary drinks tax? Would a tax be an effective obesity prevention measure? Or would it just be a slow and costly way of raising the ire of the food industry?
Australians drink a lot of soft drink
Around one third of Australians drink about a can of soft drink a day, making Australia one of the top ten soft-drink consuming countries in the world. Soft drink consumption among young people is particularly concerning, with around 47% of children (aged between two and 16 years) consuming sugar-sweetened beverages (SSBs) every day.
Why is soft drink bad for our health?
A large number of studies show that soft drink consumption increases the risk of obesity, diabetes, heart disease and dental caries, and soft drink consumption has been linked to approximately 184,000 deaths per year globally.
Soft drink has a large of amount of added sugar (when it’s not artificially sweetened), making it a key source of added sugar in our diets. Drinking soft drink displaces the consumption of healthier beverages, and we tend not to compensate for the calories we drink by reducing our food intake. Drinks that are high in sugar have been shown to reduce appetite control, which also contributes to weight gain.
Around 60% of Australian adults and 25% of children are either obese or overweight and obesity has overtaken smoking as the leading cause of preventable death and illness. Reducing soft drink consumption could be one way of reducing the burden of obesity and chronic disease, and its impact on Australia’s health care system.
Soft drink taxes are gaining momentum
Public health experts recommend soft drink taxes as one component of a comprehensive obesity prevention strategy, and a number of countries have taken this recommendation on board.
In September 2013 the Mexican congress passed an excise tax on SSBs of one peso per litre – a price increase of approximately 10%. Mexico also introduced an ad valorem tax of 8% on a defined list of non-essential energy-dense foods.
The US city of Berkeley passed a one cent per ounce excise tax on SSBs in November 2014, becoming the first US city to levy a targeted health-related tax on soft drink.
Since January 2015 Chile has levied an 18% ad valorem tax on drinks with a sugar content of more than 6.25 g of sugar per 100 mL, including energy drinks and sweetened waters. Sugary drinks with less than 6.25 g of sugar per 100 mL are taxed at 10%.
These are just a few examples of jurisdictions with soft drink taxes; others include France, Mauritus, and Barbados. Countries are also experimenting with taxes on other unhealthy food products, or on specific nutrients such as fat or salt, often in tandem with taxes on sugary beverages.
Are soft drink taxes effective?
Soft drink taxes are a relatively new initiative, meaning that there’s not much ‘real world’ evidence of their impact. However, modelling studies suggest that tax increases are effective in reducing consumption of SSBs, and a recent evaluation of Mexico’s soft drink tax provides more concrete evidence of the effectiveness of taxes in shifting consumption patterns. The study found that the average volume of taxed beverages purchased monthly was 6% lower after the tax was implemented, with reductions accelerating over time, and reaching a 12% decline by December 2014.
The effects of soft drink taxes on diet-related health are less certain, but there is some evidence for this relationship too. One review of the evidence found a statistically significant association between “substantial” food taxes and weight outcomes, particularly in relation to children, adolescents, low socioeconomic status populations, and those at risk for overweight.
Other studies are more equivocal, but keep in mind that this a recurring problem in public health – the difficulty of showing that one initiative in isolation will lead to significant weight reductions. Experts agreed that a number of complementary measures will be required if we are to see meaningful reductions in obesity and overweight.
What are some of the criticisms of soft drink taxes?
One of the main concerns about soft drink taxes is that they are regressive. In theory, SSB taxes have a larger impact on lower socioeconomic groups, given that such groups pay a higher proportion of their income towards soft drink purchases. However, the evaluation of Mexico’s soft drink tax found that reductions in soft drink purchasing were greatest among low SES households (averaging 9.1%), suggesting that low SES groups were the most price elastic and thus benefited the most from the tax.
Governments can also take steps to offset the regressive nature of soft drink taxes, for example by targeting subsidies for healthy foods and beverages to low-income households, which could be paid for using the revenue generated by soft drink taxes. Alternatively, tax revenue could be used to address disparities in health or socioeconomic status more broadly.
The effectiveness of an excise tax in reducing SSB consumption hinges on the extent to which the tax is passed on to consumers in the form of higher retail prices. Distributors or retailers may “under shift” the tax by absorbing its cost, thus lowering their profit margins, but sustaining sales. Lower than expected price increases may undermine the tax’s public health benefit. However, evaluations of SSB taxes in Berkeley and Mexico find that manufacturers and distributors have mostly passed on the costs of the taxes to consumers, suggesting that these taxes will have the desired effect.
What’s the situation in Australia?
Australia’s GST exempts many foods that are a core component of a healthy diet, such as fresh fruits and vegetables. Sugary drinks are subject to the GST, meaning that there is a kind of differential tax on soft drinks. However, the GST is not intended for this purpose and operates differently to a specific, health-related soft drink tax.
In 2008 the National Preventative Health Taskforce recommended that the government commission a review of economic policies and taxation systems, and use economic incentives to decrease the production and consumption of unhealthy foods and beverages. It cautiously recommended a soft drink tax, given the uncertain impact of these taxes on consumer health.
In its response to the Taskforce, the then federal Labor Government stated that it had already commissioned an independent review of the Australian taxation system, i.e., the Henry Tax Review in 2010. This review did not recommend health-specific taxes on foods and beverages (despite recommending tax hikes for tobacco and alcohol) and the Government said that it would not consider another review. Instead, the Government pointed to voluntary food reformulation efforts taking place through the Food and Health Dialogue.
Should Australia introduce a soft drink tax?
Jamie Oliver’s right. The Australian government does take a “weak, pathetic” approach to obesity prevention, and we could do better.
The evidence shows that an SSB tax could have a real impact on Australian’s soft drink consumption habits, as does the effectiveness of tobacco taxes and other food taxes such as Denmark’s tax on saturated fat. Soft drink has no nutritional value, making it one of the more uncomplicated food products to tax.
As well as shifting consumption patterns, soft drink taxes could prompt companies to reformulate drinks to reduce their sugar content, or to introduce new, healthier products. Taxes could also generate significant revenue for health promotion activities, preferably targeted at the most vulnerable populations.
The health outcomes of SSB taxes need further research, but this should not stop the Government from “pulling its finger out” as suggested by Jamie Oliver, and introducing a tax on soft drink, as many other countries are doing. An SSB tax would send a clear message that the government is committed to protecting the health of Australians, even if it means taking on the powerful multinational companies that dominate the beverage industry.
The World Health Organisation’s Commission on Ending Childhood Obesity, appointed by WHO Director-General Dr Margaret Chan in 2014, has now formally presented its final report.
The Commission was co-chaired by Sir Peter Gluckman, the Chief Science Advisor to the Prime Minister of New Zealand, and Dr Sania Nishtar, the founder and President of Heartfile, a health policy think tank based in Pakistan.
The Commission held hearings in all 6 WHO regions, and was supported by two technical working groups: the Ad Hoc WG on Science and Evidence, and the Ad Hoc WG on Implementation, Monitoring and Accountability.
In 2014, an estimated 41 million children under 5 years of age were either overweight or obese (this is defined as the proportion of children whose weight for height scores are more than 2 standard deviations, or more than 3 standard deviations, respectively, from the WHO growth standard median).
The Commission’s strategic approach rests on three categories of interventions:
interventions to tackle the obesogenic environment in order to improve the healthy eating and physical activity behaviours of children;
interventions targeting critical stages of the lifecourse; ie (i) preconception and pregnancy; (ii) infancy and early childhood; and (iii) older childhood and adolescence;
interventions to treat obese children in order to improve their current and future health.
A number of the Commission’s recommendations addressing the obesogenic environment, and critical stages of the lifecourse, in particular, confirm the role for law and regulation in improving the food and physical activity environment for children.
In a move sure to thrill the fizzy drinks industry, the Commission has called on countries to implement an effective tax on sugar-sweetened beverages, and noted that some countries may also consider a tax on foods high in fats or sugar.
The Commission has called for a standardised global nutrient labelling system, as well as the implementation of interpretive front-of-pack nutritional labelling supported by public education to improve nutritional literacy. Interpretive food labelling has consistently been a highly contested area of food law and policy. For example, the European Food Industry reportedly spent 1 billion euro to ensure that front-of-pack traffic light labeling did not become a Europe-wide standard. Traffic light labels interpret the quality of the nutrition of food by means of highly visible red, amber and green symbols that correspond to the amount of saturated fat, salt and added sugar in the product.
The Commission’s recommendation that schools, child-care settings and children’s sports facilities should be required to create healthy food environments may also require legislation or regulations for successful implementation in some countries. The Commission has also specifically recommended that countries eliminate the sale or provision of unhealthy foods, such as sugar-sweetened beverages and energy-dense, nutrient-poor foods, in schools.
The Commission’s report will be presented to the members of the WHA in May 2016, where further actions may be taken to support the implementation of the Commission’s recommendations.
Those with an interest in obesity should also keep an eye out for the report of the Lancet Commission on Obesity, co-chaired by Professor Boyd Swinburn (University of Auckland), and Professor Bill Dietz (George Washington University). In this paper, Professors Swinburn and Dietz outline the work of their Commission.
New York City’s Board of Health last week unanimously agreed to require ‘salt-shaker’ warning symbols on menu items with more than an entire day’s recommended limit of 2300mg of sodium. That’s around one teaspoon of salt.
Restaurants with more than 15 outlets nationally will display warnings from 1 December 2015.
Industry groups and the National Restaurant Association have been as swift in their (predictable) opposition as public health advocates have been to welcome the move. The Center for Science in the Public Interest has even begun a Pinterest board of qualifying items – a salt shaming parade of sorts.
Surrounding public debate has renewed attention on the health impact of salt. Sugar may have received more publicity of late, but population salt reduction is a World Health Organization ‘best-buy’ for public health.
Cardiovascular disease is now the world’s biggest killer, and high blood pressure the leading risk factor for these deaths. Links between salt and high blood pressure are so well established that in 2011, countries agreed to pursue a 30% relative reduction in population salt intake, aiming towards an average of less than 5 grams a day (approx. 2000mg of sodium) by 2025. In Australia, a 30% reduction could save around 3400 lives each year – that’s three times the national road toll.
Many are aware of salt’s potential harms, but it appears most people are failing to personalise their own risk – and thereby failing to modify their behaviour accordingly.
New York’s measure is built on figures that just 1 in 10 Americans are abiding by current guidelines. Most Australians aren’t aware of the daily recommended amount, yet believe their own intake of salt to be ‘about right’ (spoiler: it’s not!) People may not realise around 75% of salt intake comes from processed and restaurant foods – making it hard for even motivated individuals to reduce consumption alone, particularly without user-friendly information available on labels or menus. Ironically the source of the problem is not the salt-shaker itself. Not the one you keep at home, anyway.
Introducing a warning icon is a step in the right direction. Graphic and simple, it aligns with growing evidence from a packaging context that interpretive labelling helps consumers make healthier choices. Such measures also have broader impact by driving reformulation. If you were the maker of Jersey Mike’s Buffalo Chicken Cheesesteak – currently containing an astounding 7795mg of sodium – would you continue to invite adverse publicity via online ‘worst-of’ lists and in-store warning labels, or instead dial down salt, perhaps even phasing out the item from sale? Reformulated recipes rolled out by national chains may benefit millions of fast food customers far beyond New York City. Even before the potential ‘domino effect’ when emboldened health authorities elsewhere copy the measure, the little salt-shaker icon could have significant flow-on effects.
But what is an amount of salt worth warning us about? Burger industry representatives have been quick to proclaim most burgers in NYC wouldn’t be slapped with warnings under the current threshold. One whole teaspoon is a high bar if applied only to individual items. If a similar measure were applied in Australia, we may not see too many salt-shakers appear, though KFC’s Zinger Stacker burger comes dangerously close. Thankfully the law also applies to advertised meal combinations – in case you needed it, one more incentive not to ‘super-size me’.
Perhaps an entire day’s total is still an unreasonably high benchmark. If we allow food companies to market packaged foods as a ‘good source’ of positive nutrients like protein or fibre when containing just 20% of the daily recommended intake, and an ‘excellent’ source at 50% – why not apply a similar metric to a warning when the reverse is true?
Even if items don’t qualify for a salt-shaker, few would argue most products sold by these chains are ‘good for you’. Some point to limitations of focusing on single nutrient warnings, but such critiques miss the intervention’s place as only one component of a suite of complementary measures (including voluntary salt reformulation programs and trans-fat bans) which operate together to improve the food environment and enable consumers to make healthier choices.
In NYC – just as in New South Wales – total energy content is already displayed for all menu items. Results from NSW have been encouraging: the Food Authority found a 15% decrease in average kilojoules purchased. Despite a recent high-profile breach by McDonalds’ on its new digital menu boards, compliance has generally been high. Laws exist only in NSW, South Australia and the ACT, but many national chains have rolled out kilojoule information nationwide, delivering benefits to countless Australians.
As NSW considers extending menu labels to cover additional nutrients, New York’s salt-shaker provides global leadership. Perhaps better still, Australia has already developed a system combining information on a variety of risk factors (salt, sugar and saturated fat) with positive nutrients and total energy content into a single interpretive symbol. If ‘Health Star Ratings’ prove popular on front-of-pack of packaged foods in our supermarkets, why not extend them to fast food?
Writing in the Sydney Morning Herald, Stephen Simpson (Director of the Charles Perkins Centre at the University of Sydney) and Rosemary Calder (health policy Director at the Mitchell Institute for Health and Education Policy at Victoria University), call for community-based action to prevent chronic disease. They point to communities like Broken Hill, which has high rates of obesity, but also a strong self-identity and good social cohesion, offering exciting opportunities for a community-led approach to prevention.
Steven Simpson and Rosemary Calder contrast community-led initiatives to government action, but maybe we could have both. Legislation and regulation could be much better used to support existing local initiatives, encourage community action, and improve local-level obesogenic environments. This is a relatively unexplored area in Australia, but there is growing interest in local level action in obesity prevention in some regions of the country. The City of Sydney encourages active transport, which it links to improving health in the city. The City of Marion, in Adelaide, implemented an obesity prevention program that included community meals and physical activity sessions, targeted to at-risk populations. And some states governments have moved to strengthen the role of local governments in health promotion through legislative measures. For example, South Australia’s Public Health Act 2011 makes local governments responsible (for the first time) for taking action to preserve, protect and promote public health within their area.
The US is much further ahead than Australia in local level prevention efforts, with states and municipal governments around the country trialling innovative obesity prevention policies. A US national prevention policy framework encourages local obesity prevention policies, as do federal grants for community-based initiatives. Local efforts in obesity prevention in the US could provide some lessons for Australian local governments that want to take action in obesity prevention, but they also illustrate some of the challenges that our local governments may face in taking legislative action.
High profile initiatives in the US have attracted significant media attention, as when the former Mayor of New York City, Michael Bloomberg, attempted to ban large sized sodas sold by food service establishments in the city. However these kinds of controversial initiatives are just the tip of iceberg. A range of state and local governments are experimenting with measures to improve the obesogenic environment and encourage physical activity, including Californian legislation that reduces taxes for landowners who make their land available for urban agriculture, and laws in Maine that require grocery stores to stock a minimum number of ‘staple foods.’ Some localities have introduced broad-ranging programs that combine infrastructure development, improved urban design, and health education. In this TED talk, Mayor Mike Cornett describes his obesity prevention strategy for Oklahoma City, and how it resulted in the loss of over one million pounds by city residents. Mayor Cornett also attributes his initiatives with encouraging economic revitalisation in the city.
There are many benefits to local level action. In both Australia and America, the division of powers between state, local, and federal governments enables local governments to act as ‘laboratories of innovation,’ i.e., to trial innovative policies without facing the political barriers that would impede federal-level initiatives (e.g., aggressive industry lobbying). Local governments use their legislative and administrative powers to develop policies that are tailored to the social, economic, and demographic features of their region, and which can diffuse ‘horizontally’ to other localities and ‘vertically’ – upwards to states and national government levels. Local leaders are closer to their constituents, allowing them to be more responsive to community needs, and facilitating ‘bottom-up’ initiatives that are built on a base of community consultation and ownership.
However, local policy making in the US illustrates some of the challenges that local governments in Australia may face in preventing obesity. As in Australia, local governments in the US are creatures of state government. Some US municipalities have expansive rule-making authority, but other states delegate only narrow powers, constraining local action and creating variation in the extent to which local governments can pursue obesity-prevention measures. Popular and media discourse frame obesity mainly as the result of individual’s poor consumption choices, meaning that government intervention to encourage healthy eating and drinking are often seen as paternalistic. Critics of the soda ban referred to Mayor Bloomberg as Nanny Bloomberg, and the soda portion rule was eventually declared invalid following a legal challenge.
Another concern is that some obesity-prevention strategies disproportionately impact vulnerable communities. Like tobacco taxes, soft drink taxes can be seen as regressive because they fall more heavily on lower-income groups who drink more soft drink and have fewer resources to absorb tax increases. Policies that actively target at-risk communities may also be discriminatory when they are based on ethnicity or race, as opposed to targeting neighbourhoods or communities with poor health indicators. Effective policies can also fail to reduce – or even exacerbate – health inequalities. Redesign of the urban landscape can increase gentrification, pushing low-income residents out of the inner city into areas with fewer amenities.
A final issue is that community-level prevention policies are a relatively new area of intervention and the results of evaluating studies are still emerging. Supporters of local-level innovation argue that policies such as the soda portion rule are supported by evidence linking soft drink consumption to diabetes and obesity, for example. However, many policies lack causal evidence to support their effectiveness in producing tangible obesity prevention outcomes. Yet some local initiatives have produced demonstrable changes in health-related behaviour and weight status, with particularly good evidence for school-based initiatives.
Despite these challenges, local government action could form the centrepiece of a revitalised approach to obesity and chronic disease prevention in Australia. Local government action is particularly important in Australia, where the current federal government appears entirely disinterested in chronic disease prevention (having recently cut funding for prevention efforts, including for local policies and programs), and some state governments are withdrawing from health promotion, and actively devolving preventive efforts to local governments.
Further, local government law making could be designed to address some the barriers outlined above. Health law academics in the US call for a participatory, inclusive approach to the design of public health law and regulation, where local communities are involved in identifying areas for action, as well as in processes of policy design and implementation. Their argument is that inclusive law-making processes are more likely to produce initiatives that reflect community interests, and have a strong base of community support, potentially ameliorating the concerns about nanny statism that attach to initiatives championed by public health’s ‘elites,’ such as Michael Bloomberg. Inclusive law making that is tailored to local concerns could also help to address health inequalities, while preventing initiatives from being perceived as discriminatory.
Local governments may provide a route for stronger action on prevention in Australia, particularly in light of the apathy of the current Liberal federal government. But if we are to frame obesity as a collective problem requiring community-based solutions, we need to reconceptualise public health law as a democratic, participatory and collaborative project that ensures recognition and supports self-determination for marginalized communities. Public health doesn’t need nannies; it needs local champions, facilitators, mediators, guides and leaders.
This is the view when you look out the front gates of the World Health Organisation’s regional headquarters in Manila.
A few blocks away, in the processed food aisles of the supermarket, parents are encouraged to purchase “nutrition power for kids”.
The Western Pacific Region, which includes Australia, is home to 138 million adults with diabetes, and includes a number of Pacific Island countries where more than one third of the population have diabetes, and around one half of the population are obese. [See separate blog post]
The consultation was co-chaired by Professor Stephen Colagiuri (Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders), Professor Roger Magnusson (Sydney Law School), and Mr David Patterson (IDLO). The background paper and meeting report were written by the rapporteur for the consultation, Ms Jenny Kaldor, who is a PhD candidate at Sydney Law School.
The report illustrates the variety of legal issues that overweight, obesity and diabetes are causing for countries within the Western Pacific WHO region, as well as how law might be used to improve health outcomes. These include the problems of diabetes-related disability discrimination, discrimination in access to diabetes medications, and good practices in legislation to improve food environments and opportunities for physical activity, from across the region. The report discusses the opportunities for, and obstacles to, using law effectively, as well as the challenge of ensuring that trade agreements and trade laws do not work at cross-purposes to health policies on obesity and diabetes.
The meeting report highlights several important conclusions:
There is a strong need to build the evidence-base on legal interventions relating to obesity, diabetes and population diets. Case studies, feasibility studies, guidelines, summaries and other tools can assist countries to share their knowledge and experience with legal and regulatory interventions. Researchers and academics have an important role to play. Networks need to be built across the region to better facilitate information sharing.
Developing local expertise in public health law and in particular, law related to obesity, overweight and diabetes, is a priority.
In-depth technical advice is needed on promising interventions. These include a tax on sugar-sweetened beverages; restrictions on unhealthy marketing of food and beverages to children; requirements for interpretive, front-of-pack labelling; and legislation to create environments that facilitate and encourage physical activity.
Civil society has a vital role to play in the development, implementation and enforcement of innovative legal approaches to overweight, obesity and diabetes.
Addressing the interference of the food and drinks industries in policy development and implementation in countries across the region is a priority. Clear guidelines are needed to avoid conflicts of interest and to ensure that government interactions with the food industry are transparent and constructive, and do not jeopardise public health goals.
Law needs to be better integrated into the agenda of the World Health Organisation. Law is central to advancing the goals of WHO, and can enable countries to protect, respect and fulfil the right to health.
The rulings came after the Obesity Policy Coalition laid three complaints about the ‘Fanta Tastes Like’ campaign, which included ads during prime time TV programs, a website, and a tablet application. All three promotions featured the Fanta Crew, an animated group of teenaged characters, who engaged in activities like catching fruit, riding roller coasters, and landing in a pool filled with bubbles.
Coke, who owns Fanta, argues that it does not market any of its products to children under 12 years of age, and that the Fanta Crew characters were designed to represent 17 year olds and to reflect older teen culture. However, the Advertising Standards Board held that the characters were more likely to appeal to younger children who aspire to be teenagers, rather than being of interest to teenagers themselves, and therefore were most strongly directed to children in the 9-11 year age bracket.
Considering the overall effect of the themes, visuals and language used in the ads, the Board held that the app and the TV promotions were directed primarily to children under 12 years of age, particularly considering the simplicity of the app’s games, and the depiction of the Fanta Crew on roller coasters and jumping into a pool filled with bubbles in the television ad.
Given that Fanta was not a ‘healthier dietary choice’ that was suitable for marketing to children, the Board upheld the complaints in relation to the app and the TV ad. However, it dismissed the complaint about the website, holding that key elements were designed to appeal to adults, including the factual descriptions of the product flavours and the inclusion of nutrition information.
These decisions represent a solid win for the public health community, despite the Board dismissing the third complaint. Of particular note is that the Board held that an app fell within the scope of the Responsible Children’s Marketing Initiative, despite apps not being explicitly included in the wording of the code.
However, it is relatively rare for the Advertising Standards Board to uphold complaints under the Responsible Children’s Marketing Initiative, because of the numerous loopholes in the code’s terms and conditions. For example, the complaints tested whether Coke breached the code by placing the Fanta ad in prime time television programs, including My Kitchen Rules. However, the Board held that these programs were not directed to children because they did not have an audience share of more than 35% children (as per the code’s rules), despite My Kitchen Rules being one of the most-watched programs by children under 12.
Other critical problems with the code include a lack of independent oversight and enforcement, inadequate reporting on compliance, and limited membership. These complaints show that it’s time to junk industry self-regulation of food marketing to kids, and implement stronger restrictions that put children’s interests before those of the food industry.
The Minister is right about one thing: tobacco and fizzy drink companies have strong distribution networks that reach into the remotest parts of low income countries around the world. And they would welcome the legitimacy that comes from “being part of the solution” – from “helping to save lives”.
But conflict of interest looms large. In some islands of the Pacific, more than a third of the population have diabetes (See the table at the bottom of this post, drawn from a recent paper on non-communicable diseases (NCDs) in the Pacific. The table is worth reproducing in full, since it illustrates just how bad everything is). Combined rates of overweight and obesity among men and women in some Pacific island recipients of Australian aid reach or exceed 80%. In some countries obesity rates alone exceed 45% (in Tonga, the rate of obesity in men and women > 20 years is 59.5%). Do these countries really need Coca Cola?
There might well be novel ways of partnering with the private sector to improve aid performance. Results matter: the Minister is absolutely correct on this point. But this applies at home as well. For example, under-performing public health initiatives such as the stalled Food and Health Dialogue – which was supposed to deliver a healthier food supply with less salt and saturated fat – also need to be overhauled. (A recent paper by Roger Magnusson and Belinda Reeve illustrates how “regulatory scaffolding” could be used by government to strengthen the performance of this vital initiative while minimising the need for direct, statutory regulation).
In Pacific Island Countries and Territories, partnering with the multinationals that are driving risk factors for obesity and diabetes makes no sense. Australian Aid wouldn’t partner with a tobacco company like Philip Morris, so why partner with a fizzy drink company selling empty calories to some of the most obese and diabetic countries in the world?
Unlike, say, Unilever, which can diversify into healthier products and create healthier brands, Coca Cola and Pepsico have a real problem: their leading brands are soft drinks. It would be economic suicide to sacrifice the full-sugar variants, and yet this colours every positive contribution they might otherwise seek to make to development or public health. People who want to move towards a healthier weight – not to mention better dental health – need less soda, not more, and yet reducing consumption is bad for profits. Suffice it to say that Coca Cola would surely be delighted at the prospect of becoming integrated into the public health infrastructure in these fragile island states.
It’s worth asking: just how did Coca Cola get inside the Minister’s head? Why is its name bobbing up now?
At the Joint Forum Economic and Pacific Health Ministers Meeting in Honiara in July 2014, Economic and Health Ministers from Pacific Island Forum countries agreed that non-communicable diseases (NCDs) are ‘financially unsustainable’. They committed to develop country-specific roadmaps covering the following five priorities (Joint Economic Forum and Pacific Health Ministers Meeting 2014). These priorities are:
Strengthening tobacco control;
Considering an increase in taxation of alcohol products;
Reducing consumption of unhealthy food and drink;
Improving efficiency of existing health expenditure; and
Strengthening the evidence base to ensure optimal use of resources.
Let’s be honest here: the commitments of Joint Economic Forum and Pacific Health Ministers are not only a business risk to Coca Cola, but to tobacco multinationals and other junk food and beverage companies that operate in the region. Other risks loom on the horizon. For example, the World Health Organisation has established a Commission on Ending Childhood Obesity, which has already released an interim report which identifies a number of policy options for reducing intake of unhealthy foods and non-alcoholic beverages by children. The Commission is holding a hearing in Auckland for the Western Pacific Region within the next few weeks.
Is Coca Cola really part of the solution? If you have any lingering doubts, just ask a dentist.
a Statistics sourced from Ng M, Fleming T, Robinson M, et al (2014) Global, Regional and National Prevalence of Overweight and Obesity in Children and Adults During 1980-2013: A Systematic Analysis for the Global Burden of Disease Study 2013. Lancet 384, 766-781.
As part of its Master of Health Law program, Sydney Law School offers several units of study that consider global health, law and development. These include Critical issues in Public Health Law; Law, Business and Healthy Lifestyles; Global Health Law; and Trade Regulation, Health and the Environment.
[Thanks to Alexandra Jones for references and for information about Australia’ health aid program]