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Principles, practice, and the private sector’s role in malnutrition: Time to review red lines?

Principles, practice, and the private sector’s role in malnutrition: Time to review red lines?

The framing of malnutrition as a global problem that affects us all is long overdue. This view demands more systemic approaches, engaging the whole of society, that align with the universality of the UN Sustainable Development Goals. This framing also highlights certain challenges, some of which nutrition actors are not currently addressing well.

Food environments and food systems intersect with health and environmental systems in complex ways that may be harmful to nutrition. Private sector organizations—especially large transnational corporations—are major actors in these systems. Their products and practices may help address this nutrition problem, or they may drive, exacerbate, or deliberately confound it. Governments and public agencies therefore need to ask themselves questions about whether to engage with certain companies, for what purpose, when, and how.

Until now, there has been a tendency to frame this issue as “either/or” in terms of whether to engage with the private sector, or not. This is far too simplistic. There’s a lot of space in between these extremes where negotiations can take place and collaborations can be developed.

While stated engagement principles do exist, there are few examples of clear, practical guidelines, and even fewer examples of how they have been applied in real-world contexts. Principles tend to become individualized and atomized rather than widely agreed-upon norms. We argue that these issues need to be surfaced and debated openly, as part of a consensus-building process that leads to practical guidance, including where and how to draw red lines.

As nutrition researchers and advocates, we often have cause to think about our engagement with the private sector—particularly in terms of from whom we take money, or with whom we share an alliance or even a platform. Debates rage on, with positions ranging from full engagement to strict non-engagement.

The private sector does not exist on a different planet; it is all around us, encompassing a huge range of actors from small farmers and shopkeepers to huge corporations, all of whom have a job of delivery within the food system. Of course, we need to engage with the private sector. This fact does not—as many pro-engagement advocates imply—mean that non-engagement with particular companies is a ridiculous position. In other spheres of development, e.g. public health, climate change, and green investment more generally, there are a number of clear cases of “no-go companies”—tobacco, climate disinvestment, child labor, alcohol, gambling.

When does working with a particular private sector actor become unpalatable for malnutrition researchers and advocates? We all have our own examples, but it has been interesting to see how relative this is. Companies that we find unpalatable, e.g. serial Breast-milk Substitute Code offenders, and large unreformed transnationals that derive the greatest share of their profits from products and practices associated with obesity, are in relationships with other organizations that we respect in the nutrition world.

This has led us to examine our own reasoning, bias, and subjective assumptions about partners with whom we will and won’t work. We wonder whether ours and others’ reasoning about the seeming illogic of combining, for example, public health approaches with sugar-sweetened beverage distribution (which we see as similar to combining public health with tobacco retail) could be better channeled into the development of a clear set of practical processes and indicators.

Indices like the Access to Nutrition Index (ATNI) could help. The methodology involves an assessment of corporate and product profiles. The former assesses companies’ performance against “international guidelines, norms and accepted good practices, except when such guidance was not available” (which again highlights the gap we face). Product profiles assess the “healthiness” of products that generate the greatest revenue for the company. Since its inception, companies that perform highly (scoring 6-7 or above out of 10) only do so in relative terms. Many score below 3 out of 10. Companies tend to score better on stated commitment and governance than on product healthiness. Implementation lags behind commitments, and ATNI has been criticized for focusing too much on the latter. Nestlé is an interesting case: a company that has done a lot to reform and consistently ranks highly on the ATNI and yet doesn’t seem to manage a year without Code violations.

We argue that companies need to show pro-nutrition actions (not just words) over a reasonable length of time before discussions on engagement or partnerships start. To this end, we would need consensus on what this would look like, including what metrics, indicators and targets are sufficient to demonstrate institutional commitment to better nutrition.

A traffic light rating system could work. At present, most companies assessed by ATNI would be red or amber. Such a system (which would need to be grounded in a consensus on appropriate metrics) could improve clarity, and better incentivize the reds and the ambers to reform.

We recognize the complexities and the fact that things are changing, day by day. It is not, for example, as simple as considering whether to engage with any one organization. Some of the larger organizations have linked corporate social responsibility units and linked foundations which may be supporting pro-nutrition activities that in themselves are positive for nutrition. And yet, their core business practices encompass products and/or practices that continue to damage nutrition—at a much larger scale. There is also the distinct possibility that ignoring the “major bad” to focus on the “minor good” lets the companies off the hook, and even disincentivizes reform of their harmful core business practices. This suggests we need to go beyond judging the merits of any one project or any one type of engagement, to also look at the bigger picture of what the company is doing.

A traffic light system also aligns with the reality that nothing is static. The situation is dynamic; companies are changing. The question for wider discussion becomes one of how to judge whether and when a company’s net impacts are sufficiently “pro-nutrition” to become eligible for potential collaboration. This again will require a discussion of metrics, thresholds, and red lines. These are issues and challenges that should not be over-simplified, fudged, or hidden—especially at this time. Many in the nutrition community are gearing up for a major nutrition summit, linked to the Tokyo 2020 Olympics, in which pledges and commitments will be made to address malnutrition in all its forms. The arena for nutrition action now—compared to the last Nutrition for Growth event in 2013—is a lot wider and there are many more (actual and potential) actors. Principles and practical guidance are needed more than ever. On this basis, we want to start a new kind of conversation and would welcome views.

Stuart Gillespie and Nicholas Nisbett

The global syndemic of obesity, undernutrition, and climate change

new report by the Lancet Commission on the Global Syndemic of Obesity, Undernutrition, and Climate Change delivers a powerful, incisive analysis of the drivers of those overlapping worldwide problems with some long-overdue and hard-hitting recommendations. The starting point is a recognition that malnutrition in all its forms is by far the biggest cause of ill-health globally, and that this is because we are in the midst of a “global syndemic”.

But what is a “syndemic”?

Obesity, undernutrition, and climate change are distinct, massive global challenges. But they also overlap in time and space, interact with each other, and share common underlying drivers. Collectively, they represent a syndemic. (Originally coined as “synergistic epidemic,” the term was first applied to the interactions between different disease outbreaks. Here, the Commission has expanded its scope.)

This syndemic has thus far been notably hard to treat. The patchy progress is largely due to policy inertia and a lack of effective solutions, caused by inadequate political leadership and governance; strong opposition to policies by powerful commercial interests; and a lack of demand for policy action by the public.

The global agri-food system is a major contributor to the syndemic. Currently, it prioritizes massive, energy-rich staple production with comparatively little attention to nutrient-rich foods such as fruits and vegetables. As a result, healthy diets are often expensive or inaccessible, while ultra-processed foods (e.g. noodles, potato chips) flood markets. The food system also contributes nearly one third of all anthropogenic greenhouse gas emissions, and in the process is causing rapid deforestation, soil degradation, and massive biodiversity loss.

The Commission brings a particularly sharp focus to the private sector, which should play a major role in any comprehensive set of responses. But that will require some significant reforms. Although most food businesses are small-to-medium-sized enterprises, large food corporations (“Big Food”) are explicitly driven by a fiduciary duty to prioritize financial returns to investors. Ultra-processing involves adding steps to the value chain, which enhances profit margins. Thus it’s ultra-processed products, manufactured on massive scales and marketed globally, that bring the greatest returns.

Big Food also uses multiple strategies to obstruct efforts to prevent obesity, the report notes – including “adopting self-regulation [e.g., voluntary restrictions] to pre-empt and delay state regulation, public relations to portray industry as socially responsible, undermining and contesting the strength of scientific evidence, direct lobbying of government decision makers, and framing nutrition as a matter of individual responsibility.”

Big Food’s go-to solution for obesity—self-regulation—does not work. It lacks the force of law and public accountability, and it preserves business as usual: Commercial success (wealthy corporations) co-existing with market failure (negative health and environmental outcomes).

Clearly, a new business model is needed that works for people and planet as well as profit. To strengthen the hand of nations against the enormous power of transnational food corporations, and ensure comprehensive action to address the global syndemic, the Commission calls for a Framework Convention on Food Systems (FCFS)—a global treaty to promote healthy diets and sustainable food production.

But policy inertia stems from other causes too. The Commission argues there is a major role for civil society and grassroots social movements in rallying political pressure and consumer demand for healthy diets from the ground up. These key stakeholders can also play a larger role in in monitoring and benchmarking progress towards meeting goals, to strengthen government and corporate accountability.

Better monitoring and research are also essential to addressing the food system role in the syndemic. A substantial infrastructure is already in place, but it needs strengthening. The INFORMAS network is cited as a shining example of food environment assessment and monitoring, along with the World Cancer Research Fund’s NOURISHING database of nutrition policies.

Another key element is funding. It’s shocking to see that globally, only 2 percent of health-related aid goes to the prevention and control of non-communicable diseases, such as diabetes, despite their being responsible for two-thirds of deaths in low- and middle-income countries. The Commission recommends philanthropies and other sources donate $1 billion to support civil society alliances (such as that which pushed for Mexico’s successful tax on sugary sodas) to advocate for relevant policy action.

We also need more research into the unique problems this syndemic poses. The report highlights three areas: Application of systems science to the syndemic; research into the sociocultural dynamics that enable or stymie action; and policy research to understand the current prevailing inertia and lack of traction. The new Agriculture for Nutrition and Health (A4NH) initiative Stories of Challenge—which explores how food system problems are solved on the ground – and can help respond to the Commission’s call for more positive examples and models. Stories are emphasized as a key component of the advocacy arsenal, and the report includes many perspectives from different actors participating in its panels.

The report concludes with principles to maximize impact: Think syndemically, join thinking with action, strengthen governance (global, national, municipal), support civil society engagement, reduce commercial influence on policy, strengthen accountability, focus research on drivers and actions, and build business models that are fit for the 21st century. A syndemic, by its nature, will generate complex impacts that resist the usual solutions; the report offers an important road map to confronting this challenge.