The commercial determinants of unhealthy diets October 2022, Volume 32, Issue 3

Introduction

Unhealthy diets are a leading contributor to the global burden of disease.¹ In Australia, consumption of unhealthy foods and beverages (food and drinks that are highly processed, energy-dense and nutrient-poor) exceeds recommended guidelines for health.² Food choices are largely determined by cultural and social norms and by opportunities to access and afford a healthy diet³ and these norms and opportunities are shaped by a range of structural drivers including the commercial determinants of health (CDoH).

The commercial determinants of unhealthy diets include food and beverage industry practices that create conditions driving consumption of highly processed foods and beverages. The availability, accessibility and desirability of highly processed foods and beverages is increased by practices such as supply chain consolidation, marketing and advertising, corporate social responsibility, and corporate political activity. ⁴

Defining commercial determinants of health

As understanding of CDoH evolves, so too does its definition. Here, we draw on Freudenberg et al’s definition of “social, political, and economic structures, norms, rules, and practices by which business activities designed to generate profits and increase market share influence patterns of health, disease injury, disability, and death within and across populations”.⁵ This definition broadens the CDoH focus from industries typically associated with noncommunicable disease (NCD) risk factors (alcohol, tobacco and unhealthy food and beverages) to allow a more comprehensive consideration of the commercial drivers of health, from supply chain management, food pricing and marketing to political practices such as lobbying. In alignment with Australia’s National preventive health strategy 2021–2030⁶, this definition also acknowledges both the protective and adverse effects of CDoH, and identifies levers to improve health through action on CDoH.

Commercial practices contribute to unhealthy diets

In recent years, changes in control of different parts of the global food supply chain have seen increased penetration and concentration of transnational food and beverage corporations (TNCs) including manufacturing, retail and fast-food chains in national food environments.⁷ This concentrated commercial power influences people’s options, and ultimately diets, by creating greater global availability, affordability and desirability of highly processed foods and beverages.⁸ Consolidation of supply chains means that TNCs can easily and efficiently flood markets with the highly processed foods that they produce and sell. In Australia, a small number of TNCs dominate the food market, extending their reach and influence through ownership of multiple brands.⁹

Concentrated power can also increase food prices because of a lack of competition – small retail outlets are no longer able to compete in terms of prices, or afford commercial rents, as a result of TNCs locating close by and driving up costs for smaller, independent retailers. TNCs have displaced traditional, culturally appropriate, local and minimally processed foods and retailers with convenience, quick service, snack and ultra-processed foods.¹⁰ TNCs target profit-maximising business growth opportunities, contributing to food ‘swamps’ and ‘deserts’ – neighbourhoods saturated with outlets selling highly processed foods and devoid of affordable, nutritious food, contributing to illness and thus exacerbating health inequities.¹¹

The economic power of TNCs enables them to devote billions of dollars annually to marketing their products and brands, through media advertising, point-of-sale and on-pack marketing, sponsorship and public relations initiatives.¹² Evidence consistently demonstrates the harmful effects of food and beverage marketing on dietary preferences and consumption, and the increased risk of excess weight gain and obesity.¹³ Media companies amplify food and beverage industry marketing, reaching diverse audiences. Targeted marketing is likely to exacerbate health inequities, with people living in disadvantaged neighbourhoods exposed to more unhealthy food marketing than people living in more advantaged areas.^14,15 Children are particularly vulnerable to the harmful influence of food and beverage marketing and are exposed to advertising across multiple forms of media (television, digital, social and outdoor) and sport and community event sponsorship.¹³

Food and beverage industries seek to influence the policy landscape through lobbying, advocating for deregulation, proposing voluntary or self-regulatory codes or nonregulatory solutions, and opposing and destabilising public health efforts.¹⁶ Commercial actors use discursive power and terms such as ‘nanny state’ to frame arguments to promote individual responsibility and private self-regulation over government regulation, thus influencing norms and values. They also strategically position themselves as part of the solution to public health problems, developing relationships with government to gain a seat at the public health policy table.¹⁷ A recent examination of public-private partnerships in UK obesity policy highlights the tensions between commercial and public health goals in these governance arrangements, including the risk that commercial rather than public interests will shape public policy.¹⁸

Diet-related NCDs and inequality maintain an antagonistic relationship where one can worsen the other, with these effects exacerbated by the COVID-19 pandemic.¹⁹ In Australia, healthy diets are unaffordable for those living in low-income households²⁰ and unhealthy food outlets are more ubiquitous in low-income neighbourhoods,¹¹ exacerbating health harms for populations already at increased risk of poor health. Without attention to people’s social circumstances, including income, work, housing and transport, opportunities to access and consume a healthy diet will continue to be difficult and unequal.²¹

Government action is needed to address commercial determinants of unhealthy diets

There are many levers within and outside the food system that have potential to positively influence diets and health. Promisingly, Australia’s National obesity strategy 2022–2032 has an explicit focus on “changing the systems, environments and commercial determinants that affect Australians’ opportunities to live active and healthy lives”.²² Both this strategy and the National preventive health strategy 2021–2030⁶ propose actions to improve population diets through marketing restrictions, but they could go further with additional evidence-based strategies such as: fiscal tools to support healthy diets; a stronger stance to prevent commercial influences interfering in policy processes; clearer requirements for businesses to be accountable for health; and prioritised recommendations to address the social determinants of health.

We outline several potential actions for governments to help reduce the negative effects of commercial practices and products on people’s diets:

• Reduce the impact of, and exposure to, unhealthy food and beverage marketing, particularly to children. Implement actions in accordance with international guidelines. For example, the World Health Organization (WHO) international code for marketing breastmilk substitutes; WHO recommendations on marketing food and nonalcoholic beverages to children^23,24
• Leverage fiscal tools to create incentives for increased healthy food in supply chains, retail, and consumer purchasing, and disincentives for unhealthy food and beverages. For example, apply a levy on sugar-sweetened beverages and ensure trade agreements favour public health rather than commercial interests
• Manage and prevent conflicts of interest from commercial influences in policy development. Monitor and protect public health policies and strategies from real, perceived or potential conflicts of interest through an evidence-based approach and transparent stakeholder engagement processes. For example, use governance and transparency mechanisms, such as those employed by the National Health and Medical Research Council for the current review of the Australian dietary guidelines
• Embed health into environmental, social and governance (ESG) standards and ensure businesses are held to account for their contributions to improving or damaging community health
• Implement minimum wage and social protection schemes that reflect the real cost of living, which affects people’s ability to afford a healthy diet.

Conclusion

Commercial practices and products continue to harm people’s health. There are many untapped opportunities for governments to redress the extensive influence of commercial power and ensure that commercial entities do no harm, and instead refocus their contributions to the food system in ways that prioritise good nutrition, health and health equity. Achieving healthy diets for all requires leadership and commitment to action, putting public health ahead of vested commercial interests.

Acknowledgements

This paper is part of a special issue of the journal focusing on obesity prevention, which has been produced in partnership with the Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University. LW is employed by VicHealth, which also supported the issue. AC is a recipient of a VicHealth Postdoctoral Research Fellowship and receives funding from an Australian Government Medical Research Future Fund (MRFF) grant, APP1199826.

Peer review and provenance

Externally peer reviewed, invited.

Copyright:

© 2022 Chung et al. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, which allows others to redistribute, adapt and share this work non-commercially provided they attribute the work and any adapted version of it is distributed under the same Creative Commons licence terms.