Global health is currently threatened by three co-occurring pandemics: undernutrition, obesity, and climate change. Together, these pandemics are described as a “syndemic” coexisting in time and place, interacting with each other, and having common drivers in the underlying systems of food production, land use, urban design, and transport.1 Developing a comprehensive response to climate change is of high political concern worldwide. Transforming the food supply system globally and nationally has also become a priority on the political agenda, and a lack of government and corporate accountability has become increasingly apparent to the public. This has now been recognized by José Graziano da Silva, Director-General of the United Nations (UN) Food and Agriculture Organization (FAO), who recently stated “The current food systems do not work; they are designed for something other than guaranteeing good nutrition. Our challenge is to redesign them.”2 During the previous month, the UN General Assembly adopted a Resolution urging member states to “Reinforce actions towards the improvement of nutrition, health conditions and living standards of populations around the globe as a key element of strategies for the eradication of all forms of malnutrition and poverty in all its forms and dimensions, as well as the promotion of sustainable development.”3 The language of global institutions at a remarkably high level has been reinforced by the recent Lancet Commission on the Global Syndemic,1 for which several key background papers are published in the present Supplement. The Lancet Commission's report demonstrated the interactive nature of the three crises of undernutrition, with micronutrient deficiencies affecting nearly two billion people, overweight and obesity affecting more than two billion people, and climate change affecting the lives of more than seven billion people worldwide. In recognition of the common institutional and systemic drivers of the Global Syndemic, the Lancet Commission identified potential double- and triple-duty actions or “triple-win” solutions. The report was accompanied by a Policy Brief,4 which highlighted the need to address the “policy inertia” that has hampered effective action to reverse the rise in global temperatures, along with the rise in obesity and undernutrition prevalence. Tackling policy inertia lies at the core of the World Obesity Federation's advocacy programme. The Lancet Commission identified three main reasons for policy inertia: the reluctance of political decision makers to implement effective policies, the presence of powerful opposition from commercial interests heavily invested in business as usual, and a weak demand for change from the public and civil society. In the era of the UN Decade of Action on Nutrition (2016-2025) and the Sustainable Development Goals agenda (2015-2030), UN agencies have identified the need for a change of policy at the heart of governance for the food and agriculture, health, and transportation sectors. World Obesity is in official relations with the FAO and with the World Health Organization (WHO) and collaborates with both organisations to promote and monitor a healthy and sustainable food system at local, national, regional, and global levels. While policy statements on paper from global agencies may not translate into immediate government action, they provide support for officials, legislators, and advocates who are championing change and can help to legitimize and justify policies that otherwise may not be considered. UN agency statements can challenge the market-driven ideologies that stifle communal action and undermine health-protecting market restrictions and regulations. Further, UN agency statements can help the governments in smaller countries to defend themselves against aggressive interference from external forces, either governmental or commercial. To complement these actions, World Obesity works with our member organizations to advocate with their relevant governments to address obesity within the context of the Global Syndemic. Policy inertia within the food system is, as Dr da Silva implied, due to its being designed to benefit producers' interests rather than consumers' interests. The food system is driven by forces that have led to remarkable achievements over the past century, but which now threaten global health, namely, (a) the cost-efficiencies imposed on the supply chain by the drive for maximum returns on investment and (b) the willingness of banks and investors to fund this process, especially where markets benefit from government protection or market support mechanisms. Cost-efficiencies result from mechanized production and long shelf-life of ultra-processed food and beverage products that use standardized forms of basic commodities—starches, sugars, fats, and oils—enhanced with ingredients, flavourings, and colourings that make them attractive and foster overconsumption. Such ultra-processed products are generally cheap to produce and, as the markets mature, the supply chain becomes dominated by a high level of brand promotion from producers seeking to build brand loyalty, maintain competitive advantage, and maximize revenue and profits. Brand promotion provides the essential link between the products of a competitive food supply chain and the creation of consumer demand for these products. Imposing restrictions on brand promotion, such as setting limits to advertising for less healthy foods on children's television, are not surprisingly strongly resisted by manufacturers. While World Obesity has a long-standing reputation for challenging the food supply industry and promoting and protecting healthier food supplies—including the drafting of a Framework Convention to Protect and Promote Health Diets 5 and, more recently, proposing a Framework Convention on Food Systems. 4 We recognize the limitations of the task. Change cannot rely on civil society organizations alone. There are pioneers within industry who can act as ambassadors for change and movements within the investment and banking industry to review their policies on sustainable growth. These stakeholders can help to build a prosperous system better able to meet human and planetary needs. Researchers and research funding bodies are keen to increase our understanding of what needs to be done and how soon it should happen. World Obesity is a founding member of the INFORMAS network of researchers developing tools for monitoring food environments and food policies at governmental and corporate levels.6 Philanthropic organizations are increasingly recognizing the value of supporting local advocacy and lobbying groups to achieve significant policy change.7 We are convinced that commercial and civil society resources can be mustered to promote real change. However, there is a deep-rooted problem which requires a more deep-rooted solution, namely, the problem of “overconsumption” and, behind it, the problems of overproduction, which beset underregulated, capital-based production and lead to the systematic push for increased consumption. Overconsumption is a term that can be misused to imply that consumers are to blame for the consequences of their consuming behaviour, leading to policies for “educating” consumers to eat less, travel less, buy fewer cars, and so forth. But overconsumption is primarily stimulated by the drive for increased production and the consequential promotion of consumer goods. Overproduction is a fundamental facet of competitive industries, arising from several contributory factors. Increased output through economies of scale allow higher profits per unit item giving more efficiency and better return on capital investment: As more is produced, more must be sold. Creating multiple related versions of the same product can help a manufacturer increase market share, despite creating unnecessary choice. Short shelf-life can be used to absorb overproduction, as can designed obsolescence and stimulated changes in fashion. Meanwhile, the costs of overproduction—in waste disposal and the adverse impacts on environmental and human health—are not borne by the (over)producer. One underlying cause of overproduction is overinvestment, creating forces that produce more goods than can be consumed. Overinvestment may be encouraged by market support mechanisms funded from public sources that guarantee a return on the investment even if the goods are unsold. An example of this is the notorious wine “lake” and beef and butter “mountains” created under the EU's Common Agricultural Policy (CAP), which has continued for several decades using public money to guarantee markets and to buy the surplus food and distribute it through subsidies into the food chain.8 The CAP's guarantees have led to high levels of investment in the production of these foods using intensive forms of agriculture. This accumulated investment—eg, in types of livestock and technically advanced equipment—impedes change in farming methods, food commodities, and food supply chains and subsequently in dietary patterns. Similar arguments can be applied to the US government's support for soya, corn, and cattle-feedstock production and their potential impact on health.9 The problem may be especially pernicious where capital-intensive agricultural production has undermined smallholder production, reduced the extent of natural forests, or added to soil erosion or water pollution.10 These deep-rooted issues are now the subject of major review by those seeking to defend and protect the environment and to develop new economic models for cooperation and equitable development. Production models with greater accountability for social benefits and alternative economic models that replace the assumption of perpetual growth and production are being proposed while economic models for perpetual growth give way to more sustainable, “circular” or “doughnut” economies11 that aim to fairly distribute, reduce, reuse, and regenerate resources to support sustainable well-being for all.12 The need for greater public demand for change in the field of obesity policy is central to World Obesity's current mission. We express calls for policy development and implementation, and we encourage others to do so. We recognize the need to change the narrative on the causes of obesity so that weight bias and stigma, and the language of individual responsibility, do not undermine the arguments for public policies. We need a stronger voice from people who experience obesity, to raise the level of political demand to match the calls for attention achieved by other chronic disease sufferers. Raising demand for action takes several forms. Use of legal frameworks can challenge political inertia and counter commercial interest: For example, international treaties, declarations of rights, and multilateral conventions put duties and responsibilities on governments. These internationally agreed instruments can be employed to justify action and to require governments to generate laws and regulations to protect and promote healthy and sustainable food environments. Human rights laws—including the right to health and the right to food and the rights of children—can underpin commitments by governments, while various internationally agreed instruments—such as framework conventions (eg, tobacco products and climate change) and codes of marketing (eg, for breastmilk substitutes) and the use of health criteria to challenge or justify World Trade Organization trade dispute determinations13 and potentially the WHO's powers to use compulsory Health Regulations14—can provide legal models to operationalize food supplies for sustainable health. Agencies for setting normative standards, such as Codex Alimentarus, may also have potential for promoting healthy and sustainable food supplies, although Codex itself has been criticized for being dominated by producers' interests. These developments raise issues about the governance of such institutions and their need to fully accommodate and fairly represent consumer and global health interests in determining standards for production, trade, and consumption. World Obesity helps promote these issues as an observer at Codex. The climate change movements and the recent rise of youth action putting political pressure on legislators reflects more direct action for change. World Obesity welcomes these developments. We also recognize that in the case of the Global Syndemic, people experiencing undernutrition are rarely in positions to influence policies, while for people experiencing obesity, there is a widespread culture of fat shaming that inhibits individuals speaking out on the issue. This must change. The voices of people with obesity can be a powerful countermeasure to the prevailing victim-blaming narratives and images found in popular media15 and, regrettably, in the statements made by politicians.16, 17 World Obesity is partnering in a European Union–funded research project CO-CREATE18 to encourage youth engagement in policies for healthy child growth and in weight bias reduction. Meanwhile, 2019 has seen increasing opportunities for patients' voices to be heard, with the launch of several organizations to represent patients' concerns, including the European Coalition for People Living with Obesity, and moves to change the narrative on obesity with guidelines on acceptable language available in several countries19, 20 and a World Obesity library of acceptable images updated and expanded.21 Lastly, World Obesity's membership includes both research and clinical communities, whose experiences of the challenges of obesity are also a potential source of support for political action. Professionals may themselves benefit from support to counter stigma and weight bias and to understand how to engage with their patients—and colleagues—living with obesity. Professionals can use their positions for advocacy within their specialist associations and in their institutions and can check their own use of language in the reports, papers, and social media messages they produce. World Obesity can and does contribute to all these positive actions. This Commentary has considered some of the policy challenges we face, from overproduction to political ideology and individual agency. They may appear to be a long way from the topics reflected in the papers usually seen in Obesity Reviews, but they are linked to the task of improving food supplies, urban food environments, and ultimately global health for us all. To paraphrase Dr da Silva, our systems are currently designed for something other than guaranteeing good health. Our challenge is to redesign them.
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Tim Lobstein (2019) studied this question.
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