Feeding Profit: how the food and drinks industry (FDI) is one of the key drivers of the global epidemic of childhood overweight and obesity

Introduction

UNICEF has published a report entitled Feeding Profit: how food environments are failing children.¹ Since the 1970s, the food environment in high-income countries (HICs) has undergone change with children’s increasing calorie consumption driving a rise in prevalence of overweight and obesity in childhood.² Among HICs, this increase has been most marked in the USA where it has increased from 15% in 1972² to a plateau of around 40% in 2022, whereas during the same period, rates in other HICs plateaued around 30%.¹ Rates in low- and middle-income countries (LMICs) have increased and show the most dramatic rise in rates such that globally, overweight/obesity has replaced underweight as the dominant form of malnutrition in children.¹

The commercial determinants of child and adolescent health

The UNICEF report¹ contributes to the literature on commercial determinants of health, a concept developed by Kickbusch et al³ and expanded in a Lancet series.⁴ It details the marketing strategies by which the food and drinks industry (FDI) drives children’s food choices influencing their food-related behaviours.^{1 2} Financial interests of the FDI are huge; the global children’s beverages market was valued at around US$200.95 billion in 2022 and projected to reach US$243.01 billion by 2030.⁵ Vast profits are generated by marketing nutrition-poor, hyperpalatable, ultraprocessed foods and drinks, high in sugar, fats and salt, that induce a desire for more.⁶ The marketing targets children and adolescents with product placement, television (TV) and social media advertisements, digital games using cartoon characters as well as marketing directly in schools. The industry has a financial investment in creating overweight. From 1970 to 2011, average food and drinks consumption among US children increased by 200 kcal/day at an added cost of more than $400 per year/child. This translates to an estimated cost of excess food consumption of $20 billion/year which, carried forward through adulthood, creates a market worth over $60 billion/year.²

The FDI uses its vast resources to aggressively promote and protect its markets and has adopted many of the same methods as the tobacco industry to protect their market share.⁷ These methods are summarised by the acronym MARSH⁸ (see box 1). The FDI’s resources are being employed to neutralise and undermine overwhelming evidence that their products are a significant driver of a threat to global public health. These diversionary tactics are further enabled by governments and regulatory bodies accepting ineffective voluntary, self-regulatory agreements with the FDI,⁹ and by a predominance of education-based interventions aimed at individual behaviour change rather than societal interventions/policies aimed at addressing the commercial determinants of childhood overweight/obesity.² The assertion that nutrient-poor, unhealthy diets are primarily due to dietary decisions by parents and children blames the victim by framing these diets as a moral failure of individuals rather than a societal failure to control the obesogenic environments generated for profit.

Box 1. MARSH: tactics used by tobacco and food industries to block market regulation.

M Misinform

Reshaping evidence; lobbying (direct or via third parties); increase doubt; procrastinate.

A Attack

Neutralise, discredit, fragment and destabilise opponents: ‘Nanny State, Anti-business’, litigation, challenge policies in courts, threaten legal action or ‘job losses’.

R Recruit

Build internal constituencies, alliances and trade associations. External constituencies, other sectors; policy makers; media.

S Substitute ineffective interventions

Voluntary, self-regulation, public-private partnerships, education, individual choice.

H Heap money on politicians, journalists and scientists

Source data: Savell et al.⁸

The role of obesogenic environments in the early stages of life as a point of departure for non-communicable diseases

From a life course perspective, a major impact of overweight/obesity in childhood and adolescence is the generation of non-communicable diseases (NCDs). The UNICEF report identifies high blood pressure, elevated blood glucose and abnormal blood lipid levels induced by childhood overweight/obesity as precursors of NCDs in type 2 diabetes, cardiovascular disease and some cancers later in the life course. Globally, NCDs have a major impact on population health, causing chronic morbidity and mortality. The WHO estimated that, in 2021, there were 43 million deaths due to NCDs, 73% of which were in LMICs.¹⁰ The high costs of increasing prevalence of NCDs are borne by individuals, families and governments, not by the commercial interests that contribute to their generation. Rather than accept responsibility, corporate lobbying is engaged in weakening measures related to taxes, food labelling and marketing in the United Nations (UN) High-Level Meeting on NCD declaration that is currently in preparation.¹¹

Violation of child rights by the FDI and other contributing factors

Children’s right to a healthy food environment is asserted in the UN Convention on the Rights of the Child 1989 which imposes obligations on signatory Governments to safeguard the rights of their child populations (¹, box 5, p 18). Article 3 of the Convention asserts the primacy of the best interests of the child in all matters concerning children. This fundamental premise of the Convention is violated by the creation and continued promotion of unhealthy, obesogenic products aggressively marketed to children. Other rights that are equally violated include: rights to survival and development (article 6); food, nutrition and health (article 24); an adequate standard of living (article 27); accurate, clear and age-appropriate information to make informed decisions about the foods and beverages they purchase and consume (articles 17 and 18); and the right not to be exploited by commercial interests (article 17). Children are a vulnerable population whose rights and well-being need the voice and the will of the adults to be protected. They lack sufficient information and power to take appropriate decisions about their health. Presenting or permitting the presentation of potentially harmful choices to them is unethical as is the action of adults responsible for childcare, health professionals and scientific societies that maintain links with corporations that produce products harmful to health.

Inequalities in food environments

The UNICEF report highlights inequality between regions and countries. Historically, prevalence rates of overweight/obesity have been high in HICs and low in LMICs. The report’s findings chart a nutrition transition with LMICs now accounting for 81% of the global burden of overweight in children aged 5–19 years in 2022—rising from 66% in 2000 while still having high levels of underweight(¹, p 27). This transition is attributable to economic development associated with increased spending power among wealthier groups combined with enhanced FDI marketing in LMICs. As a result, current rates of overweight/obesity in 15–19 year-olds are highest in the wealthiest fifth of LMIC households; however, the UNICEF report identifies early trends, for example, in the Maldives and South Africa, supporting the assertion that “As nations develop economically, the burden of child overweight shifts from wealthier to poorer households”(¹, p 27). The relationship of childhood overweight/obesity with household income in rich nations underwent a similar transition over the last 30+ years¹² with a graded increase in rates from high to low income.¹³

Poverty fuels many of the challenges faced by LMICs. It perpetuates a disproportionate emphasis on economic gain over nutritional welfare, compromising population health. LMICs are more vulnerable to the overwhelming political and financial influence of the food industry, such that their policy makers may compromise integrity, weakening the formulation and enforcement of effective food safety and nutrition policies.

Transforming food environments to protect children’s right to healthy food and nutrition

Transforming food environments for children and adolescents will depend on countries implementing measures such as those shown below(¹, p 69):

• The International Code of Marketing of Commercial Infant Formula.

• Legal measures limiting the availability, marketing and purchase of unhealthy foods and drink.

• Improving the availability and affordability of locally produced nutritious foods for children and adolescents.

• Exclusion of FDI representatives from involvement in policy development and implementation.

• Mandatory reporting of industry lobbying activities.

• Social behaviour change initiatives and social protection programmes initiated by stakeholders (box 2) to empower families and communities to demand access to healthy diets.

Box 2. How stakeholders can prioritise public interest and child rights over commercial profits generated by promoting an obesogenic environment.

States and international organisations can change policy systems and incentivise investment in business models that promote children’s rights to healthy nutrition, health equity and sustainability.

Civil society groups, including parents and child caregivers, organise locally and nationally to articulate alternative visions and hold commercial actors and governments accountable.

The food and drinks industry must be forced by regulation to abandon its financial investment in promoting overweight and implement regenerative business models that promote healthy food environments for children.

Academia and researchers should shift the dominant research focus from individual responsibility for nutritional choices to powerful commercial influences on children’s nutrition and use the evidence to advocate to decision-makers and the media.

Child health professionals and their societies can break with the hegemony of a biomedical model of health by adopting a commercial determinants of child health model, and by ending conflicts of interest and dependence on sponsorship by interests inimical to child health.

Source: Adapted from Lancet Series/Global Health.⁴

The report¹ details measures enacted in three countries that have reduced child exposure to the obesogenic environment: unhealthy foods are restricted by law in schools in Brazil, Mexico and Chile; Chile banned advertising in schools, TV and cinemas, as well as child-targeted marketing hooks and digital marketing; and Mexico taxed sugar-sweetened drinks. Further evidence of measures that have limited the industry’s promotion of the obesogenic environment is described in a UNICEF/WHO toolkit of actions to protect children from the harmful impact of food marketing.¹⁴ Responsibility for the above measures rests mainly with governments; however, other stakeholders (see box 2) need to exert concerted pressure to ensure these measures are effectively introduced and sustained against the power and influence of the industry.

The role of child health professionals and their organisations

Child health professionals in their practice and through their professional societies have a role in promoting healthy food environments and combatting the influence of marketing on children. They can join with other stakeholders (see box 2) to prioritise public interest over private profit by ending conflicts of interest and sponsorship of professional society meetings and journals by companies promoting unhealthy products for infants and young children.¹⁵ As advocates for child rights to a healthy food environment, they can influence parents, communities, policy makers and the media. In their policy documents and clinical guidance related to overweight/obesity, societies can focus on the role of the FDI and their marketing techniques rather than interventions to change individual behaviour. Research funding bodies and paediatric journals also have a responsibility to promote research that examines the commercial determinants of child and adolescent health. The UNICEF report is a powerful advocacy tool that confronts the key drivers of child and adolescent overweight/obesity and challenges governments and other stakeholders to act to reverse the obesogenic environment driven by profit.

Data availability statement

All data referred to in the text is derived from publicly available publications and digital sources all of which are referenced in the article.