Big food and the World Health Organization: a qualitative study of industry attempts to influence global-level non-communicable disease policy

Introduction

Unhealthy diets are a major risk factor for non-communicable diseases (NCDs) such as heart disease, type 2 diabetes and cancer.1 Despite ongoing calls for action on obesity and dietary NCDs, no country has successfully lowered obesity rates between 1990 and 2019.2 Barriers to progress include opposition of powerful commercial actors, notably the multinational ultra-processed food and beverage industry (UPFI),3 which we define as corporations involved in the manufacture or sale of ultra-processed foods and sugar-sweetened beverages. A growing body of evidence documents how these actors have attempted to oppose regulation at the national level, for instance, through direct and indirect lobbying of decision-makers, the creation and use of seemingly independent third parties and influence on the production and use of science.4–7 We use the term ‘corporate political activity’ to describe such behaviour. Originally developed by management scholars to describe ‘corporate attempts to shape government policy in ways favourable to the firm’,8 it has since been adopted by public health researchers using a critical lens to understand industry efforts to oppose regulation.9 10 In the case of the UPFI, such political activities have been identified in low-income and middle-income countries7 11–15 as well as high-income countries,4 5 16–18 but as yet, there is little empirical evidence at the global level.

In response to calls for stronger leadership from international organisations (IOs) to curb the devastating health and economic19 impacts of NCDs, the United Nations (UN) held their first high-level meeting (HLM) on NCDs in 2011, assembling heads of state and UN agencies to discuss action towards better prevention and treatment.20 This was followed by two subsequent HLMs in 201421 and 2018,22 with a fourth scheduled for 2025. As the UN agency responsible for public health, WHO plays a key role in coordinating global efforts to prevent NCDs. Its power to set international rules which can restrict private sector activities, like the Framework Convention on Tobacco Control (FCTC),23 has been described as ‘political dynamite’.24 Although WHO has published technical guidance on obesity and dietary NCDs, Member State-led political decisions remain unambitious (key developments in table 1).25 Public health advocates largely greeted the political declaration of the third HLM22 and what were intended as ‘bold recommendations’ from the WHO independent high-level commission26 to the HLM with disappointment. The declaration was criticised for its weak language on NCD interventions and financing27 28 and the commission’s report for producing recommendations weaker than existing WHO guidance after a US representative ‘torpedoed’29 efforts to include a recommendation to tax sugar-sweetened beverages.30 31 UPFI representatives, on the other hand, welcomed both documents, lauding calls for public-private collaboration in particular.29 32

Another point of contention is WHO’s contrasting approach to the unhealthy commodity industries which drive NCDs and have a history of impeding policy progress at national level.33 The agency has a strict policy of non-engagement with the tobacco industry as mandated by Article 5.3 of the FCTC,23 but its Framework of Engagement with Non-State Actors (FENSA)34 has been described as an open door rather than a fence for other commercial actors, including the UPFI.35 The new official relations status—which business associations, philanthropic foundations and non-governmental organisations (NGOs) can apply for—is not a requirement for WHO to engage with a non-state actor but provides privileged access, for instance, allowing participation in WHO governing bodies meetings.36 Welcomed by the private sector when it was adopted in 2016 after 4 years of negotiation with Member States, FENSA was again deemed insufficient by public health advocates.37

In light of the lack of progress in addressing a major cause of ill health globally, there is an urgent need to better understand how the UPFI attempts to influence global-level NCD policy.38 We aim to address this gap by harnessing conceptual developments from tobacco control research, which were significantly advanced by the release of millions of internal tobacco industry documents through litigation in the 1990s.39 These documents offer unique and detailed insights into corporate policy influencing strategies in a way which has not hitherto been possible for the UPFI: in January 2021, the Tobacco Industry Documents Archive40 hosted 12 220 370 documents, whereas its food industry counterpart only contained 131 865.41 An evidence-based model of tobacco industry political activity, the Policy Dystopia Model (PDM)10 has been developed using two systematic reviews of tobacco industry document research. It categorises corporate political activity into argument-based and action-based strategies, showing how they work collectively to construct and disseminate a narrative that regulatory policies will fail and lead to undesirable consequences. The PDM presents two hierarchical taxonomies of instrumental (action-based) and discursive (argument-based) strategies with the respective subcategories of techniques and arguments. Researchers have successfully applied the PDM to study political activities of the UPFI and other industries at the national level, demonstrating its applicability beyond tobacco control.13 14 42–44 Our study harnesses the PDM to examine UPFI instrumental strategies at the global level. In doing so, it builds on our recent work which examined the UPFI’s discursive strategies in WHO consultations.45 The study aims to:

• examine UPFI political activity—specifically its instrumental strategies—aimed at WHO.

Additionally, we seek to explore how this differs with the better documented tobacco industry political activities against WHO’s public health efforts,46–48 and how public health actors explain these differences.

Methods

We drew on multiple sources to map the instrumental strategies UPFI actors use, focusing on post-2000 policy developments around obesity and dietary NCDs at WHO headquarters. UPFI actors were defined as including corporations involved in the manufacture of ultra-processed products, forming a key part of their supply chain, or holding a financial interest in the sale of these products, including ingredient supply and processing, fast food restaurant organisations, and retail.45

Results

We identified numerous actions which could be collapsed into 10 techniques and 3 overarching instrumental strategies which interlink and reinforce each other: coalition management, UPFI involvement and influence in policy, and information management (table 3). In this section, we present the hierarchical framework which resulted from our analysis. While we present our results through a global lens, it was clear that some attempts at influence were operationalised through the national level.

Discussion

This study addresses a significant gap in the understanding of UPFI political activity by examining its instrumental strategies in global-level NCD policy. In summary, our analysis suggests that the UPFI uses three overarching strategies which interlink and reinforce each other: coalition management, involvement and influence in policymaking, and information management (figure 1). UPFI actors established and used favourable coalitions—with allied Member States, SPIs, and between businesses—to promote their preferred policy positions, while they sought to co-opt civil society coalitions and hired former WHO staff. Pursuant to WHO guidelines, participation in consultations and meetings primarily takes place through the aforementioned groups. Moreover, the UPFI managed information strategically, funding and promoting evidence and other information favourable to their policy preferences, while challenging unfavourable information. Lastly, UPFI actors’ CSR activities and much-publicised partnerships were attributed to attempts to create a reputation as responsible, legitimate actors.

The first key limitation of this work is that we had restricted access to interviewees, notably those from IOs. This is likely a consequence of the unavoidable limitations imposed by the COVID-19 pandemic as well as the professional risk involved in discussing politically sensitive topics in the absence of freedom of information provisions within the UN system. Second, the documents analysed in this study were drawn from a limited pool of internal industry files. As such, our data do not provide a comprehensive picture of UPFI activities. Third, over half of the identified academic articles were commentaries, news pieces or editorials by individuals involved in WHO processes, rather than original research, which highlights the need for more empirical work in this area. Moreover, WHO is not the only IO involved in dietary NCD policy, thus further research addressing the wider UN system is necessary to better understand the UPFI’s role.

We sought to overcome these limitations in a number of ways. Notably, we used a conceptual model based on high evidential standards from the tobacco literature to structure our enquiry. The PDM has been successfully used to analyse political activities of the UPFI and other industries,13 14 42–44 showing similar tactics at the national level and thus providing a priori evidence to suggest comparable tactics at the global level. Nonetheless, there remains a need for a joint-up framework based on rigorous analysis of evidence from multiple unhealthy commodity industries, which would offer a more appropriate basis for cross-industry research. We also triangulated multiple data sources to overcome weaknesses of each.49 While we did not approach UPFI representatives for this study, two studies have analysed their public views on NCD policy at the WHO and the industry’s role within it in depth,45 113 finding that UPFI groups have consistently opposed statutory regulation in favour of self-regulatory approaches, and promoted a strong role for industry in policymaking while emphasising the limits of WHO’s mandate and fostering a narrow understanding of conflict of interest.45 113 Together with the current findings that the UPFI engages in a broad range of techniques to achieve these policy preferences, this renders questionable whether they can meaningfully contribute to policy development as they claim.

The UPFI remains able to exert significant structural, instrumental and discursive power in global health and nutrition governance.114 Our analysis accentuates a power imbalance which compromises the ability of global health governance to deliver in the public interest. The food industry is enormously heterogenous, but only a narrow subset of actors has the resources and capacity to engage with IOs. This imbalance means that it is easier for UPFI multinationals to have their voices heard than for parts of the food industry whose practices may be less damaging or even beneficial to health and who may therefore have a role to play, and for civil society or people living with NCDs who are more likely to represent the public interest. Although smaller actors within the food industry are likely to lack the resources for sustainable IO engagement, movements such as La Via Campesina, which has a long history of representing small-scale food producers at the UN Food and Agriculture Organization,115 provide a potential route for engagement. Speaking to a further power imbalance, our research highlights how high-income countries hosting major food companies can stymie efforts, primarily of low-income and middle-income countries, to effectively address NCDs. Addressing rather than reinforcing such power imbalances should be central to considerations on engagement and partnerships, at national and global level.

The food industry enjoys a high degree of acceptability in global health policy circles. The heterogeneity of this unhelpfully broad category seems to play a key role in legitimising those companies whose practices are most detrimental to health, and it closely links to UPFI multinationals’ own framing of themselves as ‘part of the solution’ and attempts to mitigate conflict of interest as unfair vilification.13 45 113 116 117 However, their political behaviour is strikingly similar to that of the tobacco industry. In fact, our study is one among a growing body of literature which documents parallels between a range of unhealthy commodity industries.118–120 Like at national level,121 we identify similarities in the political behaviour of the UPFI and tobacco industries at the global level. Analyses of internal documents show the tobacco industry’s aggressive campaign to delay and weaken the WHO FCTC, including lobbying through allied Member States and SPIs to oppose the regulation of their products, and recruiting ex-WHO staff,46–48 122 all of which we document the UPFI using here.

Overall, this coherence in behaviour demands greater coherence in governance approaches to unhealthy commodity industries.33 123 124 This is likely to remain contentious in light of the public health community’s ambiguity on interactions with the food industry compared with other unhealthy commodity industries,125 but others have suggested that the FCTC, specifically the way in which it deals with the conflict of interest between the tobacco industry and public health, provides a potential pathway for action on healthier diets.33 Although arguably neither perfect nor easy to implement at country level, FCTC Article 5.3, which aims to protect public health policymaking from tobacco industry interference, has had some success in reinforcing tobacco control.126–128 Our findings suggest that comprehensive, effective safeguards against undue influence and conflicts of interest are paramount for WHO to fulfil its role as a global leader in tackling NCDs. This is especially pertinent in light of the new WHO Foundation which renders it possible to circumvent WHO rules on corporate donations and thus poses a clear threat to the agency’s independence,124 as illustrated by a widely publicised donation from Nestlé in April 2021.129

The need for comprehensive safeguards against commercial interference inevitably extends to national settings: UPFI attempts to influence NCD policy through Member State governments have the potential to impede urgently needed action to address dietary NCDs globally. While we highlight such activities at the global level, there is evidence that similar mechanisms are at work between countries: some of our interviewees reported joint lobbying by the Italian embassy and a food company in Latin American countries, and after Chile introduced ground-breaking marketing restrictions and labelling rules, a public health official reported being accused of ‘food terrorism’ by a Ferrero executive and the Italian ambassador.130

We also observe tensions between attempts to address NCDs on one hand and undernutrition and micronutrient deficiencies on the other hand, the latter often affording a substantial role to the UPFI.131 With the double burden of malnutrition and NCDs prevalent within countries, communities and even individuals,132 undernutrition and overnutrition cannot be tackled separately, particularly considering that the distribution of food products by multinational corporations, a key driver of unhealthy diets, is touted as a solution to the latter by some. This underlines the need to adopt a focus on double-duty actions which tackle the common drivers of malnutrition.133

Conclusions

This work provides a means of understanding and thus addressing how the UPFI attempts to prevent or weaken regulation at global level. COVID-19 has reminded us that a strong WHO is essential for global public health. What happens in global-level policymaking, and what does not, is important. Strong recommendations on NCDs from the UN and its agencies can provide Member States with a mandate to act, while their absence offers the UPFI a means to oppose regulation. Reconsidering multistakeholder approaches which have allowed commercial interests a seat at the public health policy table may be key to rebuilding a healthier world post-COVID-19.134 By highlighting UPFI attempts to interfere with WHO’s efforts to curb NCDs, we provide a foundation for further steps to protect the agency’s work against a set of problems that presents an even greater long-term challenge to global health than the current pandemic. The implementation of stronger conflict of interest measures would be an important first step in addressing power imbalances between Member States, the UPFI, and civil society to more effectively address dietary NCDs.