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Voluntary actions by industry ‘ineffective’ for public health, warns ‘realist review’

Reliance on voluntary actions to control the composition and marketing of unhealthy foods and drinks by industry is not effective and results in weaker regulations in low- and middle- income countries, warn researchers.

The review, published in Nature Food, examined voluntary actions adopted by the food and beverage industry in low- and middle-income countries (LMIC) in relation to the production and marketing of ‘unhealthy’ foods and drink, and the potential impact on risk non-communicable diseases (NCDs).

Led by Agnes Erzse from the University of Witwatersrand School of Public Health, South Africa, the team noted that in 2013, 194 member states of the World Health Organization (WHO) endorsed a list of cost-effective NCD ‘best-buy’ policies and other recommended measures.

These endorsements included evidence-based policies like taxes on sugar-sweetened beverages (SSBs), direct restrictions and mandates limiting the sale of SSBs in schools and workplaces, reformulation, and improvement of the nutrient profile of food products, and standards regulating marketing to children.

“While an increasing number of jurisdictions have adopted many of these measures with the aim of reducing consumption of unhealthy food and drink, the comprehensive implementation of diet-related NCD policies has been limited,” said Erzse and colleagues – noting that the adoption of regulatory policies on ‘unhealthy commodities’ has faced strong opposition from industry, principally in favour of the adoption of self-regulation and voluntary actions.

“We found evidence that across four NCD prevention areas—product reformulation, simplified nutrition labelling, restricting marketing to children and limiting sales of SSBs in schools—voluntary actions negatively influence the food and beverage environments in LMICs by failing to reduce exposure to unhealthy foods and beverages, and by strategically pre-empting the introduction of evidence-based regulatory actions,” said the research team.

A ‘realist review’ of voluntary actions

Erzse and colleagues state that multinational corporations and international associations have adopted well-publicised voluntary actions that outline their commitment to voluntarily address NCDs – adding that as part of these efforts, the food and beverage industry often assert that self-regulation and voluntary actions are sufficient to protect public health.

However, Erzse and colleagues noted that the use and effectiveness of VAs by the food and beverage industry is much debated – especially given the clear evidence from the alcohol and tobacco industries that VAs do not work.

The authors performed a ‘realist review’ of the of voluntary actions by the food and beverage industry and implications for public health and policy in LMICs, noting that to date, efforts to analyse industry actions have focused on high-income settings including Europe, North America, Australia, and Canada.

“This realist review supplements and extends previous reviews of voluntary actions by adopting a theoretical lens to identify and understand for the first time how voluntary actions function as an NCD prevention intervention in LMICs,” they said, noting that although voluntary actions have a stated purpose of improving public health, they also have a notable impact on the political environment.

“Studies on the political and policy impact show how industry actors have used voluntary actions to prevent mandatory regulation by governments, thereby constraining public health policy action and/or promoting policy ‘non-decision-making’,” they said.

“Given that voluntary actions sometimes replace evidence-based regulatory interventions, evidence of their effectiveness is of particular importance to assess whether they should be a preferred measure to address obesity and NCDs.”

No evidence of benefit

The study found no evidence indicating that voluntary actions are effective in safeguarding public health, said the team, adding that the analysis also showed that actions were often initiated in response to efforts to introduce regulations and were difficult to evaluate due to vague language and a lack of enforcement mechanisms.

“Within the context of the conceptual framework, our review indicates that the effect and purpose of voluntary actions are more often aimed at policy substitution rather than as public health interventions,” they said. “This is of concern as voluntary actions are often said to be initiated and adopted as a means to pre-empt government regulation, particularly in LMICs.”

Indeed, they cited the example of a proposed ‘sugar tax’ on drinks in South Africa, noting that industry leveraged heavily on existing public–private partnerships and voluntary commitments to argue against the adoption of SSB taxation.

Furthermore, they noted that the enforcement and implementation of voluntary measures has a substantial effect on their outcomes – adding that governments often accept self-regulation on the understanding that a statutory regulation may be adopted should the voluntary actions fail to deliver its promises.

The team noted that this makes monitoring and evaluation an imperative component of using voluntary industry measures to achieve public health objectives.

“However, current vague language and lack of benchmarks make it difficult to evaluate,” they said, warning that to enable the evaluation and assessment of their effectiveness, there is a need for industry actors to include transparent accountability mechanisms, develop targets that are quantitative and measurable, and publish progress reports on agreed indicators.

Governments should not involve multinational corporations in policymaking

“In light of our evidence and given the lack of commitment from industry to improving public health, policymakers need to consider mandatory regulatory intervention as a means to effectively address the growing obesity pandemic in LMICs,” said the authors.

“However, this is not without its challenges,” they warned. “In LMICs, despite its high cost, the issue of obesity is usually not high on government health agendas, and economic pressures create barriers to regulating industry behaviour.”

“For this reason, it is necessary for governments in LMICs to adopt strong conflict-of-interest policies and work to reduce the influence and role of multi-national corporations in NCD prevention policy.”

Furthermore, they suggested that the WHO and United Nations should rescind endorsements of industry involvement in favour of mandatory measures: “There have been consistent endorsements from international governing bodies indicating that collaboration with industry is a key strategy in responding to NCDs,” they said.

“This study demonstrates that the use of voluntary actions is not evidence-based and does not lead to better public health outcomes. For this reason, the WHO’s continued endorsement of voluntary actions is not supported by evidence and should be rescinded.”