Future directions to prevent obesity within the context of the Global Syndemic

While countries are in different stages of the obesity transition,1 no country has successfully reduced overweight or obesity rates across all segments of its population.2 Achieving the World Health Organization's (WHO's) global target for countries to halt the rise in obesity by 2025 will be impossible if we continue on the current path. The global pandemic of obesity is occurring simultaneously with two other pandemics—undernutrition and climate change. A 2019 Lancet Commission report described these concurrent challenges as “the Global Syndemic” and has called on national governments and a range of other actors to implement comprehensive, coordinated, and synergistic actions to promote health for people and the planet.3 The policy responses from national governments to prevent and manage obesity, and in particular to drive systemic changes, have been inadequate to date due to “policy inertia”, which is driven by a lack of government leadership, commercial pressure and industry opposition to government interventions, and a weak demand for change by the public and civil society sectors.3 The 16 papers in this special supplement of Obesity Reviews explore how this policy inertia can be tackled and how the implementation of policy responses to prevent obesity can be accelerated within the context of the Global Syndemic.3 Several determinants have been identified that drive the obesity pandemic. The increase in food energy supply over several decades has been suggested as a major driver of the obesity epidemic.4 Vandevijvere et al5 showed that the sales of ultra-processed foods and drinks (UPFD) increased substantially over 15 years in all regions worldwide, except in Western Europe, North America, and Australasia, where UPFD product sales were already very high during the early 2000s. This study found that an increase in UPFD volume sales/capita was positively associated with population-level body mass index (BMI) trajectories. In addition, cultural factors play an important role in unhealthy weight gain and obesity. Wallace et al6 showed that dimensions of national culture, especially high scores for individualism (vs collectivism) and uncertainty avoidance (vs uncertainty tolerance), are strongly correlated with adult obesity prevalence and explain over half of the variance among countries. This study called for further research to understand the pathways for these associations between culture and obesity and also for cultural contexts to be included in policies and community actions. Four papers in this special issue addressed the Lancet Commission's recommendation that actors use systems approaches to develop and implement double-duty actions to address obesity and undernutrition and triple-duty actions to address malnutrition in all its forms and climate change. Morshed et al7 used systems science modeling approaches to clarify how shared drivers of the Global Syndemic operate and how to best address them. Most previous models focused on microlevel obesity determinants (social circles and school settings), and these authors suggest a need to develop models at broader levels to inform country responses to the Global Syndemic. Baker et al8 used a theoretically driven systems dynamic modeling approach to strengthen nutrition actor network effectiveness at several levels to generate political commitment to end malnutrition in all its forms. Causal loop diagrams and group model building were used to create a nutrition commitment system that could be used by policymakers to implement double-duty actions to address obesity and undernutrition at country levels. Allender et al9 used community-based, participatory systems dynamic modeling to develop, implement, and evaluate whole-of-community strategies to improve the health of children in Australia. This study found that community leaders willing to build new relationships and take risks to change existing practice and redesigning health promotion with a community development focus offered important levers for meaningful change. McCrabb et al10 found that interventions tested at community level often need considerable adaptation to be implemented at scale, which may reduce the effectiveness of interventions. A systematic review of scaled-up obesity interventions (six prevention and four treatment) showed that the effects reported in scaled-up interventions related to weight status, physical activity, sedentary behavior, and nutrition were typically 75% or less of the effects reported in efficacy trials before being scaled up for populations. This finding underscores a major challenge to effectively scale up obesity interventions. Patterson et al11 considered how the human rights approach to address HIV/AIDS may inform the global response to obesity. These authors suggest that framing States' obligations to address the obesity pandemic as a matter of international law provides a normative framework to guide State action and engage the extensive accountability mechanisms of the United Nations (UN) international human rights system. Civil society organizations can advocate for States to fully implement human rights obligations recognized by international laws using the right to wellbeing concept, which acknowledges the right of every human being to health, food, protection of one's cultural heritage, and a healthy environment. Nine papers in the supplement highlight the Lancet Commission's recommendation that civil society actors monitor policy implementation to increase accountability for upstream actions to prevent obesity. This recommendation is especially salient for independent bodies to monitor and evaluate the policies and commitments of governments and industry actors to hold them accountable for their actions to address obesity given other competing challenges. The International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) developed tools and processes to evaluate the extent of implementation of priority recommendations by governments and various private-sector actors. Vandevijvere et al12 describe the Healthy Food Environment Policy Index (Food-EPI) implemented in 11 countries across six regions between 2015 and 2018. The Food-EPI was found to be robust to benchmark the policy implementation at national level to create healthy food environments.12 Nieto et al13 used the Food-EPI tool to conduct a self-assessment for the Mexican government. This study found that government officials and civil society actors agreed on nine priority actions to create a healthy food environment in Mexico, which is encouraging to clarify the government's commitment and advocacy efforts for this shared goal. Vandevijvere et al14 describe a country profile similar to the Global Burden of Disease country profiles15 to compare the healthiness of upstream food environments using a case study from New Zealand. Sacks et al16 describe the Business Impact Assessment on Obesity and Population Nutrition (BIA-Obesity) tool and process that civil society organizations can use to benchmark the policies and practices of food and beverage companies and industry sectors to promote population nutrition. This tool has been tested in Australia, Canada, New Zealand, and the United Kingdom and may be used to accelerate industry accountability and identify further actions needed to improve population health.16 Kraak et al17 conducted an accountability evaluation for the International Food & Beverage Alliance's (IFBA's) Global Policy on Marketing Communications to Children, compared with the WHO and UN recommended best practices. Between 2008 and 2018, no progress was made by the UN System to appoint or empower an independent body to evaluate the IFBA firms' marketing policies and practices or to strengthen accountability structures to ensure future compliance. These authors suggested six actions for IFBA to substantially strengthen its Global Policy to protect children up to age 18 years from all forms of unhealthy marketing to reduce their risk of obesity. INFORMAS has also developed methods and protocols to enable civil society organizations and researchers to benchmark food environments across countries for marketing to children and food and beverage product reformulation. Kelly et al18 compared the healthiness of food marketing to children on television across 22 countries using the WHO Europe's nutrient-profiling model to assess the percentage of television advertisements for unhealthy food and beverage products. This study found that unhealthy advertisements were higher in countries with industry self-regulatory programs, suggesting the need for stronger government regulation to protect children from the promotion of unhealthy products that undermine optimal health. Dunford et al19 used the health-star rating (HSR) nutrient profiling system to compare the healthiness of packaged food and beverage products in the food supply across 12 countries. This study found that high-income countries had more products with better HSR nutrient profiles compared to middle-income countries including China and India. Due to the variability of the healthiness of packaged food and beverage products, the investigators recommended food reformulation as an important target for policy action. The Lancet Global Syndemic Commission, among other expert bodies, recommended that governments provide clear and understandable information to consumers to enable informed choices and to encourage industry to respond to a demand-driven market shift for products that support healthy and economically sustainable food systems. Monitoring food environments supports the collection of evidence that can be used to evaluate the effectiveness and impact of government policies. Kanter et al20 examined the extent to which the food and beverage industry reformulated products in anticipation of the implementation of the Chilean government's national food labeling and advertising law, effective June 2016, that required industry to use front-of-package warning labels for nutrients of concern including sodium, saturated fats and sugars, and energy. This study evaluated the anticipatory impact of the Chilean food labelling law on industry reformulation before the law was mandated. The investigators found minimal reformulation of products by industry and that less than 2% of products would have avoided warning labels. This study suggests that many factors must be considered to promote effective supply- and demand-driven changes for healthful products that align with dietary recommendations. To tackle the current policy inertia in relation to obesity prevention, many coordinated and synergistic strategies are needed, including the upscaling of existing upstream monitoring efforts, the successful scaling up of whole-of-community interventions, the implementation of the right to wellbeing legislation, and civil society and the public advocating for triple-duty actions to prevent obesity within the context of the Global Syndemic. Future research and action topics include (a) how to create collaborative platforms to join up the silos of efforts at local, national, and global levels to develop double- and triple-duty actions to address the Global Syndemic; (b) how to accelerate implementation of strategies to reduce the influence of powerful commercial interests in the policy development process to enable governments to protect public health, equity, and planetary sustainability; (c) how private-sector actors can reorient business models to produce beneficial outcomes for society, the environment, and the planet; and (d) how international agencies and funding bodies can realign their priorities to address the Global Syndemic.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.