International Journal of Health Policy and Management
Volume:10 Issue: 12, Dec 2021

Achieving healthy food systems will require regulation across the supply chain; however, binding international economic agreements may be constraining policy space for regulatory intervention in a way that limits uptake of ‘best-practice’ nutrition policy. A deeper understanding of the mechanisms through which this occurs, and under which conditions, can inform public health engagement with the economic policy sector. 

We conducted a realist review of nutrition, policy and legal literature to identify mechanisms through which international trade and investment agreements (TIAs) constrain policy space for priority food environment regulations to prevent non-communicable diseases (NCDs). Recommended regulations explored include fiscal policies, product bans, nutrition labelling, advertising restrictions, nutrient composition regulations, and procurement policies. The process involved 5 steps: initial conceptual framework development; search for relevant empirical literature; study selection and appraisal; data extraction; analysis and synthesis, and framework revision. 

Twenty-six studies and 30 institutional records of formal trade/investment disputes or specific trade concerns (STCs) raised were included. We identified 13 cases in which TIA constraints on nutrition policy space could be observed. Significant constraints on nutrition policy space were documented with respect to fiscal policies, product bans, and labelling policies in 4 middle-income country jurisdictions, via 3 different TIAs. In 7 cases, trade-related concerns were raised but policies were ultimately preserved. Two of the included cases were ongoing at the time of analysis.TIAs constrained policy space through 1) TIA rules and principles (non- discrimination, necessity, international standards, transparency, intellectual property rights, expropriation, and fair and equitable treatment), and 2) interaction with policy design (objectives framed, products/services affected, nutrient thresholds chosen, formats, and time given to comment or implement). Contextual factors of importance included: actors/institutions, and political/regulatory context. 

Available evidence suggests that there are potential TIA contributors to policy inertia on nutrition. Strategic policy design can avoid most substantive constraints. However, process constraints in the name of good regulatory practice (investor-state dispute settlement (ISDS), transparency, regulatory coherence, and harmonisation) pose a more serious threat of reducing government policy space to enact healthy food policies.

Comprehensive nutrition policies are required urgently to help transform food systems to more equitably deliver healthy, sustainable diets. 

Literature was searched systematically for nutrition policies of the then 34 Organisation for Economic Co-operation and Development (OECD) members as part of a scoping study. Recently, results were re-analysed, against the NOURISHING framework. 

Twenty-three nutrition policy documents were identified for 19 jurisdictions. Most policy actions focused on the behaviour change communication domain: all (100%) promoted consumption of ‘healthy’ choices. In the food environment domain, most policies included food labelling (84%), product reformulation (68%), providing healthy foods in public institutions (89%, mainly schools), and restricting food advertising (53%), largely through voluntary codes. Relatively few economic tools were being applied. There was very little focus on reducing consumption of ‘unhealthy’ food or drinks. Not all nutrition policy actions identified were covered by the NOURISHING framework. 

The NOURISHING framework could be expanded to more comprehensively encompass the health and sustainability dimensions of food systems, eg, by detailing optimum governance arrangements. As recently as seven years ago, half of the most developed economies globally did not have a publicly available nutrition policy. Existing policies were dominated by conventional nutrition education approaches, while policy actions targeting food environments, and regulatory and legislative reforms, were rare. This is consistent with a neo-liberal approach centring individual responsibility. No examples of the multi-strategy, inter-sectoral, coordinated, evidence-based policies required to drive systemic transformation were identified. Therefore, it is not surprising that rates of obesity and diet-related conditions have continued to rise in these jurisdictions, nor that governments are currently off-track to deliver the systemic transformation required to meet relevant global health and sustainable development goals.

Corporate control of the global food system has resulted in greater global availability of highly processed, packaged and very palatable unhealthy food and beverages. Environmental harm, including climate change and biodiversity loss, occurs along the supply chains associated with trans-national corporations’ (TNCs’) practices and products. In essence, the corporatization of the global food system has created the conditions that cultivate excess consumption, manufacture disease epidemics and harm the environment. TNCs have used their structural power – their positions in material structures and organizational networks – to establish rules, processes and norms that reinforce and extend the paradigm of the neoliberal corporate food system. As a result, policy and regulatory environments, and societal norms are favourable to TNC’s interests, to the detriment of nutrition, health and environmental outcomes. There is hope, however. Power, of which there is many forms, is held not just by the TNCs but by all actors concerned about and connected to the food system. This paper aims to understand these power dynamics, and identify how structurally weak, public-interest actors can release their agency and work to achieve positive structural change. Such an analysis will help understand how the status quo can be disrupted and healthy and sustainable food systems created. The paper draws from the health governance and social movement literature, examining the Doha Declaration on the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement and Public Health, the Framework Convention on Tobacco Control (FCTC), and the Divestment movement. These cases demonstrate the many ‘weapons of the weak’ that can, against all odds recalibrate structural inequities. There is no one approach to transforming the corporate food system to become a healthy and sustainable food system. It involves coalition building; articulation of an ambitious shared vision; strategic use of multi-level institutional processes; social mobilization among like-minded and unusual bedfellows, and organized campaigns; political and policy entrepreneurs, and compelling issue framing.

Diets high in red and processed meat (RPM) contribute substantially to environmental degradation, greenhouse gas (GHG) emissions, and the global burden of chronic disease. Recent high-profile reports from international expert bodies have called for a significant reduction in global dietary meat intake, particularly RPM, especially in high-income settings, while acknowledging the importance of animal-sourced foods to population nutrition in many lower-income countries. However, this presents a major yet under-investigated political challenge given strong cultural preferences for meat and the economic importance and power of the meat industry. 

A theoretically-guided narrative review was undertaken. The theoretical framework used to guide the review considered the interests, ideas and institutions that constitute food systems in relation to meat reduction; and the instrumental, discursive and structural forms of power that actors deploy in relation to others within the food system.

High production and consumption levels of RPM are promoted and sustained by a number of factors. Actors with an interest in RPM included business and industry groups, governments, intergovernmental organisations, and civil society. Asymmetries of power between these actors exist, with institutional barriers recognised in the form of government-industry dependence, trade agreement conflicts, and policy incoherence. Industry lobbying, shaping of evidence and knowledge, and highly concentrated markets are key issues. Furthermore, prevailing ideologies like carnism and neoliberalism present embedded difficulties for RPM reduction. The literature noted the power of actors to resist meat reduction efforts exists in varying forms, including the use of lobbyin, shaping of evidence and knowledge, and highly concentrated markets. 

There are a number of political challenges related to RPM reduction that contribute to policy inertia, and hence are likely to impede the transformation of food systems. Research on policy efforts to reduce RPM production and consumption should incorporate the role of power and political feasibility.

The exercise of power is central to understanding global health and its policy and governance processes, including how food systems operate and shape population nutrition. However, the issue of power in food systems has been little explored empirically or theoretically to date. In this article, we review previous work on understanding power in addressing malnutrition as part of food systems that could be used in taking this issue further in future food systems research. In particular, we examine why acknowledging power is vital in addressing food systems for better nutritional outcomes, approaches to assessing power in empirical research, and ways of addressing issues of power as they relate to food systems. 

We undertook a narrative review and synthesis. This involved identifying relevant articles from searches of PubMed and Scopus, and examining the reference lists of included studies. We considered for inclusion literature written in English and related to countries of all income levels. Data from included articles were summarized under several themes. 

We highlight the importance of acknowledging power as a critical issue in food systems, present approaches that can be taken by food-systems researchers and practitioners in assessing power to understand the ways in which power works in food systems and wider society, and present material relating to addressing power and developing strategies to improve food systems for better nutrition, health and well-being. 

A range of research approaches exist that can inform examination of power in food systems, and support the development of strategies to improve food systems for better nutrition, health and well-being. However, there is considerable scope for further work in this under-researched area. We hope that this review will support the necessary research to understand further power in food systems and drive the much-needed transformative change.

While child undernutrition is improving overall, different population groups are experiencing different outcomes. What sets some groups apart is their experience of the ‘basic determinants’ of malnutrition, that underpin the ‘immediate’ and ‘underlying’ determinants, and that have been much less studied, defined and understood. 

We undertook a qualitative narrative review based in two sets of ideas: nutrition’s basic determinants as laid out in the original United Nations Children’s Fund (UNICEF) framework, and critical concepts emerging from development studies. These ideas informed searches in Google Scholar, and resulting papers formed the basis for the review. 

Based on this literature, we expand and clarify the terminology of ‘basic determinants’ into a new framework, to include (1) resources and (material, human, social and natural) capitals at the basic level; (2) structures including social, market, legal and political systems driven by long-term demographic, economic, and environmental trends; and (3) ideas, beliefs and ideologies prevailing within a given society – crystallising into social norms and institutions – fundamentally shaping how societies are structured around power and marginalisation. We then illustrate with existing literature how these basic factors play out in the food, health and care determinants of malnutrition; and how theories of human rights and collective commons point us towards practical redressal options through improved participation and accountability. 

We show here that the basic determinants are not a black box of ‘context,’ but can be broken down into comprehensible issues that are amenable to change, and should be considered explicitly in research and action to reduce the global burden of malnutrition.

Obesity and nutrition-related non-communicable diseases (NR-NCDs) are increasing throughout Africa, driven by urbanisation and changing food environments. Policy action has been limited - and influenced by high income countries. Socio-economic/political environments of African food systems must be considered in order to understand what policy might work to prevent NR-NCDs, for whom, and under what circumstances. 

A realist synthesis of five policy areas to support healthier food consumption in urban Africa: regulating trade/foreign investment; regulating health/nutrition claims/labels; setting composition standards for processed foods; restricting unhealthy food marketing; and school food policy. We drew upon Ghana and Kenya to contextualise the evidence base. Programme theories were generated by stakeholders in Ghana/Kenya. A two-stage search interrogated MEDLINE, Web of Science and Scopus. Programme theories were tested and refined to produce a synthesised model. 

The five policies operate through complex, inter-connected pathways moderated by global-, national- and local contexts. Consumers and the food environment interact to enable/disable food accessibility, affordability and availability. Consumer relationships with each other and retailers are important contextual influences, along with political/economic interests, stakeholder alliances and globalized trade. Coherent laws/regulatory frameworks and government capacities are fundamental across all policies. The increasing importance of convenience is shaped by demographic and sociocultural drivers. Awareness of healthy diets mediates food consumption through comprehension, education, literacy and beliefs. Contextualised data (especially food composition data) and inter-sectoral collaboration are critical to policy implementation.

Evidence indicates that coherent action across the five policy areas could positively influence the healthiness of food environments and consumption in urban Africa. However, drivers of (un)healthy food environments and consumption reflect the complex interplay of socio-economic and political drivers acting at diverse geographical levels. Stakeholders at local, national, and global levels have important, yet differing, roles to play in ensuring healthy food environments and consumption in urban Africa.

For decades, the food industry has sought to deflect criticisms of its products and block public health legislation through a range of offensive and defensive strategies. More recently, food corporations have moved on to present themselves as “part of the solution” to the health problems their products cause. This strategic approach is characterised by appeasement, co-option and partnership, and involves incremental concessions and attempts to partner with health actors. This paper details how corporate practices have evolved and changed over the past two decades and gives some definition to what this new political economy signifies for the wider behaviours of corporations producing and selling harmful commodities. 

This paper draws on public health and political science literature to classify the food industry’s “part of the solution” strategy into three broad components: regulatory responses and capture; relationship building; and market strategies. We detail the key characteristics and consequences of each component.

The three components of the food industry’s “part of the solution” strategy all involve elements of appeasement and co- option. They also improve the political environment and resources of the food industry. Regulatory responses offer incremental concessions that seek to maintain corporate influence over governance processes and minimise the threat of regulations; relationship building fosters access to health and government stakeholders, and opportunities to acquire and maintain channels of direct influence; and market strategies to make products and portfolios healthier bolster the market share and revenue of food corporations while improving their public image. 

Rather being a signal of lost position and power, the food industry’s repositioning as “part of the solution” has created a highly profitable political economy of ‘healthy’ food production, alongside continued production of unhealthy commodities, a strategy in which it is also less burdensome and conflictual for corporations to exercise political power and influence.

The potential role of the food and beverage industry in addressing diet-related disease is much debated, particularly amidst evidence of the targeted strategies, including voluntary self-regulation, used by the industry to influence policy in their favour. At the same time, the need for more comprehensive action to address unhealthy diets has led to a focus on increasing the accountability of different stakeholders. However, there has been limited evaluation of the impact of accountability initiatives on food and beverage company policies and practices. This study evaluated the impact of the BIA-Obesity (Business Impact Assessment – Obesity and population nutrition) Australia Initiative that benchmarked major Australian food and beverage companies on their nutrition-related policies. 

Evaluation was conducted against the pre-specified logic model for BIA-Obesity and established frameworks for analysing organisational change and corporate political activity. Outcomes evaluated included company engagement with the Initiative, level of media coverage, and impact of the Initiative on company policies and practices based on the perspectives of company representatives. A mixed methods design was employed, including surveys and in-depth interviews with company representatives, and media reports. 

Approximately half of invited companies participated in the evaluation of the BIA-Obesity Australia Initiative. A number of company representatives indicated that the Initiative had influenced their company’s nutrition policies, strategies, and disclosure practices, and had raised their company’s awareness of the importance of addressing nutrition issues. 

Company representatives perceive benchmarking and accountability initiatives as helpful for provoking improvements in nutrition-related policies and practices in their companies. However, the benefits of these initiatives need to be assessed in the context of the broader political and economic environment. Whilst the focus of accountability initiatives, such as BIA-Obesity, are on industry self-regulation efforts, they can also play an important role in drawing attention to the need for increased government regulation.

Healthy and sustainable food systems underpin the well-being of Indigenous peoples. Increasingly governments are taking action to improve diets via population-wide policies. The United Nations Declaration on the Rights of Indigenous People states that Indigenous peoples have the right to participate in all decisions that affect them. We analysed Australian national food and nutrition policy processes to determine: (i) the participation of Aboriginal organisations, (ii) the issues raised in Aboriginal organisations’ policy submissions, and (iii) the extent to which Aboriginal organisations’ recommendations were addressed in final policy documents.

Political economy and cultural safety lenses informed the study design. We analysed publicly-available documents for Australian population-wide food and nutrition policy consultations occurring 2008-2018. Data sources were policy documents, committee reports, terms of reference and consultation submissions. The submissions made by Aboriginal organisations were thematically analysed and key policy recommendations extracted. We examined the extent to which key recommendations made by Aboriginal organisations were included in the subsequent policy documents. 

Five food and nutrition policy processes received submissions from Aboriginal organisations. Key themes centred on self-determination, culturally-appropriate approaches to health, and the need to address food insecurity and social determinants of health. These messages were underrepresented in final policy documents, and Aboriginal people were not included in any committees overseeing policy development processes. 

This analysis suggests that very few Aboriginal organisations have participated in Australian population-wide food and nutrition policy processes and that these policy development processes are culturally unsafe. In order to operationalise First Nations peoples’ right to self-determination, alternative mechanisms are required to redress the power imbalances preventing the full participation of Aboriginal and Torres Strait Islander peoples in population-wide food and nutrition policy decisions. This means reflecting on deeply embedded institutional structures and the normative assumptions upon which they rest.

Globalised and industrialised food systems contribute to human and planetary health challenges, such as food insecurity, malnutrition, and climate change. International trade and investment can serve as a barrier or enabler to food system transformations that would improve health and environmental outcomes. 

This article used health impact assessment (HIA) to analyse what we know, what we don’t know, and what we don’t know we don’t know about the role that trade and investment might play in food system transformations to improve human and planetary health. 

Evidence exists for the link between trade and investment and the spread of unhealthy food commodities, efforts to impede nutrition labelling, and increased concentration of ultra-processed food and beverage product companies. The role of trade and investment in the reduction of animal sources in human diets is emerging and may include challenging measures that restrict the use of terms like ‘milk’ and ‘burger’ in plant-based alternatives and the promotion of plantbased foods through non-tariff barriers and targeted efforts at regulatory harmonisation. Trade disputes may serve as the forum for battles around state discrepancies in the safety and acceptability of technological innovation in the food supply, as was the case with hormone treated beef between the European Union (EU) and the United States. Corporate social responsibility (CSR) obligations are unambitious but represent welcome progress in balancing public and private interests. Finally, introducing greater policy flexibility, transparency, and participation provides opportunities to shape a modern trade and investment system that can respond to future food system challenges in a timely fashion. 

Research at the intersection of trade and investment and food systems should address emergent food systems issues, particularly those that intersect health and climate, while policy efforts should be future-proofing the flexibility of the trade and investment system to enable food system design that supports improved human and planetary health outcomes.

Nutrition policies to improve the food environment frequently rely on voluntary business action for implementation, many have had mixed success. The aims of this study were to identify key food system drivers influencing the Australian packaged food sector and analyse how these might impact the willingness of food companies to voluntarily reduce salt in packaged foods. 

Business methods formed the basis of this retrospective applied policy analysis of voluntary salt reduction for the period 2013-2016 where the focal policy was the Australian Food and Health Dialogue (2009-2015). The analytical framework included political-legal, economic, social, technological (PEST) external drivers of the food system, and Porter’s Five Forces for the competitive drivers of the food system. Documentary data identifying food system drivers affecting the Australian packaged food sector (comprised of the food processing and supermarket industries) were identified through a comprehensive search of the grey and academic literatures. 

The interplay between external and competitive food system drivers created an environment in which voluntary salt reduction was found to be an uneasy fit. A high cost of doing business, soft growth, intense competition, asymmetry of power in favour of supermarkets, and marginal consumer interest in less salty food were found likely to create commercial disincentives to invest in voluntary salt reduction above more pressing commercial imperatives. Analysis of food manufacturing industries highlighted the highly contextual nature of food system drivers. Opportunities for nutrition policy included: support for ‘shared value’ in economic discourse; and, leveraging investor, supermarket, and the largely unrealised bargaining power of consumers. 

Business frameworks can provide meaningful insights for nutrition policy on how food system drivers can thwart policy goals. Our analysis highlighted areas to incentivise voluntary action and illustrated the importance of political-legal, economic and consumer strategies for salt reduction.

The global food system is not delivering affordable, healthy, diverse diets, which are needed to address malnutrition in all its forms for sustainable development. This will require policy change across the economic sectors that govern food systems, including agriculture, trade, finance, commerce and industry – a goal that has been beset by political challenges. These sectors have been strongly influenced by entrenched policy agendas and paradigms supported by influential global actors such as the World Bank and International Monetary Fund (IMF). 

This study draws on the concept of path dependency to examine how historical economic policy agendas and paradigms have influenced current food and nutrition policy and politics in Ghana. Qualitative data were collected through interviews with 29 relevant policy actors, and documentary data were collected from current policies, academic and grey literature, historical budget statements and World Bank Group Archives (1950-present). 

Despite increased political priority for nutrition in Ghana, its integration into food policy remains limited. Food policy agendas are strongly focused on production, employment and economic returns, and existing market-based incentives do not support a nutrition-sensitive food supply. This policy focus appears to be rooted in a liberal economic approach to food policy arising from structural adjustment in the 1980s and trade liberalization in the 1990s, combined with historical experience of ‘failure’ of food policy intervention and an entrenched narrowly economic conception of food security. 

This study suggests that attention to policy paradigms, in addition to specific points of policy change, will be essential for improving the outcomes of food systems for nutrition. An historical perspective can provide food and health policy-makers with insights to foster the revisioning of food policy to address multiple national policy objectives, including nutrition.

One important way to transform food systems for human and planetary health would be to reduce the production and consumption of animals for food. The over-production and over-consumption of meat and dairy products is resource-intensive, energy-dense and creates public health and food equity risks, including the creation of superbugs and antimicrobial resistance, contamination and pollution of land and waterways, and injustice to animals and humans who work in the sector. Yet the continuing and expanding use of animals is entrenched in food systems. One policy response frequently suggested by parties from all sectors (industry, government and civil society) is voluntary or mandatory labelling reforms to educate consumers about the healthiness and sustainability of food products, and thus reduce demand. This paper evaluates the pitfalls and potentials of labelling as an incremental regulatory governance stepping-stone to transformative food system change. 

We use empirical data from a study of the regulatory politics of animal welfare and environmental claims on Australian products together with an ecological regulation conceptual approach to critically evaluate the potential of labelling as a regulatory mechanism. 

We show that labelling is generally ineffective as a pathway to transformative food system change for three reasons: it does not do enough to redistribute power away from dominant actors to those harmed by the food system; it is vulnerable to greenwashing and reductionism; and it leads to market segmentation rather than collective political action. 

We suggest the need for regulatory governance that is ecological by design. Labelling can only be effective when connected to a broader suite of measures to reduce overall production and consumption of meat. We conclude with some recommendations as to how public health advocates and policy entrepreneurs might strategically use and contest labelling and certification schemes to build support for transformative food system change and to avoid the regressive consequences of labelling.

Every country is affected by some form of malnutrition. Some governments and nutrition experts look to public-private partnerships (PPPs) to address the burden of malnutrition. However, nutrition-related PPPs face opposition, are difficult to form, and there is limited evidence of their effectiveness. 

We conducted a literature review and 30 semi-structured interviews with individuals involved in or researching nutrition-related PPPs to identify the factors that shape their creation and effectiveness in food systems. 

Several factors make it difficult to establish nutrition-related PPPs in food systems: a lack of understanding of the causal pathways behind many nutrition problems; a weak architecture for the global governance of nutrition; power imbalances between public and private sector nutrition actors; and disagreements in the nutrition community on the advisability of engaging the private sector. These complexities in turn make it difficult for PPPs to be effective once established due to goal ambiguity and misalignment, resource imbalances, and weak accountability. 

If effective nutrition-related PPPs are to be established, private sector conflicts of interest must be addressed, trust deficits between private and public sector actors must be surmounted, and evidence must be assessed as to whether PPPs can achieve more for public health nutrition than private and public sector actors working separately.

Critical scholars agree that contemporary globalised and industrialised food systems are in profound and deepening crises; and that these systems are generative of accelerating multiple crises in the earth’s life systems. Why and how did we arrive at this point? This paper argues that, conceiving each individual human as one cell in the greater human body, we are afflicted by what John McMurtry termed ‘the cancer stage of capitalism.’ This provocative framing is adopted here in response to growing calls by climate, earth and physical scientists not to ‘mince words’ in the description and analysis of humanity’s current predicament, but rather ‘tell it like it is.’   

  Proceeding from McMurtry’s application of the seven defining medical properties of a ‘cancer invasion [of] an individual organism’ to the broader body politic and the earth’s life system, this paper draws on literature from diverse disciplines to investigate the fundamental cause of food systems crises. The paper references several empirical studies and meta-reviews that indicate the hastening decline in the integrity of human and ecological health, with a particular focus on the grain-oilseed-livestock complex and the accompanying social and ecological impacts on the southern cone countries of South America.   

  The cause of food system crises is to be found in the core logic of capital accumulation, the profit imperative, and the relentless and expanding processes of commodification and financialization. The key metric of ‘economic growth’ is problematised and discussed. An embryonic ‘social immune response’ is now observable, in the diverse practices of decommodification, proposals for de-growth and commoning that together constitute an emerging ‘food as a commons’ movement.  

As currently framed, the Food as Commons proposal lacks coherence, rigour and a viable strategy to move beyond the current crisis. Its transformative potential can be strengthened through a more explicitly political grounding based on appeals to and support of anti- and post-capitalist movements and initiatives.

  This paper examines the exclusion of public health from social license narratives within an increasingly financialised food system, through a case study of foreign ownership in the Australian sugar industry. As finance actors such as asset management firms, pension funds, private equity funds, state owned enterprises and sovereign wealth funds engage in speculative farmland investment, commodity futures trading, and the conversion of farmland into a financial asset, power within agro-industrial food supply chains becomes increasingly concentrated. This has been associated with increased food prices and more processed food, contributing to obesogenic diets, hunger, and poorer health outcomes for many. The potential for negative social and environmental impacts has prompted awareness of the need for financial actors to demonstrate sustainability, responsibility and accountability in their farmland investments.  

  This paper uses thematic analysis of qualitative interviews and key documents to assess four recent acquisitions of sugarcane land in North Queensland. We consider how companies’ efforts to establish or maintain a social license to operate (SLO) intersect with their capital accumulation strategies. 

Our findings demonstrate that the link between the commodification of ‘unhealthy’ food inputs (such as sugar) and financialisation remains outside the purview of financiers. Instead, agribusiness firms use narratives centred on biofuels investment and energy/food security to justify their legitimacy in the sugar sector. We organise our findings according to two ‘narratives:’ constructing trust and credibility through ethical compliance; and, biofuels expansion as a legitimate response to climate change. The concept of social license is much stronger in the second narrative, but health is largely missing.  

The ‘distancing’ between responsibility and health outcomes highlights the limits to principles of responsible financial investment, and to the legitimacy of finance to claim an SLO – the ongoing approval and acceptance by society to conduct its activities.

  Ultra-processed food (UPF) and Ultra-processed beverage (UPB) consumption is associated with higher risks of numerous non-communicable diseases (NCDs). Yet global consumption of these products is rising due to profound changes in production, processing, manufacturing, marketing, retail, and consumption practices, alongside the growth of the resources and political influence of Big Food. Whilst the sales of UPFs and UPBs in high-income countries (HICs) are stagnating, sales are rapidly expanding in more populous middle-income countries (MICs). In this paper, we adopt a political economy of food systems approach to understand how growth of Big Food in MICs drives the NCD pandemic. 

  We conducted a mixed methods synthesis review. This involved quantitative data collection and development of descriptive statistics; a search for academic, market and grey literature on the expansion of UPF in MICs; and the development of themes, three illustrative case examples (South Africa, Colombia, and Indonesia), and synthesis of the enablers of successful campaigns in MICs into recommendations for public health campaigns. 

We project that the combined sales volume of UPFs in MICs will reach equivalency with HICs by 2024, and the total sales volume of UPBs in MICs is already significantly higher than in HICs. Similarly, annual growth in UPF sales is higher in MICs compared to HICs. We also show how Big Food has entrenched its presence within MICs through establishing global production and hyper-local distribution networks, scaling up its marketing, challenging government policies and scientific expertise, and co-opting civil society. We argue that public health can counter the influence of Big Food by developing an expanded global network of driven and passionate people with diverse skillsets, and advocating for increased government leadership. 

  The projected increase in sales of UPFs and UPBs in MICs raises major concerns about the global capacity to prevent and treat NCDs.

  International food standards set by the Codex Alimentarius Commission (CAC), have become more prominent in international trade politics, since being referenced by various World Trade Organization (WTO) agreements. We examine how this impacts implementation of the World Health Organization (WHO) International Code of Marketing of Breast-milk Substitutes.

Using trade in commercial milk formulas (CMFs) as a case study, we collected detailed data on interventions across various WTO bodies between 1995 and 2019. We used language from these interventions to guide data collection on member state and observer positions during the CAC review of the Codex Standard for Follow-up Formula (CSFUF), and during CAC discussions on the relevance of WHO policies and guidelines.

Exporting member states made 245 interventions regarding CMFs at the WTO, many citing deviations from standards set by the CAC. These did not occur in formal disputes, but in WTO Committee and Accession processes, toward many countries. In Thailand, complaints are linked to weakened regulation. Exporters also sought to narrow the CSFUF at the CAC in a way that is at odds with recommendations in the International Code. Tensions are growing more broadly within the CAC regarding relevance of WHO recommendations. Countries coordinated during WTO committee processes to advocate for reapportioning core WHO funding to the CAC and in order to further influence standard-setting.

  The commercial interests of the baby food industry are magnifying inconsistencies between health guidelines set by the WHO, standard-setting at the CAC, and functions of the WTO. This poses serious concerns for countries’ abilities to regulate in the interests of public health, in this case to protect breastfeeding and its benefits for the health of infants, children and mothers.