Big Food

PLoS Medicine Series on Big Food

The PLoS Medicine series on Big Food aims to examine and stimulate debate about the activities and influence of the food industry in global health. We define Big Food as the multinational food and be verage industry with huge and concentrated market power. The series adopts a multi-disciplinary approach and includes critical perspectives from around the world. It represents one of first times such issues have been examined in the general medical literature. The PLoS Medicine Editors begin the series with an editorial discussing the rationale and process of commissioning articles for the series. As they note, industry in health has long fascinated PLoS Medicine but the journal's focus on Big Food is new. Food, unlike tobacco and drugs, is necessary to live and is central to health and disease. And yet the big multinational food companies control what people everywhere eat, resulting in a stark and sick irony: one billion people on the planet are hungry while two billion are obese or overweight. The guest editors, Marion Nestle and David Stuckler, then lay out a background to the role of Big Food in global health, and offer three competing views of how public health professionals can respond. Subsequent articles include: a comparison of soda companies' corporate social responsibility campaigns with those of the tobacco industry; an analysis of the rapid rise of Big Food sales in developing countries; an essay on food sovereignty and who holds power over food; views from South America and Africa on the displacement of traditional diets by the incursion of multinational food companies; and a perspective arguing against an uncritical acceptance of the food industry in health. www.ploscollections.org/bigfood Image Credit: Original image by Todd Hryckowian at flickr.com, with enhancements by Lizzy Parisotto, PLoS.

ndiceEditorialPLoS Medicine Series on Big Food: The Food Industry Is Ripe for ScrutinyThe PLoS Medicine Editors

EssaysBig Food, Food Systems, and Global HealthDavid Stuckler, Marion Nestle

Food Sovereignty: Power, Gender, and the Right to FoodRajeev C. Patel

The Impact of Transnational Big Food Companies on the South: A View from BrazilCarlos A. Monteiro, Geoffrey Cannon

PerspectiveThinking Forward: The Quicksand of Appeasing the Food IndustryKelly D. Brownell

Policy ForumsSoda and Tobacco Industry Corporate Social Responsibility Campaigns: How Do They Compare?Lori Dorfman, Andrew Cheyne, Lissy C. Friedman, Asiya Wadud, Mark Gottlieb

Manufacturing Epidemics: The Role of Global Producers in Increased Consumption of Unhealthy Commodities Including Processed Foods, Alcohol, and TobaccoDavid Stuckler, Martin McKee, Shah Ebrahim, Sanjay Basu

Big Food, the Consumer Food Environment, Health, and the Policy Response in South AfricaEhimario U. Igumbor, David Sanders, Thandi R. Puoane, Lungiswa Tsolekile, Cassandra Schwarz, Chrisher Purdy, Rina Swart, Solange Duro, Corinna Hawkes

Editorial

PLoS Medicine Series on Big Food: The Food Industry Is Ripe for ScrutinyThe PLoS Medicine Editors*

This article is part of the the PLoS Medicine series on Big Food. Today we launch a major new series on Big Food in the PLoS Medicine Magazine. Over three weeks beginning 19 June 2012 we will publish seven articles that examine the activities and influence of the food and beverage industry in the health arena. These articles were commissioned by the senior Magazine editor (JC) under the guidance of our series guest editors Marion Nestle of New York University and David Stuckler of Cambridge University, and together they represent a multidisciplinary approach to exploring the role in health of Big Food, which we define as the multinational food and beverage industry with huge and concentrated market power [1]. Industry in health has long fascinated PLoS Medicine but our focus on Big Food is new. Food, unlike tobacco and drugs, is necessary to live and is central to health and disease. And yet the big multinational food companies control what people everywhere eat, resulting in a stark and sick irony: one billion people on the planet are hungry while two billion are obese or overweight [2]. The time is ripe for PLoS Medicine to shine a light on Big Food. Foremost, large food and beverage companies now have an undeniably influential presence on the global health stage. Whether its food company executives providing expertise at major conferences and high-level UN meetings (e.g., [3]) or major global health funders lecturing on what nongovernmental organizations can learn from CocaCola [4], the perspectives and experiences of Big Food are shaping the field of global health. At the same time that their expertise is elevated in global health debates, food companies are rebranding themselves as nutrition companies, offering business acumen and knowledge in food science and distribution, and asserting authority over solutions to problems not just of food production but of malnutrition, obesity, and even poverty. The legitimization of food companies as global health experts is further fueled byPLoS Medicine | www.plosmedicine.org

the growing number of private-public partnerships with public health organizations [5], ostensibly designed to foster collaborative action to improve peoples health and wellbeing. And yet food companies primary obligation is to drive profit by selling food. Why does the global health community find this acceptable and how do these conflicts of interest play out? Indeed, while problems of obesity and associated disease are dominating discussions and debates in health around the world, theres a concomitant gulf of critical perspectives on the food industrys role and competing interests. Despite PLoS Medicines longstanding interest in the tobacco, pharmaceutical, and other industries in health, for example, we have paid relatively little attention to the activities and influence of food and beverage companies: just two articles in 2007 [6,7] and a recent editorial on the alcohol industry [8]. Searching PubMed, only an additional seven articles examining any aspect of the food industry have been published in the major general medical journals over the past 10 years. According to Marion Nestle, these issues have been known and discussed (though not always acted upon) within the nutrition community for decades, which makes the lack of attention in the medical literature even more disappointing. In fact, Nestles 2002 book Food Politics: How the Food Industry Influences Nutrition and Health is prescient in documenting a laundry list of Big Food misdeeds that are only receiving

more widespread attention now: aggressive lobbying of regulators and governments, co-opting domestic and international nutrition experts, deceptive and illegal marketing to children, tactical targeting of minorities and emerging economies, and undisclosed conflicts of interest, among others, resulting in her conclusion 10 years ago that the food industry plays politics better than anyone [9]. More recent evidence confirms that Big Food and Big Alcohol are mimicking (and learning from) the tactics of Big Tobacco [8,1013]. In recognition, a bold move by Journal of Public Health Policy discourages studies of individual eating and activity [14,15] because, as the editors state, they have come to believe that research studies concentrating on personal behavior and responsibility as causes of the obesity epidemic do little but offer cover to an industry seeking to downplay its own responsibility. The PLoS Medicine series on Big Food is a sampler, offering perspectives on select topics relevant to how the food industry operates in health. In this first week the guest editors lay out a background and three competing views of how public health professionals can respond [1], and Lori Dorfman and her colleagues [16] compare soda companies corporate social responsibility (CSR) campaigns with those of the tobacco industry, demonstrating how CSR deftly shifts responsibility for overconsumption from corporations to individuals, forestalls regulation, and pro-

Citation: The PLoS Medicine Editors (2012) PLoS Medicine Series on Big Food: The Food Industry Is Ripe for Scrutiny. PLoS Med 9(6): e1001246. doi:10.1371/journal.pmed.1001246 Published June 19, 2012 Copyright: 2012 PLoS Medicine Editors. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The authors are each paid a salary by the Public Library of Science, and they wrote this editorial during their salaried time. Competing Interests: The authors individual competing interests are at http://www.plosmedicine.org/static/ editorsInterests.action. PLoS is funded partly through manuscript publication charges, but the PLoS Medicine Editors are paid a fixed salary (their salary is not linked to the number of papers published in the journal). * E-mail: [email protected] The PLoS Medicine Editors are Virginia Barbour, Jocalyn Clark, Paul Simpson, and Emma Veitch. PS was on leave when this editorial was written. Provenance: Written by editorial staff; not externally peer reviewed.

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motes brand loyalty and sales. In subsequent weeks we will publish analyses of the rapid rise of Big Food sales in developing countries, an essay on food sovereignty and who holds power over food, and two perspectives from South America and Africa on the displacement of traditional diets by the incursion of multinational food companies. We decided not to provide a forum for the industry to offer a perspective on their role in global health, since this point of view has been covered many times before [1720] and fails to acknowledge their role in subverting the public health agenda, thus ignoring the deeper issues that this series aims to uncover. While our series does include perspectives from several countries around the world (including Brazil, South Africa, the

UK, and the US), our series is not as regionally diverse as would be ideal. When commissioning we had a difficult time finding authors in the developing world who had not already established links with food companies (thus disqualifying them from contributing to the series, per our Magazine competing interests policy), which might be more evidence for concerns about co-opting of international nutrition experts. The series is not comprehensive in highlighting all the relevant issues but should signal to readers our interest in considering further original research and commentary on additional areas to do with the food industry in health, including marketing to children, litigation, regulatory efforts, the impact of agriculture systems, solutions to obesity and noncom-

municable diseases, and the growth and spread of markets in emerging economies. Clearly issues of nutrition and diet are key to human health and to the health of the planet. We look forward to continuing to be part of the dialogue and invite readers to join the debate via twitter (hashtag #plosmedbigfood) and to comment on the articles, which will be published over three weeks and collected at http://www. ploscollections.org/bigfood.

Author ContributionsWrote the first draft of the manuscript: JC. Contributed to the writing of the manuscript: VB JC EV. ICMJE criteria for authorship read and met: VB JC EV. Agree with manuscript results and conclusions: VB JC EV.

References1. Stuckler D, Nestle M (2012) Big Food, Food Systems, and Global Health. PLoS Med 9: e1242. doi:10.1371/journal.pmed.1001242. 2. Patel R (2008) Stuffed and Starved: The Hidden Battle for the World Food System. Melville House. 448 p. 3. Cohen D (2011) Will Industry Influence Derail the UN Summit? BMJ 343:d5328. http://www. bmj.com/content/343/bmj.d5328.full 4. TEDxChange (September 2010) Melinda French Gates: What Nonprofits Can Learn from CocaCola. Available: http://www.ted.com/talks/ melinda_french_gates_what_nonprofits_can_ learn_from_coca_cola.html. Accessed 14 May 2012. 5. Freedhoff Y, Hebert PC (2011) Partnerships between Health Organizations and the Food Industry Risk Derailing Public Health Nutrition. CMAJ 183: 291292. doi:10.1503/cmaj.110085. 6. Lesser L, Ebbeling CB, Goozner M, Wypij D, Ludwig DS (2007) Relationship between Funding Source and Conclusion among Nutrition-Related Scientific Articles. PLoS Med 4: e5. doi:10.1371/ journal.pmed.0040005. 7. Katan MB (2007) Does Industry Sponsorship Undermine the Integrity of Nutrition Research? PLoS Med 4: e6. doi:10.1371/journal.pmed. 0040006. 8. The PLoS Medicine Editors (2011) Lets Be Straight Up about the Alcohol Industry. PLoS Med 8: e1001041. doi:10.1371/journal.pmed. 1001041. 9. Nestle M (2002) Food Politics: How the Food Industry Influences Nutrition and Health. Berkeley: University of California Press. 10. Brownell K, Warner KE (2009) The Perils of Ignoring History: Big Tobacco Played Dirty and Millions Died. How Similar Is Big Food? Milbank Quarterly 87: 259294. 11. Chopra M, Darnton-Hill I (2004) Tobacco and Obesity Epidemics: Not So Different After All? BMJ 328: 15581560. 12. Ludwig D, Nestle M (2008) Can the Food Industry Play a Constructive Role in the Obesity Epidemic? JAMA 300: 18081811. 13. Wiist W (2011) The Corporate Playbook, Health, and Democracy: The Snack Food and Beverage Industry Industrys Tactics in Context. In: Stuckler D, Siegel, K, editor. Sick Societies: responding to the global challenge of chronic disease. Oxford: Oxford University Press. 14. Robbins A, Nestle M (2011) Obesity as Collateral Damage: A Call for Papers on the Obesity Epidemic. J Public Health Policy 32: 143145 15. Journal of Public Health Policy (2011) Special Issue Section: Food and Obesity Collection. Available: http://www.palgrave-journals.com/ jphp/collections/food_and_obesity_collection. html. Accessed 14 May 2012. Dorfman L, Cheyne A, Friedman LC, Wadud A, Gottlieb M (2012) Soda and Tobacco Industry Corporate Social Responsibility Campaigns: How Do They Compare? PLoS Med 9: e1241. doi:10.1371/journal.pmed.1001241. Yach D, Feldman ZA, Bradley DG, Khan M (2010) Can the Food Industry Help Tackle the Growing Burden of Undernutrition? Am J Public Health 100: 974980. Alexander E, Yach D, Mensah GA (2011) Major Multinational Food and Beverage Companies and Informal Sector Contributions to Global Food Consumption: Implications for Nutrition Policy. Global Health 7: 26. doi:10.1186/17448603-7-26. Yach D (2011) Nutritional Change Is Not a Simple Answer to Non-Communicable diseases. BMJ 343. doi:10.1136/bmj.d5097. Acharya T, Fuller AC, Mensah GA, Yach D (2011) The Current and Future Role of the Food Industry in the Prevention and Control of Chronic Diseases: The Case of PepsiCo. In: Stuckler D, Siegel, K, editor. Sick Societies: Responding to the global challenge of chronic disease. Oxford: Oxford University Press.

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Essay

Big Food, Food Systems, and Global HealthDavid Stuckler1,2*, Marion Nestle3,41 Department of Sociology, University of Cambridge, Cambridge, United Kingdom, 2 Department of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom, 3 Department of Nutrition, Food Studies, and Public Health, New York University, New York, New York, United States of America, 4 Department of Nutritional Sciences, Cornell University, Ithaca, New York, United States of America

This article was commissioned for the PLoS Medicine series on Big Food that examines the activities and influence of the food and beverage industry in the health arena. As the PLoS Medicine series on Big Food (www.ploscollections.org/bigfood) kicks off, lets begin this Essay with a blunt conclusion: Global food systems are not meeting the worlds dietary needs [1]. About one billion people are hungry, while two billion people are overweight [2]. India, for example, is experiencing rises in both: since 1995 an additional 65 million people are malnourished, and one in five adults is now overweight [3,4]. This coexistence of food insecurity and obesity may seem like a paradox [5], but overand undernutrition reflect two facets of malnutrition [6]. Underlying both is a common factor: food systems are not driven to deliver optimal human diets but to maximize profits. For people living in poverty, this means either exclusion from development (and consequent food insecurity) or eating low-cost, highly processed foods lacking in nutrition and rich in sugar, salt, and saturated fats (and consequent overweight and obesity). To understand who is responsible for these nutritional failures, it is first necessary to ask: Who rules global food systems? By and large its Big Food, by which we refer to multinational food and beverage companies with huge and concentrated market power [7,8]. In the United States, the ten largest food companies control over half of all food sales [9] and worldwide this proportion is about 15% and rising. More than half of global soft drinks are produced by large multinational companies, mainly CocaCola and PepsiCo [10]. Three-fourths of world food sales involve processed foods, for which the largest manufacturers hold over a third of the global market [11]. The worlds food system is not a competitive marketThe Essay section contains opinion pieces on topics of broad interest to a general medical audience.

place of small producers but an oligopoly. What people eat is increasingly driven by a few multinational food companies [12]. Virtually all growth in Big Foods sales occurs in developing countries [13] (see Figure 1). The saturation of markets in developed countries [14], along with the lure of the 20% of income people spend on average on food globally, has stimulated Big Food to seek global expansion. Its rapid entry into markets in low- and middleincome countries (LMICs) is a result of mass-marketing campaigns and foreign investment, principally through takeovers of domestic food companies [15]. Trade plays a minimal role and accounts for only about 6% of global processed food sales [15]. Global producers are the main reason why the nutrition transition from traditional, simple diets to highly processed foods is accelerating [16,17]. Big Food is a driving force behind the global rise in consumption of sugarsweetened beverages (SSBs) and processed foods enriched in salt, sugar, and fat [13]. Increasing consumption of Big Foods products tracks closely with rising levels of obesity and diabetes [18]. Evidence shows that SSBs are major contributors to childhood obesity [19,20], as well as to long-term weight-gain, type 2 diabetes, and cardiovascular disease [21,22]. Studies also link frequent consumption of highly processed foods with weight gain and associated diseases [23]. Of course, Big Food may also bring benefitsimproved economic performance through increased technology and know-how and reduced risks of undernu-

tritionto local partners [24]. The extent of these benefits is debatable, however, in view of negative effects on farmers and on domestic producers and food prices [25].

Public Health Response to Big Food: A Failure to ActPublic health professionals have been slow to respond to such nutritional threats in developed countries and even slower still in developing countries. Thanks to insights from tobacco company documents, we have learned a great deal about how this industry sought to avoid or flout public health interventions that might threaten their profits. We now have considerable evidence that food and beverage companies use similar tactics to undermine public health responses such as taxation and regulation [26,27,28,29], an unsurprising observation given the flows of people, funds, and activities between Big Tobacco and Big Food. Yet the public health response to Big Food has been minimal. We can think of multiple reasons for the failure to act [30]. One is the belated recognition of the importance of obesity to the burden of disease in LMICs [13]. The 2011 Political Declaration of the United Nations High-Level Meeting on Prevention and Control of Non-communicable Diseases (NCDs) recognized the urgent case for addressing the major avoidable causes of death and disability [31], but did not even mention the roles of agribusiness and processed foods in obesity. Despite evidence to the contrary, some development

Citation: Stuckler D, Nestle M (2012) Big Food, Food Systems, and Global Health. PLoS Med 9(6): e1001242. doi:10.1371/journal.pmed.1001242 Published June 19, 2012 Copyright: 2012 Stuckler, Nestle. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: No specific funding was received for writing this article. Competing Interests: MN and DS are the guest editors of the PLoS Medicine series on Big Food. Abbreviations: LMIC, low- and middle-income country; SSB, sugar-sweetened beverage * E-mail: [email protected] Provenance: Commissioned; not externally peer reviewed.


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Engaging with Big FoodThree ViewsWe see three possible ways to view this debate. The first favors voluntary selfregulation, and requires no further engagement by the public health community. Those who share this view argue that market forces will self-correct the negative externalities resulting from higher intake of risky commodities. Informed individuals, they say, will choose whether to eat unhealthy foods and need not be subjected to public health paternalism. On this basis, UN secretary-general Ban Ki Moon urged industry to be more responsible: I especially call on corporations that profit from selling processed foods to children to act with the utmost integrity. I refer not only to food manufacturers, but also the media, marketing and advertising companies that play central roles in these enterprises [35]. Similarly, the UK Health Minister recently said: the food and drinks industry should be seen, not just as part of the problem, but part of the solutionAn emphasis on prevention, physical activity and personal and corporate responsibility could, alongside unified Government action, make a big difference [36]. The second view favors partnerships with industry. Public health advocates who hold this view may take jobs with industry in order to make positive changes from within, or actively seek partnerships and alliances with food companies. Food, they say, is not tobacco. Whereas tobacco is demonstrably harmful in all forms and levels of consumption, food is not. We can live without tobacco, but we all must eat. Therefore, this view holds that we must work with Big Food to make healthier products and market them more responsibly. The third approach is critical of both. It recognizes the inherent conflicts of interest between corporations that profit from unhealthy food and public health collaborations. Because growth in profit is the primary goal of corporations, self-regulation and working from within are doomed to fail. Most proponents of this viewpoint support public regulation as the only meaningful approach, although some propose having public health expert committees set standards and monitor industry performance in improving the nutritional quality of food products and in marketing the products to children. We support the critical view, for several reasons. First, we find no evidence for an alignment of public health interest in curbing obesity with that of the food and beverage industry. Any partnership must create profit for the industry, which2

Figure 1. Growth of Big Food and Big Tobacco sales in developing countries: An example. Shaded blue line is developed countries, dashed grey line is developing countries. Source: Passport Global Market Information Database: EuroMonitor International, 2011 [12]. doi:10.1371/journal.pmed.1001242.g001

agencies continue to view obesity as a disease of affluence and a sign of progress in combating undernutrition [32]. A more uncomfortable reason is that action requires tackling vested interests, especially the powerful Big Food companies with strong ties to and influence over national governments. This is difficult terrain for many public health scientists. It took five decades after the initial studies linking tobacco and cancer for effective public health policies to be put in place, with enormous cost to human health. Must we wait five decades to respond to the similar effects of Big Food? If we are going to get serious about such nutritional issues, we must make choices about how to engage with Big Food. Whether, and under what circumstances, we should view food companies as partners or as part of the solution to rising rates of obesity and associated chronic diseases is a matter of much current debate, as indicated by the diverse views of officials of PepsiCo and nutrition scientists [24,27,28,33,34].PLoS Medicine | www.plosmedicine.org

has a legal mandate to maximize wealth for shareholders. We also see no obvious, established, or legitimate mechanism through which public health professionals might increase Big Foods profits. Big Food attains profit by expanding markets to reach more people, increasing peoples sense of hunger so that they buy more food, and increasing profit margins through encouraging consumption of products with higher price/cost surpluses [2831,37]. Industry achieves these goals through food processing and marketing, and we are aware of no evidence for health gains through partnerships in either domain. Although in theory minimal processing of foods can improve nutritional content, in practice most processing is done so to increase palatability, shelf-life, and transportability, processes that reduce nutritional quality. Processed foods are not necessary for survival, and few individuals are sufficiently well-informed or even capable of overcoming marketing and cost hurdles [38]. Big Food companies have the resources to recruit leading nutritional scientists and experts to guide product development and reformulation, leaving the role of public health advisors uncertain. To promote health, industry would need to make and market healthier foods so as to shift consumption away from highly processed, unhealthy foods. Yet, such healthier foods are inherently less profitable. The only ways the industry could preserve profit is either to undermine public health attempts to tax and regulate or to get people to eat more healthy food while continuing to eat profitable unhealthy foods [33,39]. Neither is desirable from a nutritional standpoint. Whereas industry support for research might be seen as one place to align interests, studies funded by industry are 4- to 8-fold more likely to support conclusions favorable to the industry [40]. Our second reason to support the critical view has to do with the precautionary principle [41]. Because it is unclear whether inherent conflicts of interest can be reconciled, we favor proceeding on the basis of evidence. As George Orwell put it, saints should always be judged guilty until they are proved innocent. We believe the onus of proof is on the food industry. If food companies can rigorously and independently establish self-regulation or privatepublic partnerships as improving both health and profit, these methods should be extended and replicated. But to date self-regulation has largely failed to meet stated objectivesJune 2012 | Volume 9 | Issue 6 | e1001242

[42,43,44,45,46,47], and instead has resulted in significant pressure for public regulation. Krafts decision to ban trans fats, for example, occurred under pressure of lawsuits [48]. If industry believed that self-regulation would increase profit, it would already be regulating itself. We believe the critical view has much to offer. It is a model of dynamic and dialectic engagement. It will increase pressures on industry to improve health performance, and it will encourage those who are sympathetic to the first or second views to effect change from within large food and beverage companies.

Public health professionals must recognize that Big Foods influence on global food systems is a problem, and do what is needed to reach a consensus about how to engage critically. The Conflicts of Interest Coalition, which emerged from concerns about Big Foods influence on the U.N. High-Level Meeting on NCDs, is a good place to start [29,49]. Public health professionals must place as high a priority on nutrition as they do on HIV, infectious diseases, and other disease threats. They should support initiatives such as restrictions on marketing to children, better nutrition standards for school meals, and taxes on

SSBs. The central aim of public health must be to bring into alignment Big Foods profit motives with public health goals. Without taking direct and concerted action to expose and regulate the vested interests of Big Food, epidemics of poverty, hunger, and obesity are likely to become more acute.

Author ContributionsAnalyzed the data: DS. Wrote the first draft of the manuscript: DS. Contributed to the writing of the manuscript: DS MN. ICMJE criteria for authorship read and met: DS MN. Agree with manuscript results and conclusions: DS MN.

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Wilde P (2009) Self-regulation and the response to concerns about food and beverage marketing to children in the United States. Nutr Rev 67: 155 166. 40. Lesser L, Ebbeling CB, Goozner M, Wypij D, Ludwig DS (2008) Relationship between funding source and conclusion among nutrition-related scientific articles. PLoS Med 4: e5. doi:10.1371/ journal.pmed.0040005. 41. Raffensperger C, Tickner J (1999) Protecting public health and the environment: implementing the precautionary principle. Washington D.C.: Island Press. 42. Lewin A, Lindstrom L, Nestle M (2006) Food industry promises to address childhood obesity: Preliminary evaluation. J Public Health Policy 27: 327348. 43. Lang T (2006) The food industry, diet, physical activity and health: A review of reported commitments and prctice of 25 of the worlds largest


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food companies. London: Oxford Health Alliance. 44. Sharma L, Teret SP, Brownell KD (2010) The food industry and self-regulation: Standards to promote success and to avoid public health failures. Am J Public Health 100: 240246. 45. Bonell C, McKee M, Fletcher A, Haines A, Wilkinson P (2011) The nudge smudge: misrepresentation of the nudge concept in Englands public health White Paper. Lancet 377: 21582159.

46. Campbell D (2012) High street outlets ignoring guidelines on providing calorie information. The Guardian. London. Available: http://www. guardian.co.uk/business/2012/mar/15/highstreet-guidelines-calorie-information 47. Hawkes C, Harris JL (2011) An analysis of the content of food industry pledges and marketing to children. Public Health Nutr 14: 14031414. 48. Zernike K (2004) Lawyers shift focus from Big Tobacco to Big Food. New York Times. New

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Essay

Food Sovereignty: Power, Gender, and the Right to FoodRajeev C. Patel*School of Development Studies, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa

This article was commissioned for the PLoS Medicine series on Big Food that examines the activities and influence of the food and beverage industry in the health arena.

Power over FoodOne of the most enduring misconceptions about hunger is that it is primarily the result of a deficit in global food production. If this were so, we might expect food to be absent at times and in places where people die of hunger. Yet economist Amartya Sen has shown that in the majority of cases of widespread famine-related death since WWII, food has been available within the famineaffected area. People have died not for want of food, but for want of the entitlement to eat it [1]. Questions about hunger and its attendant pathologies, therefore, ought to begin with questions about social and political configurations around power over food, rather than about the mere presence or absence of food in the vicinity of a hungry individual. Although no single commonly agreed definition of hunger exists, two common standards prevail: undernourishment and food security. The former refers to the number of people whose dietary energy consumption is continuously below a minimum dietary energy requirement for maintaining a healthy life and carrying out a light physical activity [2]. Undernourishment is a condition suffered by individuals. It is, however, usually established not through individual surveys but through an analysis of a countrys food availability, household purchasing power, and entitlements [3,4]. Current estimates put the worldwide number of undernourished people at nearly one billion [3]. The concept of food security attempts to capture the notion of hunger as a deficit not of calories, but as a violation of a broader set of social, economic, andThe Essay section contains opinion pieces on topics of broad interest to a general medical audience.

physical conditions. In 1996, the Food and Agriculture Organization of the United Nations (FAO) established at its World Food Summit the most widely agreed definition [5] that Food security, at the individual, household, national, regional and global levels [is achieved] when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life. By definition, more people are food insecure than are undernourished, and food insecurity precedes undernourishment. Although there are few people in the United States whose calorie intake is continuously below the threshold of a maintaining healthy life, there are many who, at some point during any given year, are unable to meet their food needs. According to the United States Department of Agriculture (USDA), in 2010 there were 48.8 million US citizens living in food-insecure households. The distribution of food insecurity is uneven. In the US, 21.6 million children lived in foodinsecure households, and 35.1% of all female-headed households were food insecure in 2010, compared to 25.4% of maleheaded households [6]. Since food insecurity is a broader measure than that of undernourishment, it has been correlated both with hunger and obesity, particularly among women [7]. If hunger is a symptom of a lack of control over the socioeconomic context in

which one attempts to eat, it is not unreasonable to understand that lack of control as correlated with factors associated with obesity too. It is possible to have sufficient calories, but insufficiently nutritious food for a healthy life. Armed with this understanding, and with persistent evidence across countries of women and girls disempowerment compared to men and boys [8], it becomes easier to appreciate the systematically higher rates of food insecurity among women.

Gender and FoodThe link between gender and food becomes clearer through an understanding of power and control in the food system. Giving away food does little to address the underlying causes of disempowerment that lead to hunger [9]. One group that has articulated this is an international peasant movement called La Via Campesina (see Box 1). They argue that if governments aim merely for food security as a policy goal, the politically difficult questions of inequality in power that produced food insecurity would be ignored, and a broken system would be patched up with entitlements [1]. It is possible, after all, to be food secure in prison where one might continually access safe and nutritious food, yet remain fundamentally disempowered over the process and politics of the foods production, consumption, and distribution. Instead of food security, Via Campesina has advocated for food sovereignty. Just like the definition of food security, food

Citation: Patel RC (2012) Food Sovereignty: Power, Gender, and the Right to Food. PLoS Med 9(6): e1001223. doi:10.1371/journal.pmed.1001223 Published June 26, 2012 Copyright: 2012 Rajeev C. Patel. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: No specific funding was received to write this article. Competing Interests: RP is both a Fellow at the Institute for Food and Development Policy, and a Fellow of the Institute for Agriculture and Trade Policys (IATP) Food And Community Fellowship program. This program is funded, in part, by the W. K. Kellogg Foundation though fellows are appointed by IATP. RP has no relationship with La Via Campesina. Abbreviations: FAO, Food and Agriculture Organization of the United Nations; NCD, non-communicable disease; USDA, United States Department of Agriculture; WTO, World Trade Organization * E-mail: [email protected] Provenance: Commissioned; externally peer reviewed.


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Summary Points

N N N N N

Understanding hunger and malnutrition requires an examination of what systems and institutions hold power over food. The concept of food security captures the notion of hunger not as a deficit of calories, but as a violation of a broader set of social, economic, and physical conditions. Gender is key to food insecurity and malnourishment, because women and girls are disproportionately disempowered through current processes and politics of foods production, consumption, and distribution. La Via Campesina has advocated for food sovereignty, through which communities have the right to define their own food and agriculture policy. Womens rights are central elements to food sovereignty. The role of the food industry demands attention within the food system, where power is concentrated in the hands of a few corporations.

sovereignty is an evolving and manyfaceted term, but it has an invariant core: communities have the right to define their own food and agriculture policy [10]. To be clear, sovereignty is not a call for self-sufficiency, for states to grow within their borders sufficient food to feed their citizens. La Via Campesina instead calls for people to be sovereign over their food systems, for people to have the power to decide what the system should look like. This is an intentionally vague call, with many questions left open-ended, so that the communities involved in claiming food sovereignty might answer issues around production, distribution, and consumption of food for themselves. It is through food sovereignty, La Via Campesina argues, that food security might be achieved, and undernourishment eradicated. The main demand in food sovereignty is that, for the first time, decisions about the shape of the food system ought to be in the hands not of powerful corporations or geopolitically dominant governments [11],

but up to the people who depend on the food system. For the discussion to be representative of the communitys desires, however, a non-negotiable element of food sovereignty is womens rights. In order for a democratic conversation about food and agriculture policy to happen, women need to be able to participate in the discussion as freely as men. Peasant movements, and those who support them, have been castigated as romantics pining for an unattainable past [12]. An insistence of womens rights places food sovereignty firmly in the twenty-first century. This has a practical purpose. Of those undernourished, 60% are women or girls [13]. It is hard to conceive a discussion about hunger without connecting the epidemiology of hunger to womens disempowerment. On the production side of the food system, women constitute 43% of the agricultural workforce, more often involved in producing food for domestic consumption than export. They are dis-

criminated against in issues ranging from land tenure to wages, from government support to access to technology. The FAO notes that if women had the same access to productive resources as men, they could increase yields on their farms by 2030 percent. This could raise total agricultural output in developing countries by 2.54 percent, which could in turn reduce the number of hungry people in the world by 1217 percent [14]. In addition, women stand to bear a disproportionate burden of the consequences of the twenty-first centurys predicted global increase in non-communicable disease (NCD) prevalence. In South Asia, for example, NCDs are projected to account for 72% of deaths by 2030, up from 51% in 2008. In Sub-Saharan Africa, the estimates are 46%, up from 28% over the same period [15]. In addition to the duties of paid work, women bear a disproportionate burden of care work in the management of morbidity associated with NCDs [16,17], especially in contexts of poverty [18]. These are the kinds of inequities to which food sovereignty calls attention.

Systemic Inequity and the Right to FoodBeyond an examination of the inequitable distribution of power at a household level, food sovereignty suggests an investigation of power relations at meso- and macroeconomic levels. La Via Campesina members are, for example, concerned about corporate power within the global economy. The food systems dysfunction continues to be lucrative for a range of food and agriculture companies. Profits often derive from the increased consumption of processed food, which in turn have driven a global obesity epidemic. Yet the distribution mechanisms within the food system that ration food on the basis of ability to pay have produced the paradox of a billion hungry during a time when there are more than 1.5 billion people overweight [19,20]. Within the food system, power is concentrated in the hands of a few corporations. In 2008, the top ten agrochemical corporations controlled almost 90% of the global sales of pesticides. Of the US$22 billion global proprietary seed market, only ten corporations controlled 67% [21]. In 2005, the top four beef packing firms controlled 83.5% of the market in the US [22], and worldwide, 40% of all groceries were sold by only 100 retailers [21]. These trends across the food industry have been on an almost-steadyJune 2012 | Volume 9 | Issue 6 | e1001223

Box 1. La Via CampesinaLa Via Campesina is an organization of farmers, peasants, and landless workers movements with over 150 million combined members in 70 countries [46]. Its first meeting was held in 1993, and it was constituted as an umbrella organization for a range of social movements that had, through the 1980s, begun to work more closely in Asia, the Americas, and Europe. These movements had come into contact with one another through their attempts to understand, resist, and offer alternatives to free market agricultural trade. Even before the organization was officially created, La Via Campesinas member organizations had undertaken a range of actions to confront what they saw as inequality in power within the food system. In India, 200,000 farmers protested the patenting of seeds by multinational corporations. In Europe, 30,000 farmers marched on Brussels to offer an alternative policy goal to the achievement of food security. In Brazil, hundreds of thousands of people occupied farmland, upon which they built thriving communities. In 1996, at the same World Food summit at which the most recent definition of food security was written, La Via Campesina codified its vision for an alternative food system under the rubric of food sovereignty. At a 2009 La Via Campesina meeting, one of the slogans offered by the assembly was that food sovereignty is an end to all forms of violence against women.


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climb since they were recorded first in the 1970s. As the US government recently found, for example, in the pork sector, the market share of the largest four hog slaughtering firms increased from 36 percent in 1982 to 63 percent in 2006. In addition, at the retail level, the share of grocery store sales held by the largest four firms more than doubled, from 16 percent in 1982 to 36 percent in 2005 [23]. This concentration of power has gendered consequences. In contexts where women perform the majority of horticultural and agronomic innovation, they can find their agroecological knowledge supplanted by the technologies of industrial agriculture. Pesticide companies own the largest seed companies, and their agricultural model, dependent on purchased supplies of hybrid seeds and chemical inputs, favors larger, more capital-intensive farms. Women have systematically less access to both land and capital than men, and despite an often sophisticated level of knowledge about farming systems, womens views seldom matter in the shaping of choices around agricultural technologies and food policy [24]. In addition, employment within agriculture consistently pays women around 25% less than men. When food is accessed through market mechanisms, this increases womens systemic risk of hunger [25]. It is for these reasons that women leaders within peasant movements have taken strong stands against multinational corporations such as Monsanto and Cargill [26]. To be sure, concentration of agricultural power is not new. At the turn of the nineteenth century, four firmsDreyfus, Cargill, Continental, and Bungedominated global grain trading [27]. Today, however, the extent to which food markets matter is far greater. Agricultural market concentration is evident not only in international trade, but across domestic production, distribution, and consumption. This concentration matters more when there are fewer alternatives to the markets in which concentration occurs.

The Role of Markets and GovernmentsTo understand why the private sector has achieved such power, it is worth

looking at other actors roles within the food system. Philanthropic foundations have, for example, been responsible for advancing the kinds of industrial agriculture that has imperiled La Via Campesinas members [28,29]. The Green Revolution, in which farmers were encouraged and sometimes forced by governments to adopt a system of farming involving hybrid seeds, fertilizer, and pesticides, was initially funded by the Rockefeller and Ford Foundations, and is currently being encouraged by the Gates Foundation in Africa [30,31,32]. These farming systems have had gender-negative impacts, as womens knowledge is excluded, and women are systematically less able to control the capital required to participate in resource-intensive farming [33,34,35]. National governments and international organizations have also been faulted for their behavior in shaping the food system. Of particular interest to La Via Campesina is the extent to which, through international economic agreements such as the World Trade Organizations (WTOs) Agreement on Agriculture, governments have enabled private sector markets to expand their influence within the food system. A central demand in La Via Campesinas call for food sovereignty is for the WTO to get out of agriculture [36]. By this they mean not only ought the Agreement on Agriculture within the WTO be nullified, but that a range of other WTO provisions that affect agriculture, such as rules on intellectual property rights on seeds and phytosanitary measures, also be suspended. Trade agreements rules are influenced by the corporations that subsequently benefit from them [37], with demonstrated gendered impacts as a result [38,39]. Food corporations continue to attempt to shape domestic and international public policy. PepsiCo, for instance, has gone to great lengths to claim a place at the table in addressing public health issues [40]. Yet the company has since 2000 spent US$26.88 million on lobbying in the US [41], in particular in response to taxes on its products and voicing its concerns on restrictions on marketing its foods to

children [42,43]. PepsiCos behavior is emblematic of a wider trend in private sector spending within the food system. In a context of shrinking public budgets, and the transformation of public institutions such as schools into sites for the sale of obesogenic products [44], the influence of private interest in public policy matters immensely. Yet the food industry is pushing public debate toward an interpretation of the rise of NCDs as fundamentally a problem of individuals [45]. To accept this is to urge a policy response in which NCDs can be remedied by better individual behavior, rather than more regulation. With women more responsible than men for childrens diets, this has the effect of pathologizing individual women, rather than finding fault with a system that removes their freedom to make their childrens diets healthier.

ConclusionThe inequalities in power that characterize the food system can be found in households, corporations, regional and state governments, private philanthropic foundations, and international organizations. The strengths of a food sovereignty approach lie in the heuristic approach to power relations that it invites, particularly with respect to gender. For La Via Campesina, and many others, identifying inequities in power within the global food system is more than an academic exerciseit is a means not only to interpret the system, but also to change it.

AcknowledgmentsThe author gratefully acknowledges invaluable comments from Maninder Kahlon and the research support of Meredith Palmer.

Author ContributionsWrote the first draft of the manuscript: RP. Contributed to the writing of the manuscript: RP. ICMJE criteria for authorship read and met: RP. Agree with manuscript results and conclusions: RP.

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Essay

The Impact of Transnational Big Food Companies on the South: A View from BrazilCarlos A. Monteiro1*, Geoffrey Cannon1,2 o Paulo, Brazil, 2 Editor, World Nutrition, World Public Health 1 Center for Epidemiological Studies in Health and Nutrition, School of Public Health, University of Sa Nutrition Association, Rio de Janeiro, Brazil

This article was commissioned for the PLoS Medicine series on Big Food that examines the activities and influence of the food and beverage industry in the health arena.

Summary Points

N N N N N

IntroductionThroughout human history, traditional food systems and dietary patterns have been intrinsic to social, cultural, and economic life, and to personal, community, and national identity. Although these long-established dietary patterns are rarely if ever nutritionally ideal, they are linked with low rates of obesity and chronic diseases, and can be readily improved by modifications that respect tradition and culture, and national and local resources. However, the policies and practices of transnational food and drink corporations (see Box 1), most of whose products are ultra-processed and whose headquarters are almost invariably in the US and Europe, are now steadily displacing traditional food systems around the world. This process of displacement is not merely commercial, it is also ideological. Economic globalization, systematic privatization, and minimally regulated international capital flow have all shifted the balance between governments and corporations. Governments and international institutions now tend to cede their prime duty to protect the public interest to vast transnational corporations whose primary responsibility is to their shareholders. The prevailing political, economic, and commercial policies and practices have also given these corporations freedom to expand across borders [1]. Consequently, the leading food and drink product

Traditional long-established food systems and dietary patterns are being displaced in Brazil and in other countries in the South (Africa, Asia, and Latin America) by ultra-processed products made by transnational food corporations (Big Food and Big Snack). This displacement increases the incidence of obesity and of major chronic diseases and affects public health and public goods by undermining culture, meals, the family, community life, local economies, and national identity. The penetration of transnational companies into Brazil has been rapid, but the tradition of shared and family meals remains strong and is likely to provide protection to national and regional food systems. The Brazilian government, under pressure from civil society organizations, has introduced legislation to protect and improve its traditional food system; by contrast, the governments of many industrialized countries have partly ceded their prime duty to protect public health to transnational companies. The experience of countries in the South that still retain traditional food systems provides a rational basis for policies that protect public health.

corporations are now colossal concerns. Their brands sell throughout the world in outlets that range from large supermarkets to filling stations, and from restaurants to kiosks. The individual annual revenue of the largest corporations is as high as the annual gross domestic product (GDP) of middle-size countries [28] and, unlike many national governments, these corporations are able to plan strategically and to divert or invest billions in new technologies and markets.

Big Food corporations now claim that they work in the public as well as the private interest, and even that they are in the business of protecting public health. For example, according to executives working for PepsiCo, food and drink transnationals penetrating emerging markets can at the same time support low- and middle-income countries, helping them to eliminate hunger and undernutrition and to prevent and control obesity and non-communicable diseases

Citation: Monteiro CA, Cannon G (2012) The Impact of Transnational Big Food Companies on the South: A View from Brazil. PLoS Med 9(7): e1001252. doi:10.1371/journal.pmed.1001252 Published July 3, 2012 Copyright: 2012 Monteiro, Cannon. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: No specific funding was received for writing this article. Competing Interests: Since 1993 GC has worked for the World Cancer Research Fund International and the American Institute for Cancer Research (both not-for-profit organisations). He is an honorary Council member of the World Public Health Nutrition Association, its Publications Secretary, and editor of its journal World Nutrition. GC was an advisor to the Brazilian federal government in the period 20002002 when he worked within its Ministry of Health, and also occasionally for UN agencies including WHO. GC has occasionally advised the food and beverage industry, but not since 2007 when he advised PepsiCo on the possibility of ethicallybased products using the products of Brazilian tropical fruits. CAM has acted as advisor to the Brazilian Ministry of Health and also for WHO. * E-mail: [email protected] Provenance: Commissioned; externally peer reviewed.

The Essay section contains opinion pieces on topics of broad interest to a general medical audience.


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Box 1. Big Food, Big Snack, and Ultra-Processed ProductsThe term Big Food refers to the transnational and other large corporations that increasingly control the production and distribution of ultra-processed products throughout the world. These products are created from substances extracted from whole foods such as the cheap parts or remnants of animals, inexpensive ingredients such as refined starches, sugars, fats and oils, preservatives, and other additives [34,35]. The products are formulated to be intensely palatable and to fool the bodys appetite control mechanisms [36,37]. Many of these products, while legal, are in effect fakes, made to look and taste like wholesome food. They are formulated and packaged to have a long shelf life and to eliminate the need for culinary preparation. They can be consumed anywhere, immediately or almost immediately, and often dispense with the need for tables, chairs, dishes, cutlery, and cups. They are therefore often termed fast or convenience products. Some ultra-processed products, such as breads and sausages, have been part of dietary patterns in many countries since before industrialization. Others, such as burgers, chips, cookies, sweets, nuggets, energy bars, and carbonated and other sugared or sweet drinks, are more recent, at least in the quantity now manufactured. Since the 1980s, Big Snackthe transnational manufacturers of packaged, long shelf-life snacks designed to displace mealshave greatly increased their penetration first of high-income countries, and now of lowerincome countries, including Brazil [21].

[9]. In our view, this claim is part of a damage limitation exercise, which is further eroding the duty of governments to protect public health and public goods [10]. The ongoing globalization, privatization, and deregulation of food systems and supplies may have relatively little impact on public health in high-income countries whose dietary patterns are already fully industrialized. But the displacement of traditional food systems in Africa, Asia, and Latin America (the South) by the fatty, sugary, or salty long-life ultraprocessed products marketed by transnational food and drink corporations, which has been increasing rapidly since the 1980s, has the potential to undermine public health by increasing the incidence of chronic diseases and obesity. We believe that the experience and situation of those countries in the South still retaining their traditional food systems provide a rational and reliable basis for the development of international public health policies related to food. In this essay, we describe the incursion of Big Food and Big Snack into the South, based upon our experiences in Brazil, a very large country that still retains, at least in part, its traditional food systems. We outline the nature of traditional Brazilian food systems and dietary patterns and the impact of the rapid penetration of the transnational food corporations into Brazil. We identify some implications of the partnerships between food corporations and public bodies. Finally, we propose ways to protect public health and public goods in Brazil and in other countries andPLoS Medicine | www.plosmedicine.org

regions that still retain traditional food systems and supplies.

Traditional Brazilian Dietary PatternsAnalyses of household food expenditure surveys conducted in Brazil over the past 40 years [1113] show that, in common with other Latin American countries, Brazil retains many long-established food systems and dietary patterns. These dietary patterns show the influences of native (Indian) populations, the countrys Portuguese colonizers, and African slaves and their descendants. Minimally processed food staples include rice, a variety of beans, and the root cassava (manioc). These staples form the basis of everyday main meals, and are made delicious and attractive by various methods of preparation and cooking, and by the addition of oils, seeds, leaves, herbs, and spices, some of which are rich in nutrients. (Wheat is not native to Brazil; processed wheat products such as breads, cakes, and biscuits followed relatively recent immigration of people from the Mediterranean region to the southern states of Brazil, and nationally were uncommon until well into the second half of the last century.) The amount of meat, fish, and other animal products in long-established Brazilian diets depends on availability, price, and income. In the past, these foods were usually eaten only in small amounts on a daily basis, and in large quantities only as part of feasts or other special occasions. All Brazilian cities have restaurants, bars, and popular canteens, where a good2

variety of locally sourced traditional Brazilian food is offered, often buffet-style and affordably priced on a per kilo basis. More importantly, meals prepared and eaten by the family at homeincluding the midday mealand therefore the habit of eating together, remain an integral part of the Brazilian way of life. Notwithstanding intense pressures, which include ubiquitous television and internet propaganda designed to turn eating and drinking into constant individual snacking [10], food and drink consumption is not yet dislocated and isolated from family and social life in Brazil. This is probably the most important factor protecting national and regional traditional food systems. It would be wrong, however, to romanticize Brazilian traditional food systems and dietary patternsthey are far from ideal. The influence of the seafaring Portuguese colonizers and the need to preserve animal foods by salting before the widespread availability of refrigeration mean that the typical Brazilian diet is high in salt, which has resulted in high rates of hypertension and stroke in the country [14]. The traditional diet is also sugary, the result of Brazil being for centuries the worlds largest producer of sugar, and of table sugar being the cheapest source of calories in the country. Further, while a variety of indigenous or established tropical fruits is consumed, commonly at breakfast or as desserts, consumption of green vegetables remains low, particularly among the lowest-income families. More positively, undernutrition is generally uncommon or rare at all stages of life and, as with many Asian, African, and other Latin American countries, rates of obesity in Brazil were low until the late 1970s [15].

Big Food and Big Snack Move InDuring our work on this essay, we went for lunch to a workers restaurant near the University of Sa o Paulo, where a traditional freshly cooked meal of rice, beans, and a choice of meat, together with mixed salad, cost the equivalent of $US 6. We noticed that the bottled water offered was made by a once Brazilian company now owned by Coca-Cola, and that the artisanal water-based ice lollies containing fruit juice, which are still sold by pedlars on Brazilian beaches and supplied by traders to simple restaurants, had been replaced by fatty, sugary brands of Nestle ice cream. These same ice creams, together with other Nestle popularly positioned products, which are targeted at and bought by low income consumers [16],July 2012 | Volume 9 | Issue 7 | e1001252

are now being sold door-to-door in the outskirts of several Brazilian cities, on trains and subway stations, in retail chains that sell electronic and house appliances, and also on floating supermarkets that take Nestle products to remote Amazonian villages [10]. Our experience in the workers restaurant illustrates how transnational food corporations are changing dietary patterns in Brazil. For these corporations, the move into emerging markets is necessary because the market for their ultra-processed convenience, meals, dishes, snacks, and drinks is already saturated in high-income countries [17]. Research we are undertaking suggests that in any country a saturation point is reached when ultraprocessed products supply around 60% of total calories, as has been the case in the UK [18] and in Canada and the US for the last two decades (unpublished data being prepared for publication). Indeed, in the US, consumption of sugared cola and other soft drinks is now declining from a very high peak [19], and transnational corporations have moved into designer water and soft drinks for which health claims can be made because the drinks have been reformulated to contain more substances chemically identical to micronutrients or the dietary fibre found in whole foods. The saturation of developed market economies with ultra-processed products may also explain why transnationals appear to be aiming for double-digit growthsales that increase by an annual 10% or morein the South. For instance, the growth of the Nestle line of popularly positioned products is up to 25% a year, and the market for these products in Asia, Africa, and Latin America is now estimated to be over CHF 80 billion, or a little over $US 87 billion [20]. In Brazil, the consumption of ultra-processed products has already risen from less than 20% of calories in the 1980s to 28% [21], but this figure is still well short of 60%, the possible saturation level. Similarly, the current prevalence of obesity in Brazil (14% among adults in 2009) [14], has some way to go before it reaches the levels seen in countries like the UK and the US (currently 24% and 34%, respectively) [22]. More generally, the opportunities for transnational food and drink corporations to increase the penetration of ultra-processed products in very highly populated countries such as India and China, where until recently most of the populations were rural and on very low incomes, are immense. In such countries, the strategiesPLoS Medicine | www.plosmedicine.org

these corporations are employing to introduce their products undermine and displace long-established traditional food systems. The impact is not only on nutrition and risk of disease. Snacking replaces meals. Commensal family and community life is undermined. Local food producers, distributors, retailers, and caterers are driven out of business. Social networks collapse. Regional and national culture and identity are eroded [2326]. Epidemic obesity and serious chronic diseases can be seen as an integral part of economic development. Thus, Kenneth Rogoff, a former chief economist at the International Monetary Fund, recently wrote that: Highly processed corn-based food products, with lots of chemical additives, are well known to be a major driver of weight gain, but, from a conventional growth-accounting perspective, they are great stuff [27]. Given the disability caused by obesity, and the attendant diabetes, heart disease, cancer, and other diseases that need lengthy and expensive treatment, we suggest that the concept of development needs revision.

PublicPrivate Food PartnershipsIt is now commonly agreed in UN, government, public health, and scientific circles that the prevention and control of noncommunicable chronic diseases can be achieved only by publicprivate partnerships, meaning collaborations with the private sector. However, this term does not refer to industry as a whole. It is code for the food, drink, and associated industries. Indeed, in practice, the term only refers to the transnational and other large suppliers, manufacturers, and distributors of ultra-processed products and their raw materials, together with allied and associated corporations and institutions. Excluded are national industries (with a few exceptions), the retail trade (unless burger chains are counted), low-input and organic producers and growers, the horticulture industries (again, with a few exceptions), food and farming cooperatives, and family and smaller manufacturers, all of which have minimal or no representation in the partnership. It is Big Food and Big Snack, above all, that have sought and achieved partnerships with the public sector. Indeed, with support from the World Economic Forum and other organisations that represent the interests of transnational industry, food corporations have already engaged in the committees convened by the UN that are tasked to set and develop the global3

agenda specified in the Political Declaration of the recent UN High-Level Meeting on prevention and control of noncommunicable diseases [28,29]. Within countries where food systems are already more or less saturated with ultra-processed products, these committees are mainly focused on proposals to adjust the formulation of ultra-processed products so that they contain, for example, less salt and trans-fats or more synthetic micronutrients. But such reformulation often allows manufacturers to advertise their products as healthy, which is likely to result in sustained or even increased purchase and consumption of such products, additional displacement of fresh and minimally processed foods, and therefore further increases in obesity, diabetes, and other chronic diseases. Moreover, the reformulation strategy of transnational corporations may have the effect of heading off legislation designed, for example, to sharply limit or prohibit the advertising and marketing of ultraprocessed products to children. The reformulation strategy is also likely to contribute to the displacement of traditional food systems in Brazil and other countries of the South, and to the replacement of shared meals with ready-to-heat or ready-to-eat dishes and snacks labelled as healthy, often with the blessing of governments and support from nutritionists and public health professionals. Partnership with industries whose interests do not conflict with those of public health is essential. But we see partnerships with Big Food and Big Snack as analogous with tobacco control or alcohol restriction policy-making in which Big Tobacco or Big Alcohol manufacturers are partners. The growth of production and therefore consumption of ultra-processed food and drink products in Brazil and elsewhere in the South is already undermining and even destroying public health and public institutions in countries that cannot afford the costs of treatment of obesity and other epidemic diseases of which unhealthy food products, consumed in typical quantities, are a major cause.

Protecting and Improving Traditional Food SystemsThe long-established Brazilian diet, in common with the diets of other Southern countries, can readily be improved from the nutritional and public health points of view. Indeed, it has already improved. Because food supplies have become secure in almost all parts of the country, and because most Brazilian populations andJuly 2012 | Volume 9 | Issue 7 | e1001252

communities have risen up out of severe impoverishment, the consumption of meat, milk, and other animal products in Brazil has increased, undernutrition has become uncommon, and childhood stunting and wasting have ceased to be major problems [30,31]. Remaining undernutrition can be alleviated by special programs involving redistribution of cash or goods, as carried out by recent Brazilian governments [32]. Remaining faults in the Brazilian traditional dietary patterns can be addressed by a combination of fiscal and other legislation. This legislation should support cooperatives and family farmers, protect and stabilize the prices of healthy staple foods and ingredients, and make green vegetables and other fresh and minimally processed foods more attractive to produce and more affordable and available. It should also reduce the volume of salt and sugar entering food supplies, either as raw materials or as contained in ultra-processed products [21]. Programs of information and education at the national and state levels should be used to reinforce this legislation. More generally, we also advocate worldwide prohibition of the hydrogenation process that generates industrial saturated fats and trans-fats. The use of law to protect and improve food systems and supplies, and thus public health, may be difficult in parts of the world where governments have already surrendered the responsibility of governance to transnational and other corporations. However, in Brazil protection of public health still remains a prime duty of government that has not eroded as it has in other countries. Thus, by law, all Brazilian children are entitled to one daily meal at school, at least 70% of the food supplied to schools must be fresh or minimally processed, and a minimum of 30% of this food must be sourced from local family farmers [14]. Brazil also has more than 200 human milk banks, the largest suc

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