Lenias Hwenda, Ph.D., Contributing Blogger
Access to Medicine Foundation Independent Expert Advisor on Global Health and Access to Medicine

640px-Rice_grains_(IRRI)Wealthy and poor countries alike face a growing incidence of non-communicable diseases (NCDs). NCD-related mortality is projected to increase by 17% in the next decade. Countries face major obstacles to preventing and controlling NCDs, which surpass the health sector. The food and beverage industry directly and significantly contributes to diet-related chronic illness. The sector undermines the global target to achieve 25% relative reduction in preventable deaths from NCDs by 2025. Its commitment to taking action towards reducing the global burden and impact of NCDs is limited by poor accountability. An NCD index that assesses the sector’s corporate policies and practices towards its commitments to voluntary global standards for tackling NCDs could increase accountability.

Background

NCDs have become a major cause of death and disability worldwide that constitutes a major health challenge in the post-2015 development goals. Of the global total of 57 million deaths in 2008, NCDs accounted for about 63% (36 million); 80% (29 million) of which occurred in low and middle-income countries (LMICs).[1] Alongside persistent infectious disease challenges facing LMICs, the growing NCD prevalence creates a double burden of disease.

The risk of death from NCD-related premature death is greatest in LMICs where they represent 58% of total deaths. By 2030, NCDs could become the most common cause of death across the poorest regions including Africa. Socio-economic factors like income, education and gender significantly influence and exacerbate NCDs[2] with the poor being the worst affected.[3] The demographic impact of NCD-related premature death makes them a key development challenge requiring greater focus in the post-2015 development agenda.

Major NCDs like cancer, diabetes, heart disease, stroke and chronic respiratory illness account for most deaths. They share modifiable risk factors, predominantly unhealthy diet, harmful use of alcohol, physical inactivity and tobacco use. Mitigating these risk factors could ameliorate NCDs[4] by reducing physical risk factors such as high blood pressure, and blood lipid and glucose concentrations that predispose individuals to NCDs.

Unhealthy diets significantly contribute to NCDs. They account for last decade’s estimated 50% increase in OECD country health expenditure.[5] Consequent growing demand for diagnosis, treatment and chronic care escalates cost to unaffordable levels. The poor face greater out of pocket expenses, loss of income and sinking deeper into poverty whilst countries face soaring national health expenditures. The estimated cumulative economic cost to LMICs of major NCDs between 2011-2025 is US$500 billion per year.[6] With 55 million deaths projected by 2030, effective global solutions resilient against national constraints are urgently needed.

Global efforts must address NCD primary determinants related to food as an essential component of a multi-pronged approach. Most premature deaths are avertable through policies outside the health sector. Diet being a major risk factor with lifelong effects that commence before birth makes the global food and beverage sector particularly important. The globalization of food and beverage supply chains has exacerbated the ubiquitous availability of cheap calorie-rich, nutrient-poor foods and beverages that accentuate NCD risk factors, and are attractive to the poor.[7]

Public health safeguards must increase the availability of affordable healthy choices and discourage consumption of unhealthy foods. Governments could use economic tools such as subsidies to counter the marketing of cheaper processed, ready-to-serve meals with excessive salt, sugars, and trans-fatty acids. However, the impact of fiscal tools such as taxing unhealthy foods and regulating harmful marketing practices is constrained by the unenforceable nature of voluntary standards, which limits the impact of global agreements such as the WHO set of recommendations on the marketing of foods and non-alcoholic beverages to children.[8]

High-income countries use fiscal, legislative and policy measures, but LMICs face various obstacles to their ability to launch a vigorous response, including limited capacity and resources. WHO Member States’ draft action plan for reducing exposure to modifiable risk factors proposes comprehensive measures for prevention and control of NCDs including health promotion and strengthened health systems.[9] However, disparate country situations, such as national health priorities, and legal and political environments limit the global impact of a single NCD action plan. Solutions impervious to national constraints could effectively help countries manage commercial complexities surrounding the private sector drivers of NCDs.

Food and beverage multinationals are central to diminishing population exposure to diet-related risk factors by simultaneously addressing consumer choices and the food supply chain. Their global reach makes them potentially cost effective, politically and financially feasible targets. However, the WHO action plan’s proposal for private sector engagement lacks accountability frameworks capable of encouraging their meaningful contribution.

Recommended here is a feasible conceptual framework based on simple priority interventions with beneficial health effects. They include reducing salt, free-sugars and saturated fatty acids in food and beverages, eliminating industrially produced trans-fatty acids and replacement with polyunsaturated fatty acids.[10] Their wide adoption could reduce NCD-related deaths by 2% per year averting millions of avoidable deaths.[11]

Rationale and what to measure

Global efforts to reduce unhealthy products relying exclusively on voluntary industry-led pledges have nominal impact.[12] Alongside public health measures by relevant stakeholders, an NCD index that ranks corporate policies and practices promoting healthy diets with demonstrable impact on food consumption habits and behavioral risk factors for NCDs could significantly reduce NCD-related premature mortality.

The sector’s commitment to global voluntary standards requires concurrent measurable objectives and targets, explicit, transparent, and comprehensive corporate policies and practices including responsible marketing standards universally applicable to all markets and media channels. Proof of concept from a mechanism[13] that has successfully galvanized the global pharmaceutical industry to promote greater access to medicines for the poorest,[14] strongly suggests that an NCD index, like the recently launched Access to Nutrition Index[15] could have similar effects.

It could dissuade irresponsible practices such as unethical marketing practices targeting children by rewarding responsible corporate practices with far-reaching impact on diet-related illness such as Coca Cola’s recently launched advertisement.[16]  Its cost-effectiveness enhances potential impact even in limited resource settings. The index could empower advocacy groups’ demands for greater transparency and accountability. Consumer and investor demands and the public image incentive are strong motivators.[17] It can complement ongoing efforts such as the WHO global monitoring framework and the draft action plan, which provide a credible basis for the index.

The WHO monitoring framework establishes 25 indicators and 9 voluntary targets seeking to reduce NCD-related risk factors essential to reducing preventable NCD-related premature deaths.[18] The NCD index could measure corporate compliance with the 9 voluntary targets, and other national policies limiting harmful components like partially hydrogenated vegetable oils in the food supply chain, and irresponsible marketing practices. The monitoring framework’s systematic data collection provides requisite data. The complexity of NCD prevention and control merits collective action and accountability from all relevant stakeholders. An NCD index could complement global efforts to reduce the NCD burden.

References


[1] WHO. Global Status Report on Non Communicable Diseases. 2011. WHO Geneva

http://whqlibdoc.who.int/publications/2011/9789240686458_eng.pdf

[2] Di Cesare M, Khang Y,Asaria M et al. Inequalities in Non-communicable Diseases and Effective Responses. Lancet 2013 ; 381 :585-597

[3] Lim SS, Gaziano TA, Reddy KS, et al. Prevention of Cardiovascular Disease in High-risk Individuals in Low-income and Middle-income Countries: Health Effects and Costs. Lancet 2007; 370: 1954-1962

[4] WHO. Prevention and Control of Noncommunicable Diseases: Formal meeting of Member States to conclude the work on the comprehensive global monitoring framework. 2013. WHO EB132/6. Geneva: http://apps.who.int/gb/ebwha/pdf_files/EB132/B132_6-en.pdf

[5] Sassi F, Cecchini M, Lauer J, Chisholm D. Improving Lifestyles, Tackling Obesity: The Health and Economic Impact of Prevention Strategies. OECD Health working paper 48. Paris: OECD. 2009. http://www.who.int/choice/publications/d_OECD_prevention_ report.pdf

[6] WHO. From Burden to ‘Best Buys’ Reducing the Economic Impact of Non-Communicable Diseases in Low- and Middle-income Countries. 2011. Geneva http://www.who.int/nmh/publications/best_buys_summary.pdf

[7] Beaglehole R, Bonita R, Horton R, et al. Priority actions for the non-communicable disease crisis. Lancet 2011; 377: 1438-1447

[8] Moodie R, Stuckler D, Monteiro D. et al. Profits and Pandemics : Prevention of Harmful Effects of Tobacco, Alcohol and Ultraprocessed Food and Drink Industries. Lancet 2013 ; 381 : 670-679

[9] WHO. Draft action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020. 2013. WHO Geneva: http://apps.who.int/gb/ebwha/pdf_files/EB132/B132_7-en.pdf

[10] Beaglehole R, Bonita R, Horton R, et al. Priority actions for the non-communicable disease crisis. Lancet 2011; 377: 1438-1447

[11] Beaglehole R, Bonita R, Horton R, et al. Priority actions for the non-communicable disease crisis. Lancet 2011; 377: 1438-1447

[12] Moodie R, Stuckler D, Monteiro D. et al. Profits and Pandemics : Prevention of Harmful Effects of Tobacco, Alcohol and Ultraprocessed Food and Drink Industries. Lancet 2013 ; 381 : 670-679

[13] Ali KA, Narayan KMV. The Access to Medicine Index. Lancet 2008 ; 372 : 891

[14] Morris K. Bridging the Gap in Acess to Medicine. Lancet 2010 ; 10 : 514-515

[15] Global Index 2013. Access to Nutrition Index. March 2013. http://www.accesstonutrition.org/

[16] The Guardian. Coca Cola’s New Ad: Obesity ‘Concerns All of Us’. 15 Jan 2013. http://www.guardian.co.uk/business/video/2013/jan/15/coca-cola-ad-obesity-video

[17] Morris K. Bridging the Gap in Acess to Medicine. Lancet 2010 ; 10 : 514-515

[18] WHO. Prevention and control of Non-communicable diseases: Formal meeting of Member States to conclude the work on the comprehensive global monitoring framework. 2013. WHO EB132/6. Geneva: http://apps.who.int/gb/ebwha/pdf_files/EB132/B132_6-en.pdf