Published Ahead of Print on April 15, 2010, as 10.2105/AJPH.2009.187666 The latest version is at http://ajph.aphapublications.org/cgi/doi/10.2105/AJPH.2009.187666⏐ ON THE OTHER HAND ⏐

The Snack Attack

In the second decade of this century the time for collective action in the public interest has come once again. Transnational food and drink companies will respond in ways that can help to slow, “stop, or even reverse the current global deterioration of public health, after they are obliged to do so by laws that change the rules of their game in favor of fairness, equity, and a better future.” ARE THE TRANSNATIONAL Among other things the Strat- foods and drinks to children and | Carlos A. Monteiro, PhD, food and drink manufacturing, egy recommends that food and in primary schools.5 Fabio S. Gomes, MSC, and catering, and allied industries— drink manufacturers limit levels However, the “EU Pledge” ap- Geoffrey Cannon, MA whose bottom lines depend on of saturated fats, trans-fatty acids, plies only to advertisements in pathogenic products—really plan- free sugars, and salt in current media vehicles with an audience ning to help control and prevent products; formulate new prod- of at least 50% of children worldwide public health calami- ucts with better nutritional pro- younger than12 years. It does not ties? This seems to be what Yach files; and reduce their promotion restrict use of licensed characters, et al., who all work for PepsiCo, and marketing of processed games, and toys on packages or at are suggesting. They claim sup- products, especially to children.1 points of sale. It exempts all prod- port from other companies who The initial response to the ucts that conform to nutrition cri- they say have “a vital role to play Strategy in its draft stages by teria devised by the individual alongside governments, nongov- transnational industries was to companies themselves. It allows ernmental organizations, and force its dilution and to impede promotions in primary schools academics in addressing nutri- its approval by WHO member “where specifically requested by tion.” We examine what this states. The heaviest pressure or agreed with the school adminis- may mean. came from industry sectors tration for educational purposes.”5 whose profits depend on prod- Examination of the criteria OBESITY AND CHRONIC ucts high in sugar and salt, and used to exempt products from any DISEASE also from the US government.2,3 voluntary restriction suggests to Later, after approval of the Strat- us that the EU Pledge can also be Yach et al. state that transna- egy and in response to pressure seen to be a damage limitation tional food and drink industries from several European govern- exercise, designed to deter statu- are now responding to the World ments that were considering stat- tory regulation and to maintain Health Organization (WHO) utory regulation of food and growth in product volume and Global Strategy on Diet, Physical drink advertisements,4 11 trans- profits. Thus, PepsiCo6 allows Activity, and Health, the main national companies committed advertising of any of its products purpose of which is to control and themselves to a voluntary code. to children of any age, even if prevent obesity and chronic dis- This includes pledges to restrict those products have levels of fat, eases. Indeed they are, but how? advertising and marketing of Continued on page 5

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Continued from page 3 Ferrero, Kraft Foods, McDonald’s, they would develop and market governmental regulations that re- saturated fat, dietary cholesterol, Nestlé, and PepsiCo) were not products for consumers in lower- strict marketing and claims made added sugar, or sodium that following their own codes.11 A income countries.10 Following for complementary feeding prod- exceed the limits specified by context for this is the spectacular this, Yach et al. propose that ucts and weaning foods.23 WHO,7 if the levels of any single annual retail sales growth of soft transnational food and drink The brutal penetration of in- one of these items is reduced by drinks, breakfast cereals, and companies can help to solve un- fant formulas in lower-income 25% relative to the 2004 formu- ready meals seen in Brazil from dernutrition. Given the current countries in the 1960s and 1970s lation. PepsiCo breakfast cereals 1998 to 2003, of 5.9%, 8.9%, linked financial, food, and fuel was followed by virtual abandon- and snacks with up to 25% of and 17.3%, respectively.12 crises, this is a remarkable claim. ment of breastfeeding and a con- added sugar may be advertised In Brazil, industry is also trying Yach et al. give a special value sequent predictable increase in without restriction to children of to thwart formal control. In to novel enriched food products child disease and death.24 Yach et any age, as long as they contain response to a recent proposal by and downplay the value of local al. ignore more recent successes 2.5 g of dietary fiber per serving. the Ministry of Health to regulate foods. They focus on food avail- in increasing breastfeeding in Further, voluntary codes so far advertising and marketing of food ability, but the issue is not merely many countries.25 Breastmilk is of are not addressing other trouble- and nonalcoholic drinks,13 the one of lack of food. The nutri- course free and cannot be some and pathogenic aspects of Brazilian food trade representa- tional status especially of young branded or patented. processed foods and drinks, such tive association first announced children is protected not just by as extremely high energy density, that all major food companies adequate food but also by secure Ready-to-Eat Foods inflated portion sizes, consump- would comply with the pledges local food systems and supplies, Yach et al. are also enthusiastic tion of high levels of calories in made in Europe and North access to safe water and adequate about novel packaged products the form of sugary soft drinks, America.14 However, this did not sanitation, access to health care, originally designed to treat se- glamorization of overconsump- deter the government’s proposal appreciation of food production verely malnourished children. tion, inducement of snacking in- to use law in the public interest. and of preparation of family These ready-to-use therapeutic stead of having regular meals, The next industry response has meals, and empowered mothers foods (RUTFs) are energy-dense, eating while watching TV, dis- been to claim that any statutory and other caretakers.17 ,18 Reduc- mineral- and vitamin-enriched couragement of meals and cook- regulation would be illegal be- tion of child undernutrition above products currently used by com- ing, association of processed cause it would infringe the princi- all depends on improvements in munity-based programs, mostly foods and drinks with sex appeal, ple of commercial freedom; if income and other types of equity; in Africa. One leading RUTF is and equation of happiness with government persists in enacting population and community self- Plumpy’Nut, a patented paste spending.7–9 These aspects are any law, they say they will appeal determination; and public invest- made from peanuts, pow- not addressed in the EU Pledge. to the Brazilian Supreme Court.15 ments in education, health, water der, sugar, oil, and a mineral/vi- In May 2008 some of the sig- To succeed, the Court would have supplies and sanitation services; tamin mix.26 natories of the EU Pledge also to overturn the Brazilian Consti- and indeed in social security and RUTFs can indeed save lives signed a global commitment to tution, which states that when so- cohesion. Overall what is needed and also enable outpatient treat- action in support of the WHO cial and economic rights are in is a better wealth distribution and ment in cases of acute, severe Global Strategy. This includes conflict, social rights will prevail.16 strong public health services.19–21 malnutrition. However, they are pledges to reformulate food and The struggle in Brazil is not relatively expensive and are im- drink products, and global exten- likely to be exceptional. The strat- Weaning Foods ported or made from imported in- sion of the European marketing egies of transnational companies A common feature of the pro- gredients. Experts in community- and advertisement pledges.10 are global. In this context, though posals made by Yach et al. is ad- based treatment of severe Are the transnational compa- the United States, the European vocacy of processed and often malnutrition prefer products with nies following their own codes? Union, and Japan together now branded and patented packaged comparable nutritional profiles Not in Brazil. Early in 2009, two account for about two thirds of all foods. However, proliferation of based on locally available grains Brazilian public interest organiza- heavily processed food sales, three food products designed to com- and legumes which also support tions monitored the advertise- quarters of the world’s population plement breastmilk is a further local producers and economies.26 ments broadcast on four television live in lower-income countries.12 threat to exclusive breastfeeding However, Yach et al. believe that channels by the companies that up to six months of age, followed a big push by transnational com- signed the self-regulatory pledge FOOD INSECURITY AND by breastfeeding complemented panies is needed. They say that in North America and Europe. UNDERNUTRITION with safe, locally available, afford- Josette Sheeran, executive director Nine out of the 12 monitored able, nutritious foods.22 This threat of the United Nations World Food companies (Burger King, Cadbury In May 2008 the same is most potent in impoverished Programme, “believes that there is Adams, Coca-Cola, Danone, companies also declared that countries with few or no effective Continued on page 7

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Continued from page 5 by 15% per year, and currently and share price. The food and characteristically works efficiently need to create incentives for food account for 7% of the US $8 bil- drink transnationals enjoy subsi- and effectively. National, state, companies to develop a wider total annual sales of Nestlé dies on processed oils, starches, and local governments, as well as range of healthy weaning foods.” products in Brazil. The chief ex- and sugars. Most of their products international governing bodies, RUTFs branded with the logos ecutive officer of Nestlé in are made from such cheapened supported by civil society and of transnational companies such Brazil has said to Época “Stomach ingredients with use of cosmetic professional organizations and as Nestlé and PepsiCo could in- does not have class. This project additives, and claim to be healthy other actors, are legislators whose deed become monster sellers, works. By the end of 2009 we when they also contain added duty perhaps above all others is and, when presented to mothers will have 10 000 door-to-door synthetic microconstituents. They to enact laws in the public inter- who are led to believe that the sellers and 250 microdistribu- lobby for abandonment of laws est. Significant protection or im- products have saved the lives of tors.”27 He says that popularly and regulations designed to pro- provement of public health has their children, potent ambassa- priced products target middle-in- tect the public interest. They always involved legislation, the dors for equivalently branded come and low-middle-income spend colossal budgets on adver- best of which carefully enables baby foods, cola drinks, and families, not low-income families.28 tising and marketing of unhealthy and encourages the equitable en- snack foods. The Nestlé overall chief execu- products. They take over national joyment of life. Examples include tive officer in Vevey, Switzerland, and local industries, and public the protection of wildernesses, LET THEM EAT SNACKS agrees: goods such as water supplies. control of immigration, closed The evidence that food and sewers, speed limits, pedestrian Popularly priced product is a suc- Yach et al. recommend “prod- cessful business model . . . that drink transnationals are now be- precincts, prohibition of smoking uct reformulation of low-cost nu- adapts the whole marketing coming even a small part of the in public places, and indeed re- mix—be it product, nutritional public health solution—rather striction of baby formula and tritious foods for all markets.” benefit, distribution, or communi- One example is “popularly posi- cation—to the specific needs and than just a large part of the prob- weaning food advertising. tioned products” which is a possibilities of the emerging con- lem—is anecdotal, weak, and con- The privatization of public sumer. In fact, it allows emerging flicted. Evidence that transna- health does not work. Once disci- Nestlé initiative. As explained in market consumers to buy Nestlé the Brazilian weekly business products for the first time.29 tional industry initiatives are plined in ways that will benefit news journal Época,27 this in- overall improving food supplies responsible industry, big busi- volves door-to-door selling of NAMING THE CORPORATE in any setting, let alone improv- nesses can become trusted part- small packages or individual sa- GAMES ing public health, does not exist. ners with independent actors, chets of Nestlé products by local We suggest that public health including those in the public women trained by Nestlé repre- Industry is indeed a crucial professionals see papers such as health profession. Q sentatives in the Nestlé concept partner in policies and programs those of Yach et al. as part of the of good nutrition. These include designed to protect and improve marketing strategies of transna- About the Authors global brands such as Bono public health. Enterprises such as tional food and drink companies. Carlos A. Monteiro is with the Department of Nutrition and Center for Epidemiologi- (filled biscuits), (instant the Grameen Bank and the Gates Once upon a time Coca-Cola pro- cal Studies in Health and Nutrition, School powder milk chocolate drink), Foundation, and also industries moted its main brand with a of Public Health, University of Sao Paulo, Mucilon (instant baby food), and whose products do not directly global advertising campaign Sao Paulo, Brazil. Fabio S. Gomes is with the Food, Nutrition and Cancer Division, products (instant soups impact public health, have done whose theme song was “We’d National Cancer Institute of Brazil, Rio de and noodles). The products are and can continue to do great Like to Teach the World to Sing.” Janeiro. Geoffrey Cannon is with the 10 to 20% more expensive than good. Many sectors of the food, PepsiCo is now the biggest manu- World Public Health Nutrition Associa- tion, Rio de Janeiro, Brazil. those sold in supermarkets. The drink, and associated industries facturer of globally branded pro- Correspondence should be sent to Car- sellers also offer “exclusive” min- can also be constructive partners. cessed snack foods. With other los A. Monteiro, Avenida Arnaldo 715, eral and vitamin fortified prod- The problem lies with food, drink, transnational companies, their Sao Paulo 01246-904, Brazil (e-mail: [email protected]). Reprints can be or- ucts “especially developed to and associated companies whose current mission is to teach the dered at http://www.ajph.org by clicking cover nutritional deficiencies.”27 profits depend on products that world to snack. This is commer- the “Reprints/Eprints” link. Nestlé popularly positioned damage public health and that cially ingenious but not, we sug- This article was accepted November 11, 2009. products are also sold in train also have damaging social, eco- gest, part of the solution to any doi:10.2105/AJPH.2009.187666 and subway stations in large nomic, and environmental im- global public health problem. Brazilian cities such as Rio de pacts. These most of all include Contributors Janeiro and São Paulo, and transnational companies, of which THE SOLUTION C. Monteiro initially drafted this article placed in popular retail chains PepsiCo is one. To succeed, big in response to an invitation from the editors. All authors contributed to fur- that sell electronics and house business must sustain and Happily, one strategic ap- ther drafting and editing of the article. appliances. Sales are so far growing increase annual turnover, profit, proach to public health crises Continued on page 9

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Continued from page 7 the global strategy on diet, physical ac- 21. Monteiro CA, D’Aquino Benicio Acknowledgments tivity and health [letter from food and MH, Conde WL, et al. Narrowing socio- economic inequality in child stunting: Geoffrey Cannon was invited by PepsiCo beverage CEOs to Margaret Chan, di- the Brazilian experience (1974–2007) to develop an initiative designed to pro- rector general of the World Health Or- [published online ahead of print Febru- tect food producers and traders in Brazil ganization]. May 13, 2008. Available ary 22, 2010]. WHO Bulletin. while developing attractive and healthy at: http://www.idec.org.br/pdf/OMS_ doi:10.2471/BLT.09.069195 products in the public as well as private companies_commitment_WHO.pdf. interest. This project, now part of his ed- Accessed October 29, 2009. 22. World Health Organization. Global ucation on the topic of this paper, began 11. Gomes FS. Marketing of unhealthy Strategy for Infant and Young Child Feed- and ended in 2007. food to young children. Brazilian David ing. Geneva, Switzerland: World Health and multinational Goliath [letter]. Public Organization; 2003. Human Participation Protection Health Nutr. 2009;12(7):1024–1025. 23. Ferguson EL, Darmon N. Tradi- No funding or approval of an institu- 12. Gehlhar M, Regmi A. Factors shap- tional foods vs manufactured baby tional board were required for this work. ing global food markets. In: Regmi A, foods. In: Agostoni C, Brunser O, eds. Gehlhar M, eds. New Directions in Issues in Complementary Feeding. Vol 60. References Global Food Markets. Washington, DC: Nestlé Nutr Workshop Ser Pediatr Pro- US Dept of Agriculture; 2005:5–17. gram; 2007:43–61. 1. World Health Organization. Resolu- Agriculture information bulletin 794. 24. Chetley A. The Baby Killer Scandal. tion WHA57.17. Global strategy on diet, 13. Agência Nacional de Vigilância Sa- War on Want Investigation into the Pro- physical activity and health. Fifty-seventh nitária. Propaganda de produtos sujeitos motion and Sale of Powdered in the World Health Assembly; 2004 22 May à vigilância sanitária. Available at: Third World. London, England: War on 2004. Geneva, Switzerland: World http://www.anvisa.gov.br/propaganda/ Want; 1979. Health Organization; 2004. consulta_71_2006.htm. Accessed Octo- 25. Pérez-Escamilla R. Breastfeeding 2. Norum KR. World Health Organiza- ber 29, 2009. Detalhes da consulta pú- and the nutritional transition in the tion’s Global Strategy on diet, physical blica 71/2006—alimentos. Latin American and Caribbean region: activity and health: the process behind 14. Associação Brasileira de Indústrias a success story? Cad Saúde Pública. the scenes. Scand J Food & Nutr. de Alimentação. Associação Brasileira 2003;19(suppl 1):S119–S127. 2005;49(2):83–88. de Anunciantes (ABA). Comunicado de 26. 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